Health Service: Statements

I am delighted to be back in the Seanad to have an opportunity to have a discussion about the health service and outline some of my priorities for the health service during 2017. When I spoke to the Seanad in July last year, we had what I considered to be a frank and positive exchange on a number of issues. I look forward to an equally interesting exchange of ideas today. On that occasion in July I spoke of my hopes for building a health service that would make us all proud as citizens. We have a unique opportunity to put in place a long-term vision for health services. Eight months on, I have not lost that sense of hope. We continue to face challenges and I get frustrated like everyone else on behalf of patients waiting on trolleys or for an appointment. It makes me and must make all of us more determined than ever to tackle the problems we face.

When I was appointed, it became abundantly clear to me that this was going to be a process that was going to take a number of years and that what we needed was to try to build a political consensus on a direction of travel in order that when the Minister changed, the plan would not change. When I have visited hospitals and other facilities within the health service, what I have detected from many people working within the service is frustration that every time the Minister or the Government changes, the policy and plan change. It is almost like going back to the beginning and starting all over again. We need to genuinely try to embed long-term planning and building blocks for where we want to get to. In my visits to hospitals and health facilities it has been valuable and important for me to see for myself what professionals, patients and families experience and there are positives and negatives too. I have witnessed the exceptional levels of commitment of health care professionals and had so many patients tell me of the great care they have been given and how the treatment they have received has improved their lives, but equally I am not blind to the fact that we still face significant challenges. We all know someone who is accessing services, a family member, a friend or a colleague. We all share the same goal. Each of us wants to have a health service where people feel valued, respected and well cared for and a service where the patients are at the centre.

We are now back in an era of reinvestment in health care. The budget for 2017 delivered the highest ever health budget in the history of the State, at €14.6 billion. This unprecedented investment will serve to make a real difference in the services we can deliver. It is not just about the size of the budget. It must also be about where that money is spent, where the focus is and the output and the outcome from the patient's perspective.

I would like to set out some of my priorities. I acknowledge the distress for patients and their families and the impact on staff caused by cramped and overcrowded conditions in many hospital emergency departments. Behind every trolley number - there is a tendency to count trolley numbers - there is a patient in need of effective, timely and compassionate care from the health service. We must all try harder across the health service and do more to improve the experience of every single one of these patients. I am very conscious of the unacceptably high number of patients on trolleys at the beginning of the year, but I am glad to report that while numbers remain far too high, they have reduced more recently and now remain consistently lower than each of the corresponding days of last year. In fact, the number of patients on trolleys in January this year, although far too high, is lower than the number of patients who were on trolleys in January last year. It is important to acknowledge, not politically, the intensive efforts of staff and management across the health service who have contributed greatly to stabilising the situation after the high number reached immediately after Christmas.

The rate of increase of flu throughout the country increased substantially in the weeks directly after Christmas and the strain of flu circulating has been affecting elderly people in the main. I know people ask is there not flu every year. Of course, there is, but there are different strains and different times when flu strikes. This was a particular strain of flu of which we had last seen a prevalence in Ireland in 2009 and it was a particular strain that impacted on older citizens, as we saw with the very significant increase in the number of older patients requiring health services. Although recent figures from the Health Protection Surveillance Centre suggest this outbreak of flu may be reaching its peak, thankfully, I continue to urge all “at risk” individuals who have not, as of yet, received the flu vaccination to contact their general practitioner or pharmacist as soon as possible. It is still not too late to be vaccinated.

Some €40 million in additional funding was provided for the winter initiative 2016 to 2017 to help to alleviate overcrowding. I would like to report to the House on the implementation of this initiative. One of the key objectives of this year’s plan is to reduce the numbers of patients waiting to be discharged from hospitals by providing the specific supports and pathways to allow patients to move home or to an alternative suitable community setting which meets their needs. Achieving this objective frees up beds in the acute hospital system, thereby reducing overcrowding in emergency departments. However, it does much more than that. It is about the dignity of the patient, the person who is ready to go home, who does not want to be stuck in an acute hospital and who wants to go home and be in a more appropriate setting. I want to commend those teams across acute hospitals and social care that work together on a daily basis because they have exceeded the target set in the winter initiative and reduced the number of delayed discharges in hospitals to an all-time low, with 458 people recorded last week, down from 638 at the start of the winter initiative.

A number of other practical measures have also been implemented. We have seen over 7,500 patients avail of community intervention teams, meaning that these patients were able to avoid hospital or be discharged earlier from hospital. Of this number over 1,000 patients received treatment directly from funding provided under the winter initiative. We have seen almost 3,500 patients avail of aids and appliances, enabling them to be discharged from hospital. We have seen 670 additional home care packages and 330 additional transitional care beds. We have seen an additional 35 acute beds open before Christmas in the Mercy University Hospital in Cork, Beaumont Hospital and the hospital in Mullingar. On 5 January I sought and received additional, enhanced measures from the HSE and these measures focus particularly on augmenting the supports for primary and community care services, targeting acute capacity, opening additional transitional care beds and more beds in acute hospitals.

Reducing waiting lists is a key priority in 2017. It is not necessarily the headline number - how many patients are on a waiting list - that is a cause of concern to patients. It is how long they must wait. I am encouraged that we were finally able to make some progress in 2016. We made investments in a targeted way, as a result of which we saw the number of patients waiting over 18 months for a procedure halved. We saw the first fall in the overall numbers on waiting lists in around two years. Now we have put aside €20 million for the National Treatment Purchase Fund, NTPF, in the budget for 2017, and committed a further €50 million in 2018. That is €70 million for dedicated waiting lists initiatives, to get down the length of time patients are waiting. We used to be quite good at this before the economic crash and we really need to get back to it as quickly as possible. I acknowledge the considerable work done across hospitals and in conjunction with the NTPF to reduce waiting lists.

Senators Colette Kelleher and Colm Burke have raised a specific issue about Cork University Maternity Hospital, on which I am sure they may touch later. I am very concerned about that matter. I do not understand how we have arrived at a situation where the waiting lists in Cork are twice as long as the next highest. It is not acceptable. Every hospital has gone through the same challenges in terms of finances, but we need to get in under the bonnet of what has happened in Cork. I had a very good meeting with the consultants there a couple weeks ago and will be following up on it with them. I have asked them, the new maternity strategy team in the HSE and the soon to be new clinical director for maternity services to report back to me on a range of suggestions they want to see implemented. I am looking forward to having a further meeting and engaging further with Members of the Oireachtas from Cork in that regard.

We need to have a very honest debate about how we are going to break what has now become a vicious cycle. Every year for the last two decades, if not longer, the Minister for Health of the day has stood here, or in a spot similar to here, and talked about hospital overcrowding, trolleys and apologised and meant it. Ministers have done their best to improve it, but they have never managed to break it. The reason we have never managed to break it is that we have failed to take a number of the fundamental steps that we are now going to take and on which I want to hear the views of Senators in terms of what we need to do. Some of those on which I would like to touch are bed capacity, recruitment and retention and making the decisive shift to primary care services a reality, rather than just a catch-phrase.

On capacity, my Department will undertake a capacity review in line with the commitment in the programme for Government. Systematic analysis of the capacity requirements of the health service is an obvious requirement of proper planning and management. Such reviews should ideally be undertaken on a periodic basis and have a medium to long-term focus. The last report was in 2007. There is no doubt that a review at this stage is appropriate, given that we are all aware of population and demographic changes in the interim. I cannot understand how the last new acute hospital we built was in 1998. If the Minister for Education and Skills was standing here and said the last school we built was in 1998, we would all understand why there would be a problem in accessing school places. We have not built a new hospital since 1998, yet demographic pressures have increased. The troika was not in town for all of those years. This is a collective challenge to which we are going to have to rise. We need a capital investment, an investment that will result in an increase in bed capacity. We need to do this properly and on the basis of evidence.

We need to see where the beds are needed and how much more we can do in primary care services. If we really implement and embed primary care, how many beds should be in the community, rather than acute hospitals? How will we manage chronic diseases? These are all issues that need to be considered in the provision of acute and non-acute beds. For that reason, I am anxious the review will have a wider scope than previous reviews and will examine key elements of primary and community care infrastructure, in addition to hospital beds. Initial work on the capacity review has focused on expanding the concept of a preferred model of care and how it can inform the assessment of future capacity requirements. Given the current pressures being experienced within hospital services, the process must also have a short-term focus and determine how capital investment in the coming years can be best targeted. We need to have a clear crystalised ask for the mid-term capital review in the context of capacity.

I take the opportunity to address the recruitment and retention of nurses and midwives. The Department, the HSE and I recognise the importance of recruiting and retaining nurses and midwives in the public health service. As I have said on a number of occasions, recruitment is one of the key building blocks we need to put in place to break the cycle. It is also recognised that the fall in numbers employed between 2008 and 2013, from 39,000 to 34,000, had to be addressed when the moratorium ended. There is a global shortage of nurses and midwives and it is a challenging environment in which to grow nursing and midwifery numbers. However, the number of nurses and midwives employed in the public health service increased from 34,178 at the end of 2013 to 35,835 at the end of December 2016, an increase of 1,657 nurses. I accept that there is much more we need to do and initiatives are under way to improve staffing levels throughout the country. The HSE is offering permanent posts to 2016 degree programme holders and full-time permanent contracts to those in temporary posts. So many nurses to whom I have spoken who went abroad left because they did not have the option of a job in the health service, or certainly not a job on a contract for longer than a number of months. That is no longer the case. The HSE is also focused on converting agency staff to permanent staff, while also accepting that there will always be a need to have some element of agency. The HSE's national recruitment service is actively operating rolling nursing recruitment campaigns. The campaigns encompass general, mental health, intellectual disability and registered children's nurses and also midwives. In addition, a relocation package of up to €1,500 continues to be available to nurses who return from overseas.

The HSE ran a three-day open recruitment event over the Christmas holiday period in Dr. Steevens' Hospital for nurses and midwives from all disciplines who are interested in working in the public health service and 220 candidates attended the event. I also had the opportunity to attend. A total of 115 nursing and midwifery candidates were deemed successful and placed on a panel following an interview. The files on successful candidates have been passed to the contracting unit. It was the first of a number of career and recruitment events for nurses throughout 2017, with the next one scheduled for 31 March.

In September 2016 the HSE set up a project group to review nursing workforce planning, recruitment and retention. The main objectives of the project group include identifying current recruitment black spots in a co-ordinated way and developing measures to incentivise and attract nurses to these essential posts. I accept that nursing recruitment and retention are challenging issues. We are engaged in discussions with the INMO. It is important in the interests of the health service that we have these discussions and outcomes from them because the health service needs stability in the interests of all patients and does not need any disruption. The talks adjourned last night and management will revert to the INMO later this week with details and further nursing and midwifery recruitment measures to be undertaken in 2017. The challenge this year and the objective is to recruit 1,000 additional permanent nursing posts. These posts are provided for in the HSE's service plan and HSE management is committed to engaging constructively with the INMO to address its concerns and agree a range of initiatives that will support future recruitment.

I am firmly committed to making the decisive shift of the heath service to primary care a reality in order to deliver better care close to home in communities across the country. The programme for Government emphasises the need and focus on enhancing primary health care services, including the building of GP capacity, increasing the number of therapists and other health professionals in primary care services and continuing to expand the development of primary care infrastructure.

The Government is also committed to ensuring patients throughout the country will continue to have access to GP services, especially in remote rural areas and also in disadvantaged urban areas, and that general practice will be sustainable in such areas. There have been significant developments in general practice services recently, with more services being made available to citizens and additional support provided by the HSE. I have emphasised repeatedly the need for a new GP services contract which will help modernise the health service and develop a strengthened primary care sector. Health service management has already progressed a number of significant measures through engagement with GP representatives, including the following: free GP care for all children under six years and those aged over 70; a specific diabetes cycle of care for adult patients with type 2 diabetes; a new rural practice support framework; and a revised list of special items of service that can be provided by GPs. The effect of these measures has been an increase in State funding to general practice of approximately €100 million as well as, importantly, improving services and accessibility for patients.

Preparations for the next phase of discussions on a new GP contract are under way. I am keen to ensure future contractual terms for GPs will enjoy the support of the broad community of GPs. In that regard, officials from the Department of Health and the HSE will engage with the relevant GP representative bodies on a wide range of matters which will need to be encompassed by the contract development process. The aim is to develop a new modern GP service contract which will incorporate a range of standard and enhanced services to be delivered. If we can get this right, we can unlock new potential in primary care services. GPs want to do more, they tell me they can do more, we know they can do more and they are qualified to do more, but they need to be resourced and supported to do more. We cannot expect them to do more or patients to benefit from more when people operate on a 44 year old contract. The new GP contract is a major priority for me in 2017 and a major priority for the Department of Health and the HSE.

Many Senators will be interested in the Government's commitment to providing medical cards for children in receipt of domiciliary care allowance. The Department recently received permission to draft a new Bill to deliver on the commitment that all children, in respect of whom a domiciliary care allowance payment is made, will automatically qualify for a medical card and will, therefore, no longer be subject to the medical card means test at any point in the future while in receipt of domiciliary care allowance. The legislation is being prepared and will be brought before the Oireachtas as quickly as possible. With the help and assistance of Senators, I would like to have it passed and issue the medical cards as early as possible this year. In addition to the preparation of the legislation, I have asked the HSE to commence the process of planning for the requirements of the scheme, how the cards will issue and how people can apply for them in order the proposal can be implemented in a smooth and efficient manner. This will benefit approximately 10,000 children with certain disabilities and special needs who do not receive a medical card. It will also benefit 30,000 children in receipt of domiciliary care allowance who have a medical card but are subject to reviews. The reviews will no longer be necessary.

I have been asked for an update on the relocation of the National Maternity Hospital to St. Vincent's University Hospital campus and I am pleased to provide one because it is such an exciting flagship project for maternity services. In fact, the area of maternity care is one in which we are making significant progress. Following from what I have described as a landmark year for maternity services in 2016, the agreement reached on a governance structure for the new National Maternity Hospital at St. Vincent's University Hospital has enabled the project which was stalled to recommence. The existing National Maternity Hospital has been located at Holles Street since 1894 and much of the existing building dates from that era. Its redevelopment has been a Government priority for some time; in fact, it has been a priority for many Governments and I am very pleased we will get on with it and it will proceed. A planning application will be launched early this year. I have seen the exciting designs for the new hospital which will cater for up to 10,000 births per annum. The design team has produced a very high-quality design which integrates the new maternity hospital into the existing St. Vincent's University Hospital building. I have no doubt that such a state-of-the-art development will raise the international profile of the entire St. Vincent's University Hospital campus. In that regard, the potential for cross-campus research and development is immense. Work to finalise the strategic infrastructure development application is under way and I expect the application to be made to An Bord Pleanála early this year. The new maternity hospital will give physical expression to the new model of care proposed by the national maternity strategy and will ensure women will receive care in an environment where their need for dignity and privacy is respected. The level of care provided in the hospital is superb and it has a long and proud tradition, but the building is simply not fit for purpose. It does not provide women with the dignity and privacy they deserve and should expect and it certainly is not acceptable for staff to have to work in the building either. We need to get on with this project as quickly as possible.

We are very committed to progressing the development of maternity services in general and 2016 saw the publication of Ireland's first ever national maternity strategy. In some sense, it is unbelievable we did not have one before 2016. The HSE's national standards for bereavement care following pregnancy loss and perinatal death were also published in recent months, as were HIQA's national standards for safer better maternity services. These three publications represent key building blocks to provide a consistently safe and high quality maternity service. In addition, the new national women's and infants' health programme will lead the management, organisation and delivery of maternity, gynaecology and neonatal services, strengthening such services by bringing together work currently undertaken across primary, community and acute care services.

I should also mention that additional funding provided last year and continued this year has enabled us to build capacity in the maternity workforce, including the approval of an additional 100 midwives, including for the development of specialist bereavement teams.

It also provided for the implementation of the maternal and newborn clinical management system, the new electronic health record system which I saw in action when I visited Cork University Maternity Hospital. Yesterday, in just 24 hours, the eHealth team visited every other maternity hospital in the country in an initiative to quickly establish the next steps in rolling out the electronic health record system across the maternity network.

In a related development, I want to see construction start in 2017 on the National Children’s Hospital. The Government decision that the new children’s hospital should be co-located with St. James's Hospital on its campus in Dublin 8 was made in the best interests of children, with clinical considerations paramount in the decision. Co-location with St. James's Hospital and, ultimately, tri-location with maternity services on the St. James's Hospital campus will deliver the excellence in clinical care children deserve. St. James's Hospital has the broadest range of national specialties of all acute hospitals, as well as a strong and well established research and education infrastructure, making it the acute hospital that best meets the criteria to be the adult hospital co-location partner.

While we must invest in children’s health, we must also consider the needs of older people. We know that we live in a country where people are growing older. This year we will see an additional 20,000 people over the age of 65 years and another 3,000 over the age of 85; therefore, Government policy must be about providing care in the community for older people in order that they can continue to live in their own homes. A political consensus is emerging on this issue. We have a statutory care scheme for nursing homes. We say that, as a country, we want older people to be able to live and grow old in their own homes, yet the only statutory scheme states a person must go into a nursing home. We need to underpin home care through a statutory scheme. I know that there are a number of ideas across this and the other House about how to do this and we will have a debate on it in the other House. The Minister of State with responsibility for mental health and older people has taken a significant step in launching a consultation scheme and listening to the views of older people and policy makers in order that we get this right. It is really important that we get it right and that there are no unintended consequences. Bearing in mind the fact that thousands of people benefit from home care packages, we do not want to accidentally impact on them. We need to get the public consultation process under way, have it concluded within months, allow people to have their views and get on with legislating for it. Meanwhile, a review by the Health Research Board of the way in which home care services are funded and regulated in four comparable European countries which was commissioned by the Department of Health last year is to be published shortly. I hope it will inform all of our thinking on future decisions about the structure and governance of home care services.

A Programme for a Partnership Government is committed to reducing the cost of medicines, including prescription charges, for medical card holders. In budget 2017 the Government announced that the prescription charge for medical card holders aged 70 years and over would be reduced this year. This measure will benefit over 300,000 people. Legislation is required to introduce this reduction and it is being drafted. I will continue to examine opportunities to address the cost of the charge to patients having regard to the funding available.

That brings me to the particular issue we, in common with many other countries, are facing concerning the cost of medicines. Advances in medicines have played a key role in improving the overall health of the population. However, it comes at an ever-increasing price. For example, the medicines bill in Ireland increased from €400 million in 1998 to over €2 billion in 2016. Securing access to innovative medicines for citizens at an affordable price is, therefore, a major challenge but one that is not easily solved. A number of key initiatives have been introduced in recent times, including agreements with industry, the most recent being signed in June last year, as well as the introduction of generic substitution and reference pricing. These initiatives have generated significant savings and reduced prices in Ireland to a more sustainable level. That is to be welcomed. Nonetheless, the medicines bill is forecast to rise significantly in the years ahead, driven primarily by the increase in cost and usage of recently introduced medicines and the very strong pipeline of new medicines. Therefore, the financing model for medicines needs to be both sustainable and affordable. However, the pricing model proposed by the industry must also be sustainable and affordable. It is important that we challenge the pricing structure and practices adopted by the pharmaceutical industry where they are wrong in order that patients can access innovative products. That is why I have reached out to my colleagues in other countries seeking international collaboration in this area. I attended an OECD health ministerial meeting in Paris last week. Countries around the globe are facing the same challenge, but if we do not work together as countries - certainly as EU member states - in the same way the drug companies collaborate with each other, we will be unable to meet this challenge; therefore, we must work together. We have huge buying power when we work with other countries. I was impressed with what the Benelux countries had done in coming together to buy drugs and we can learn a lot from them. Therefore, I am in talks with a number of other EU and OECD Health Ministers to see how we can share information and help each other in order that citizens in all of our countries can access drugs.

Turning back to my priorities for 2017, we will also see a new national cancer strategy. I am very excited about its publication which will happen in the coming weeks. It is a strategy for the development of cancer services for the next ten years. Much of the heavy lifting was done by my predecessors in getting the model of care right. We must now look at things like survivorship. Thankfully, people are living beyond cancer, but how do we look after them after cancer? How do we look after all of their needs such as their psychological needs, their well-being and the needs of their families and help them to get back into employment? The new national cancer strategy will endeavour to set out a roadmap in that regard.

We will also publish an implementation plan for the neurorehabilitation strategy, which is so important. It concerns how we look after people who need neurorehabilitation such as those who have suffered a stroke and those with multiple sclerosis or a range of neurological conditions. I thank all of the stakeholders and interest groups that have worked with us in that regard. We need an implementation plan and it will be published this year and provide the roadmap for the delivery of the service. It is specifically mentioned in the service plan and is a priority.

I will also take the opportunity to mention some priorities being progressed by my ministerial colleagues at the Department of Health. Empowering people with disabilities to live independent lives and have greater choice and control over the services and supports they need to make that goal a reality is a key priority. The Minister of State with responsibility for disability issues is progressing that commitment through the task force on personalised budgets. It involves actually empowering people with disabilities, not thinking that the State's responsibility stops when it writes a cheque and sends it to a service provider. It involves asking people with disabilities what they want done with those resources and what they want for their lives. The Minister of State is leading on that issue.

The Minister of State with responsibility for health promotion is driving the health and well-being agenda. Work is progressing on the public health (alcohol) Bill which is really important legislation that needs to be passed and enacted and on implementing A Healthy Weight for Ireland: Obesity Policy and Action Plan 2016-2025. We are on course to be the most obese nation in the European Union if we do not get on with delivering on this plan.

The Minister of State with responsibility for communities and the national drugs strategy is actively progressing a new national drugs strategy which will set out Government policy from 2017 onwards in the areas of drug awareness and prevention, treatment of substance misuse and addiction, promoting rehabilitation, reducing the supply of illicit drugs and piloting supervised injecting facilities. I expect progress on the legislation related to injecting facilities in the coming weeks.

The Minister of State with responsibility for mental health and older people chairs the national task force on youth mental health. This group is considering how best to introduce and teach resilience, coping mechanisms and greater awareness to children and young people and how to access support services voluntarily at a young age.

I thank the Seanad for inviting me again and look forward to hearing Members' thoughts and views on the direction the health service should take. I have tried to touch on a number of issues, health being a broad topic. I will be delighted to interact on any other issue.

I thank the Minister for coming to the House to facilitate this debate. We all know the pressures the health service is under. The Minister is aware of my belief the problems we see in secondary care services will never be rectified until primary care services are adequately resourced. To that end, we need to reinvest our efforts in training more young GPs, practice nurses and community health nurses. I know that we spoke about the funding of the Institute of Community Health Nursing this morning during a Commencement debate, for which I thank the Minister.

I believe in a solution driven and pragmatic approach. To that end, I urge the Minister to sanction some extra funding for general practice out-of-hours services in order that multiple GPs can work during particularly busy periods from mid-December to mid-January to help to reduce referrals to emergency departments. It is a simple, practical and solution-driven idea that would alleviate some of the pressures on the secondary care system.

I also ask the Minister to review the district hospital network, particularly district hospitals in rural areas like my own. Senator Rose Conway-Walsh is also very familiar with the hospital in Belmullet. These hospitals are a good distance from acute hospitals. For example, the hospital in Belmullet is over 50 miles from one. The community hospital network should not be seen as a relic of a bygone era. Community hospitals have a pivotal role to play in a modern health service as they can fulfil multiple roles. For example, they can prevent admissions to acute hospitals because GPs can admit directly to them. They also facilitate discharges from acute hospitals. If somebody has a hip replacement, he or she can be transferred to a community hospital and receive rehabilitation with the help of a community physiotherapist in the community, thus freeing up an acute hospital bed. More importantly, district hospitals can play a role that has been under-utilised. They can work as an interface between the fair deal scheme and the acute hospital sector. If somebody is an acute hospital patient and applies to participate in the fair deal scheme, he or she often waits a number of weeks in an acute hospital bed, possibly up to 12 weeks. There is no reason a patient cannot be transferred to a community hospital in the intervening period before being transferred to a nursing home.

That is another role at which we should look.

We also need, as the Minister said, to encourage community based investigations in general practice. My surgery has an ultrasound scanner, a DEXA scanner for osteoporosis, spirometry for breathing testing and audiometry for hearing, to mention a few, but they are being under-utilised as there is no funding model available for medical card patients. This means that patients are disenfranchised as they have to travel to acute hospitals to have these investigations carried out, when they could be carried out in the community.

I take the opportunity to touch on two further topics. One is alpha-1 antitrypsin deficiency and the other is narcolepsy. The Minister will be aware that 350 people throughout the country have been diagnosed with alpha-1 antitrypsin deficiency. It is the most common genetic lung disorder in Ireland and can lead to severe lung, liver and skin problems. The majority of people with alpha-1 antitrypsin deficiency present with emphysema or chronic obstructive pulmonary disease, COPD. A new groundbreaking drug called Respreeza was shown to slow the progress of emphysema in a recent clinical trial. It was called the rapid study clinical trial and 21 Irish alpha-1 patients took part. Since the trial ended these patients have been receiving the treatment from CSL Behring on a compassionate use basis. On 26 July last year patients were informed by the company that it would stop providing this treatment on 30 September. On 23 September this date was extended until the 31 December 2016. Two further extensions were given, one until the end of January and the other until 28 February. The people concerned are living in limbo, waiting month to month to find out whether they will receive the treatment which is changing the quality of their lives for the better. Unfortunately, on 9 December, the National Council for Pharmacoeconomics, the NCPE, published a decision to recommend against funding Respreeza. Alpha-1 patients are naturally devastated by this decision. They desperately need this issue to be resolved to prevent further distress and anxiety. I would be grateful if the Minister considered this issue.

The Minister will be familiar with the organisation SOUND, the support group for sufferers of unique narcolepsy disorder. It is seeking support to fund a national narcolepsy and related disorders service at St. James's Hospital. It is envisaged that the unit will complement the existing paediatric service for younger people with narcolepsy. It is something which is urgently needed. Its cost, €1.6 million, is a drop in the ocean in the grand scheme of things within the HSE. The reason this is particularly time sensitive is that the 80 young people who suffer from narcolepsy as a result of the pandemrix vaccine will soon be adults and will no longer be provided treatment under paediatric services. There are approximately 1,600 patients with narcolepsy in Ireland. SOUND represents the people who developed the disorder as a result of the swine flu pandemrix vaccine. There are 80 plus members and the funding amount of €1.6 million will provide staff, including a neurologist, a neurophysicist, a respiratory consultant, clinical nurse manager, dietitian, laboratory nurse and four laboratory technicians. The recognition of the association between the pandemrix vaccine and narcolepsy disorder has exposed the lack of proper treatment pathways for patients. A 2012 Government report recognised the link between the vaccine and the disorder and it was withdrawn from clinics. Sufferers have to live with a range of debilitating symptoms, including hallucinations, cataplexy, increased risk of accidents and obesity, to name just a few. It is an incurable, life-long illness which impacts on all areas of their daily lives. This is a unique problem. As a result of a public health programme, there are over 80 young people who will never know what a normal life is. There needs to be a commitment from the Government to ring-fence funding in order that life-long supports will be put in place for sufferers. There must be a seamless transition from paediatric treatment to the treatment of adult sufferers and a commitment for a multidisciplinary centre of excellence.

The health committee meeting is starting at 1.30 p.m. and as we are under pressure to attend that meeting, it is unfortunate that it is clashing with this debate. However, I appreciate the Minister coming into the House to attend the debate.

It is interesting to look at the figures for accident and emergency medicine. As I understand it, last year approximately 1.3 million people attended emergency departments. My understanding is that figure is up around 6.5% or 7% across the country, which means that in real terms there are some 1.35 million to 1.4 million attendances, or approximately 26,900 per week. That is a huge number of people attending emergency departments. If there is a sudden increase of 20% in any one week, that is an increase of over 3,500 or 4,000 people into the system. It works out at around 3,800 per day. That is the challenge the staff who are working in the hospital system face. About 25% of that number are being admitted to hospital.

Demographic changes are an important factor and present us with a major challenge. I visited a hospital before Christmas. In 2015 it cancelled 40% of its elective surgery cases because of emergency department admissions. Its biggest challenge was a 12% increase in the number of people over 80 years of age who were admitted to emergency departments. That is a huge problem because it is very difficult to say a person in that age group can be referred home easily or sent back to a nursing home. As there is a higher level of risk, there must be a higher level of service provided for that age group. That is a major problem we are going to have to address in the next few years.

Having studied the set-up of the health service in the past few months, I understand we are on a figure of about 2.8 beds per thousand. The OECD equivalent is 4.3 beds. I understand Germany has 8.3 beds per thousand. The Minister is right to say there has been no major hospital centre built since 1998. Nothing was built between 1998 and 2008 at a time when we were flush with money. Even starting the process of building new hospitals takes time. We have been talking about the new children's hospital for almost 25 years. We now need to start planning for new building programmes. The Irish Association of Emergency Medicine, IAEM, produced a report in 2012. We need to look at it now and take on board what it states as we have parked this issue for far too long. It sets out clearly what needs to be done regarding trauma networks, emergency networks, emergency care networks, clinical decision units, staffing levels and advanced nurse practice. Very little of the report has been implemented. It is something at which we need to urgently look, including discussing with the IAEM how we can best deal with it.

We seem to have a big problem - my colleague Senator Colette Kelleher is also involved in this issue in the case of gynaecological services in Cork - where there appears to be one set of plans by the administration and another by the medical workforce. As a result, patients are suffering because there is no co-operation and co-ordination between the two, which is unfortunate. Some 4,000 people are now waiting for gynaecological services in Cork. I agree with the Minister and I am surprised that this has been allowed to happen. It appears that we have a problem with the administration not reacting fast enough to such situations. Even in 2009 there was a substantial waiting list of over 2,900 people. That figure has grown since because it was not dealt with. We have a problem in building a new maternity unit and providing two theatres for gynaecological services. Only one has been opened in the past ten years and it is only open for 3.5 days per week, which does not make sense. Many hospitals are looking for theatres. This is a hospital that has theatres but the staff cannot be provided.

There have been a number of proposals to deal with these issues, to one of which, the National Treatment Purchase Fund, the Minister referred. I am not satisfied that is the solution in Cork. One of the solutions put forward in the case of gynaecological services was buying space in another facility.

The available doctors would then be allowed to perform the procedures in another facility in order that care would be continuous and patients would not be passed from A to B and back to A again, which does not allow for the same continuity. This issue needs to be examined. My understanding is space is available in other units to deal with these patients. We should not have to debate this matter today. It should have been highlighted and dealt with long before 4,000 people were on waiting lists.

It has been identified that a six-bed day care unit for gynaecological services in Cork should be prioritised, as it would allow for fast-tracking. Approximately 42% of all patients waiting for gynaecological services are doing so at Cork University Hospital. This matter needs to be addressed. The Minister referred to hospitals and the need for increases, but he should remember that, between 1986 and 2016, Ireland's population increased by 1.2 million. The population of Cork alone increased from 410,000 to 542,000, or more than 30%, but we did not receive one new hospital bed in those 30 years. That is why we need to prioritise a second major facility for Cork. We have good hospitals in the Mercy University Hospital and South Infirmary Victoria University Hospital, but they are no longer capable of dealing with their workloads. The 1960 Fitzgerald report set out clearly what needed to be done in Cork, including the provision of two major hospitals. We built one, but we do not even have a site for the second. This issue needs to be given priority and accelerated as soon as possible.

I thank the Minister for the work he and his Department are doing, but we must prioritise a number of issues in the next 12 months.

In case I do not go over time and have some left-----

I will be watching the Senator. She should not worry.

-----could Senator Rose Conway-Walsh take the remainder?

Do the Senators wish to share?

No, because I am not sure how much time I have. We will see, given the rush on time.

The Senators are playing it by ear.

I thank the Minister of State for attending. Is the Minister stepping out?

Not yet. I will stay for the Senator.

It is time that we accepted that the health service is on dodgy life support in intensive care. Yesterday 520 citizens were lying on trolleys throughout the State. This figure is growing towards the dangerously high levels seen over the Christmas period. The INMO's trolley figures date back almost a decade. They were unwanted at the time and it took a fight to get them accepted, but they eventually were. Traditionally, as the last week of January and the first week of February see the peak, I do not know whether we are out of the woods. I hope we are.

It is not just the trolley crisis that has the health service on life support. Surgeries are being cancelled and wards are closed because of chronic understaffing. Current staff are stretched to the point of despair. The persistent problem with patients on trolleys is a direct consequence of decades of failed Fine Gael and Fianna Fáil policy. Coincidentally, they are now in government together. Deputy Micheál Martin's pledges are in the past; former Taoiseach Brian Cowen called it "Angola", Senator Reilly said never again would we see 559 patients on trolleys and the next prospective leader of the Senator's party was removed from his position. In some cases, the treatment of patients in hospitals is an attack on human rights. I do not say that lightly. That 612 patients are on trolleys cannot be attributed to the flu alone. The Minister was given plenty of warning in advance. The sick are facing these delays. The national service plan identified these risks. As to the extra €40 million for the winter initiative that was announced at the end of September or in October, front-line staff were sceptical that it would reach its target, to put it politely. Unfortunately, responsibility lies with the Government.

I was glad to hear in the Minister's response to the crisis during a radio interview his forced acknowledgement of a capacity issue, which had been denied for long. I was also glad to hear the CEO of the HSE outlining last week that at least €9 billion extra would be needed in the next decade to fix the health service.

The Minister rightly referred to how the last new hospital had been built in 1998. Primary care centres are being built, which is welcome, but if hundreds of patients are lying on trolleys annually, it is not rocket science to figure out that more beds are needed quickly. This will require significant capital investment from the proper collection of taxes. Proposing to abolish USC while still treating our families, friends and neighbours in hospitals is fairytale economics. Allowing corporations, vulture funds and the like to use every loophole possible to avoid paying tax is a national scandal, given what is happening in hospitals. People have died on trolleys. Irish people are fair and understand the need for taxes and the retention of USC. They want the provision of services, not piecemeal tokens in their payslips that strip front-line services even further.

The arrogant attitude of some among the HSE's management is unbelievable. Recently, they alluded to people keeping elderly family members in hospital beds in order to prevent them from entering the fair deal scheme, thereby protecting their inheritances. It was a sad departure for the HSE. I believe the claim came from the same department that issued the memo, also rescinded, stating nurses could use minimal force to remove patients from beds. I do not know what that department is doing, but its statements have been incredible. To have this attitude towards frail and vulnerable people who have contributed for all of their lives to the country is an uncompassionate - that is not even the right word - trend that has developed in our hierarchical, non-practising management hospital structures. I have always advocated that compassion be returned to the health system.

I noted the HSE's recruitment initiative for nurses who were returning over the Christmas period. I will refer to the vox pop conducted by the media with some of them. I mentored, trained and, at the airport, waved goodbye to a number of them. The majority maintained that they received better pay, conditions, training, respect and lifestyles abroad. They felt let down by the State, having been forced, as Mr. Tony O'Brien said, to leave. I do not blame them. I received a message from a young nurse at the weekend. She had returned from Australia, which was great to see. She told me that our system was doing her head in. She was trying to figure out pay scales and hours. As an ex-union person, she asked whether I could figure it all out for her. To her, it was no wonder that no one was returning. We must examine how to make the transition into our system as smooth as possible. Will the Minister update the House on the many nurses he mentioned had been recruited under this initiative over Christmas? I am concerned that talks between unions and management on the crisis in recruiting and retaining nurses adjourned last night. Are we looking at more industrial action? No one wants it, but it is often necessary to get things done. There is no time to waste. The union council meets next Monday and is likely to sanction strike action.

In early December hundreds of seriously ill cystic fibrosis sufferers demonstrated outside the Leinster House gates about the availability of Orkambi. There has been a similar battle about the availability of Kalydeco for younger children suffering from the same illness. I understand Vertex has made a revised reimbursement offer. Will the Minister update the House in that respect? He has updated us generally on the corporate greed of many drug companies. Will he also update us on the position on medicinal cannabis? I am thinking of a particular case, of which he would also be aware. I chatted to the parents of a seven year old a couple of weeks ago.

I cannot conclude without referring to mental health. I stress the immediate need for the introduction of a 24/7 crisis intervention service to try to reduce the number of citizens who die by suicide. We all advocate for the implementation of A Vision for Change, but that will not happen anytime soon. I have held regional health conferences in the past month. The main issue raised time and again was that of access to 24/7 services. My party laid a Private Members' Bill before the Oireachtas, but it was amended, diluted or voted down by the Government or Fianna Fáil. If we can do only one thing in this era of new politics, I plead for us to work together on a cross-party initiative to deliver in that regard. Starting at 7 a.m. today, I have had three conversations with two sets of parents and one young woman with a child about how to access services.

One of the parents had a 13 year old who had sent a text message showing a rope. This 13 year old was ready to commit suicide and had nowhere to go. Public representatives and councillors across the country deal with this issue on a daily basis, in the expectation of a bed or professional help being provided, but we are lost. I look forward to receiving the work of the Committee on the Future of Healthcare which will I hope deliver a long-term vision. In the meantime, the Minister can look forward to my support and criticism and that of the Sinn Féin team.

Senators Frances Black and Colette Kelleher are sharing time.

I want to talk about the correlation between physical and mental health difficulties. If the issue of mental health was addressed, it could reduce the pressure on hospital beds. It is imperative that mental health be recognised and afforded appropriate priority within the wider health agenda to reflect its contribution to the burden of disease in Ireland and its impact on other areas of life. The Healthy Ireland survey reports that almost 10% of the population aged over 15 years have a probable mental health problem at any one time. This equates to a figure of approximately 325,000, based on the census 2011 population data. Almost 20% of young people aged between 19 and 24 years and 15% of children aged between 11 and 13 have had a mental health disorder. According to the Suicide in Ireland survey, suicide is the leading cause of death among young males, exceeding road traffic accidents and cancer. There is a strong correlation between physical and mental health difficulties. A recently published report by the substance abuse and mental health services administration in the United States found that adults aged 18 years or over with any mental disorder or major depressive episode in the past year were more likely than adults without these conditions to have high blood pressure, asthma, diabetes, heart disease and stroke. In terms of health service utilisation, adults with any mental disorder used both emergency departments and hospitals more than those without a mental disorder, leading to higher health care costs.

The Healthy Ireland framework states it is important to acknowledge the interplay between mental health problems and chronic disease. Depression is a very important public health problem and often comorbid with chronic conditions. Mental health problems such as depression, when existing with any chronic condition, incrementally worsen health compared with having depression or chronic conditions alone. This reinforces the need to improve mental health well-being as a public health priority to reduce the disease burden and disability and improve the overall health of populations by tackling risk factors and promoting protective factors for lifelong health and well-being in the early years.

Building children's and adults' resilience to adversity is a central requirement of any population health framework. Healthy Ireland continues to report that mental health problems have a huge personal impact on those who experience them and result in significant costs related to loss of productivity, premature death and disability and additional costs to the social, education and justice systems. It is estimated that the economic cost of mental health problems in Ireland is €11 billion per year. Despite the high costs of mental health difficulties to Irish society, including the wider health sector, resources for mental health services continue to be disproportionately low compared to resources for physical health services.

In 2017 there will be a 3% increase in revenue funding for mental health services. However, this is much lower than the 7.4% increase in revenue funding for the overall health budget. In 2017 mental health services funding represents just 6% of the overall health budget, which is significantly lower than in other leading countries and lower than that recommended in Irish mental health policy. A Vision for Change recommended that the proportion of the total health budget allocated to mental health services be progressively increased to 8.24%. In both Britain and Canada the proportion of funding is approximately 13%, while in New Zealand it is 11%. The current funding allocation will do little to redress the historical underfunding and decades of neglect of Ireland's mental health system, let alone put in place the foundations for a modern mental health system as required by national and international standards. In addition, the impact of failing to adequately invest in the development of mental health services will continue to have an adverse effect on other areas of society, including the wider health environment. Will the Minister make a commitment that the proportion of the health budget allocated to mental health services be increased to 8.24%, in line with the recommendations in A Vision for Change?

I also wish to highlight some issues with the lack of services and the denial of help for people with a dual diagnosis. "Dual diagnosis" is the term used for people who are experiencing a mental health problem and a substance misuse issue. The presentation of dual diagnosis is now considered to be the norm, rather than the exception. Dual diagnosis presents many challenges for health services. It is difficult to treat and has poorer outcomes such as increased risk of self-harm and suicide. In the United Kingdom 74% of users of drug services and 85% of users of alcohol services experienced mental health problems. Dual Diagnosis Ireland, a registered charity, states 76% of services fail to offer a specific service for people with dual diagnosis. People must be dry to access most addiction rehab services, but they cannot get dry because of mental health issues such as social anxiety issues and they drink to reduce this anxiety. Another problem is that addiction treatment services usually do not assess for other mental health problems.

The main problem experienced by people who have a dual diagnosis is that when they present to a rehabilitation centre, they are not treated for their underlying mental health issue and that when they present to the mental health services, the substance misuse is not addressed. I recently heard a woman in Cork talk about her sister who had a dual diagnosis but would not be accepted into a drug treatment centre as she was not clean and who was subsequently raped while living on the streets. The fact that something like this can happen in our society is an indictment of the health service. There is general agreement that integration of mental health and addiction services is sorely needed and long overdue.

I commend the Minister for his support for the Public Health Alcohol Bill and believe the passage of this legislation would not only address our unhealthy relationship with alcohol but that it would also help to reduce the 1,500 hospital beds taken up every day because of alcohol misuse. I have no doubt that this legislation will save many lives and hope the Minister's party support him on the Bill.

I commend the Minister for the range of work outlined in his statement. I listened keenly to what he said about older people and people with dementia and other disabilities. I commend him for the attention he has given to home care services on foot of the documentary on RTE by Brendan Courtney. Deputy Mary Butler and I, co-convenors of the all-party group on dementia, are going to visit Scotland this evening to meet NGOs, officials and the Scottish Minister for Health to learn more about their progressive policies on dementia care and care for older people, including home care. We have made the Minister of State at the Department of Health, Deputy Helen McEntee, aware of this and I will report back to her on it.

The matter I wish to raise will be no surprise to Members. The longest waiting lists in the country are the 4,300 women on the CUMH gynaecology outpatient waiting list and the 512 on the surgery waiting list. I thank the Minister for making time to meet the doctors involved on his recent visit to Cork. It had been hugely frustrating to them that their side of the story was not being told, which was also the case on the management side. Building on the goodwill emerging from that meeting, what concrete actions will the Minister take? What is the timeframe for these actions? I know from the reply a recent parliamentary question that he will have a follow-up meeting in six weeks. What date has been set for that meeting? The Minister has requested a report from the HSE on action plans in 2017 to deal with both inpatient and outpatient waiting lists. Will the report address the particular issues in Cork Univeristy Maternity Hospital which are outliers? What action will he take to provide a sustainable solution to build real capacity, not something which just relies on the National Treatment Purchase Fund? Will we have to wait for a "Prime Time Investigates" programme to get action on this issue, in the same way we had to wait for action to be taken on home care services?

Senator Gerald Nash has eight minutes.

I am glad-----

My apologies to the Senator. I have jumped the order.

I am happy to cede to Senator Kieran O'Donnell.

I appreciate the benevolence of my colleague.

I acknowledge the Minister's wide-ranging contribution, one of the key features of which was the fact that, despite the increase in population, no new acute hospital had been built.

I wish to make two brief points in that regard. First, the National Maternity Hospital in Dublin and the National Children's Hospital are both very welcome projects, but given that they are very large projects, there is a danger that the rest of the country may lag. That is why it is so critical that when the capital plan is reviewed, that that factor be taken into account.

More specifically, I wish to deal with my area of Limerick. The Minister referred to progress on the planned maternity hospital. It is hugely important that we relocate to the site of University Hospital Limerick. The Minister will examine that matter in the context of the capital plan. More specifically on acute services, as I am sure he is well aware, we should focus on acute services when there is not a crisis. I have heard people say the crisis is over. Now is the time to talk about it because it is cyclical and it will always come around again. We need to resolve the issue now. I accept that we need to discuss the crisis when it happens but now is the more critical time. When the reconfiguration was taking place in University Hospital Limerick in 2009, part of it involved the building of 138 co-located beds on the hospital site. The emergency units in Ennis, Nenagh and St. John’s hospitals were closed, but the project never went ahead. In the HSE capital plan there is an application for 96 acute beds to be built on the University Hospital Limerick site. Following discussions with the Minister, Mr. Tony O'Brien and, more particularly, Mr. Liam Woods, the national director of acute services in the HSE, I am pleased that we have got the go-ahead for the design element of the project to get under way. That is welcome. When the mid-term capital review takes place, it is hugely important that this €25 million project be funded. We have a major capacity issue in Limerick University Hospital. We are short of beds. We closed three emergency units with the loss of 18 bays. At the time 50 beds were closed in Ennis, Nenagh and St. John’s hospitals. A new state-of-the art emergency unit is due to open this year. We hope it will be opened in May. I very much hope management will stick to the target and that the unit will open on time. However, that is only one side of the equation. The other side of the equation - the missing piece of the jigsaw - is the 96 acute bed unit to be built alongside it, over the dialysis unit, with four floors of 26 beds each. It is welcome that the design phase is under way. However, when the HSE mid-term capital review takes place, that project, worth €25 million for a 96 acute bed unit, must be funded. The Minister will have our full backing when the mid-term capital review takes place. Additional funding of capital projects must be available for the health sector. We have an increasing population. University Hospital Limerick now has the highest throughput of any emergency unit nationally, with more than 66,000 patients, yet we have half the number of beds of University Hospital Cork.

In addition to more primary care and GP contracts, we have a fundamental lack of beds at University Hospital Limerick for the mid-west region and Limerick. There is provision in the HSE's capital plan for 96 acute beds. It is very welcome that the design phase is under way, but we want to see the project go ahead. The Minister will have our full support in advocating for €25 million in funding to be provided in thie mid-term review of the HSE’s capital plan in order that the people of Limerick and the mid-west can receive the level of service to which they are entitled, an equal service to that provided in other areas in the country which is not the case owing to a lack of beds.

I call Senator Gerald Nash. I apologise for my earlier intervention.

Where was I before I was so rudely interrupted? I forgive you, a Leas-Chathaoirligh, for interrupting me. We will not fall out over it.

We note the Senator's benevolence.

I was happy to cede the floor to my colleague.

I am pleased that what we have heard to date is a measured approach to the debate on health because that has not always been possible in this or the other Chamber. I can understand why colleagues would want to take some time to focus their attention and that of the Minister on the emergency department crisis throughout the country. We all have our own experience of dealing with crises in emergency departments on a local basis and, in some cases, a national basis. I have had much experience over the years of dealing with the perennial problem in my local hospital, Our Lady of Lourdes Hospital in Drogheda. Despite the best efforts of staff, HSE officials and successive Ministers, it has always been very difficult to address the issues that both staff and patients face. It is very easy to kick the Minister of the day and accuse him or her, the HSE and hospital managers and staff of not doing enough and claiming they do not care about the state of the health service and the lack of adequate resources.

I am pleased that there is a degree of consensus in this Chamber on the issue, as the approach I outlined is not one we want to take. We will not fix the problem facing constituents and the far too many patients who are lying on hospital trolleys by taking that approach. After all, Ministers for Health are human beings too. They are compassionate, concerned individuals who do not want to have to preside over such a situation. I take the Minister's interventions on the issue at face value and accept his bona fides that he is doing his utmost in difficult circumstances to resolve an issue that has confronted the State for far too long. Very tough decisions will have to be taken on how we resource and manage the health service. I hope it is not beyond our ability in this Chamber and across the political system to do that on a consensus basis to a large degree because the challenges are too great to become overtly politicised. There is a broad degree of consensus on what needs to be done in the health service, while there are some differences on how the system can be resourced. The Minister is correct; issues such as bed capacity, retention and recruitment and how we properly resource and plan the primary care system are key to solving the problems experienced in the expensive acute service area.

The challenges that face emergency departments across the country cannot be separated from the question of how we deal, for example, with the frail elderly population. That is an area in which I have become particularly interested in recent years. I am especially concerned about how we might better confront the challenges presented to citizens, families and the health service in general by the growing number of people with dementia and Alzheimer's disease in taking a patient-centred approach to the delivery of appropriate care for them. In talking to those who work in emergency departments I am always struck by the number of possibly avoidable admissions of frail elderly people to hospital. I refer to people with dementia and Alzheimer's disease who might be better served in a different system. In fairness, thinking in the health service and the political arena has evolved considerably in how we deal with these challenges.

The development of the national dementia strategy is very welcome. It has often been the case that many of us working in our constituencies have found it difficult to access integrated services for people with dementia and Alzheimer's disease. Families become extremely frustrated at the difficulties they face in accessing the type of integrated services their older loved ones require. In the national dementia strategy reference is made to the consideration of appointing community dementia case managers. If we took such initiatives, the health service and society would be much better off. Active consideration is being given to that approach in County Louth where there are approximately 1,200 to 1,400 people with dementia. County Louth is Ireland's first age-friendly county. The HSE, local authorities, DKIT, voluntary bodies and others have come together in recent years in a very co-ordinated fashion to look at how we can better deliver services for older people and how we can meet some of the challenges that will face society and the immediate community in the near future. The appointment of a community dementia case manager is being actively considered and would be a great boon for service users and their families.

It would also allow health care professionals to take a closer look under the bonnet at what was needed for frail elderly persons, particularly those with dementia. Families would also have the benefit of having a go-to person to allow them to access the broad services people with dementia need. The ambition would be to develop it further in the next few years and, for example, resource community dementia case managers with the euros and expertise they need to commission services that could be provided for people who need them in a timely and efficacious way. There is a gap in the primary care system in how we deal with cases such as this, notwithstanding the fact that significant improvements have been made in recent years and the new emphasis on primary care services, which should be acknowledged.

I do not expect the Minister to have an answer today to these very localised challenges, but it is something to consider. It is reflected in the national dementia strategy that we should be looking at different ways of dealing with frail elderly persons with dementia to avoid repeated hospital admissions which have a considerable knock-on effect n bed capacity, staff and so on. There is a better way of dealing with people with dementia and the primary care services they require such as speech and language therapy, physiotherapy, occupational therapy and so on. The outcomes would be much better. We need to put the patient, the client, the citizen, at the centre of the delivery of all health services. A co-ordinated strategy would be better for hospitals, patients and families and allow the system to obtain improved data for how we can provide better services for frail elderly persons, particularly those with dementia and Alzheimer's disease. As all of us in this Chamber know, this challenge is becoming deeper and we need to be better prepared. The national dementia strategy allows us to do that and there has been a new emphasis in this and previous budgets on how we can better address these issues.

I do not want to repeat what has been said, but I wanted to meet and speak to the Minister for Health, Deputy Simon Harris, because he is my neighbour in County Wicklow. I have been dealing with him on a particular case, of which I am sure the Minister of State has heard, involving the respite centre, Tír na nÓg, which at this stage has been closed for more than a year. Even though we are receiving information every few weeks from the HSE - I am constantly ringing it - I still have not been told when the respite service will open and where it will be. It is unacceptable.

To go back to what previous speakers said, the position on emergency departments and patients waiting on hospital trolleys is unacceptable. I know that the Minister and the Minister of State are doing their best, but every year for at least the past nine or ten years, the Minister for Health of the time has, particularly at Christmas which seems to be the peak, apologised for the system. That is unacceptable, given that we are now in 2017. I can give the Minister of State the examples of two cases that were raised with me in the past two days where families rang me, but I could give many more. In one case, a particular elderly man was brought to hospital in Kilkenny. He was put in the special unit and was there for a day or two. They took him out and put him on a trolley in the corridor, which is unacceptable. I have been ringing and he is still there. I then had a lady who is 82 years old who was admitted yesterday into the new emergency department in Kilkenny, which I have to say is lovely, because she had fallen and broke her hip. They had to leave her in the emergency department last night because they had no bed for her in a ward. I did not allow her to be put in the corridor. I do not know if it worked, but I insisted on an 82 year old lady not being put in a corridor because it was unacceptable.

I am here, looking at us all, and wondering who is to blame. I think we are to blame and think, with the people of Ireland and Deputies, we need to look at this issue. We need to start getting out and picketing. We need to hold rallies and make sure that in 2018 we do not see the same figures we have seen this year for people waiting on trolleys. I have received some figures that show up to 400 people are on trolleys every week in hospitals. That is unacceptable. It is unacceptable because we pay our taxes. Many of the people concerned seem to be elderly. They have their pride and dignity and do not want to be on a corridor on a trolley. I ask the Minister of State to raise this issue with the Minister. It is so important that, if nothing else this year, the trolley issue be sorted out and that we start either to build or reopen wards because the problem is that we have wards that are not being opened. The reason is we do not have enough staff. We are also told that it is a health and safety issue. I am really annoyed because I find lately that I am receiving more representations from families about this issue and that I cannot help them. It is unacceptable. It is a very broken system.

I have mentioned respite care. I would also like to mention Holy Angels, a school in Carlow for children with special needs. Five years ago it was promised a new school. I will compliment the Minister because six months ago he came down and provided €150,000 to repair a leaking roof and for some other works, but that is not good enough. We have been told that Holy Angels will receive the money to build a new school this year. It is needed because Holy Angels cannot take in children because it does not have the proper facilities or space. A bigger school is needed because children on the waiting list are not being looked after.

Mental health is a massive issue all over Ireland. Statistics were given this week for areas that did not have aftercare services such as the mental health service in Carlow. There is a service and everyone in it is working so hard. I compliment them, but there is no after-hours service. Again, we were on the list because there is no service available after 5 p.m., which is unacceptable.

I welcome the packages the Minister mentioned. They are good because people are living longer and want to stay in their homes. Putting a system and a fair deal scheme in place will help because many people do not want to go into a home or hospital. They want to stay at home. We need to look at the issue in the long term. I know that the Minister of State will take this back to the Minister. I know that he is doing his best, but it is a very broken system. Unless somebody is accountable and responsible, we will be back here in 2018 and have the same system, which is not good enough.

I welcome the debate. I also welcome the Minister of State, Deputy Corcoran-Kennedy, and the Minister, Deputy Simon Harris, who has just left the Chamber. I ask the Minister of State to raise with the Minister the point that there needs to be an analysis of the health care groups which have been established and how they are actually operating, how effective they are and at what cost. We know the theory that streamlining health care services in hospitals, with academic input, will improve the system, but I just question if that is really happening.

Since the advent of the health care groups and to facilitate them, in the past year or more some 122 new general manager positions have been created in Dr. Steevens' Hospital. These are new grade VIII positions at a cost of perhaps €100 million. Some 90% of managers are based in Dr. Steevens' Hospital. As I understand it, 10% are in the rest of the country. At the same time as we see 122 new grade VIII general managers in Dr. Steevens' Hospital, while there are 120 vacant consultant posts throughout the country that we cannot fill. We all know that we cannot recruit front-line staff, including nurses, occupational therapists, physiotherapists and speech therapists. Why are we hiring more managers in what is supposed to be a streamlined and better service? What are these managers doing? Do they have budgets and what are their responsibilities? Why are they necessary? I am very impressed by many of the managers in my area. They are under a lot of pressure and making ends meet very well, but I was quite shocked to hear that these positions were being created at this time. I acknowledge the additional funding provided in the last budget, but how can the Minister of State justify these positions? I would like some answers. I appreciate that this may not be something the Minister of State can answer now, but I would like to know what is going on in Dr. Steevens' Hospital.

How are the health care groups operating on a regional basis? In my area there is the Saolta University Health Care Group which incorporates counties Galway, Roscommon and Mayo. The budgets for home care packages and primary care services up to hospital services are going towards Galway where the main university hospital is located.

The reality is that the budgets for home care packages are not coming, as they ought to, to County Mayo. There is proportionately more money going to Galway to clear out trolleys, etc., but we have a trolley problem in County Mayo too. What is happening is that the big fish are getting more food, while smaller hospitals such as those in counties Roscommon and Mayo which are under pressure and, as far as I am concerned, give very good value for money are losing out. We need more transparency. I have received representations from people who need home care packages. They need to be at home or get out of a step-down facility or nursing home, where the State has to pay for them because no bed was available in a step-down facility.

The next issue is that of primary care. In the Saolta group, west-north west region, we have seen a 16% increase in demand in primary care services, but there has been a 25% cut in the budget in the past year. As a direct result, primary care services have been severely diminished, which is a reversal of what we ought to be doing, given what we know about early intervention and it being cheaper if we get to people earlier. However, resulting from this, in the past year alone 167 whole-time positions have been lost in my area. They included occupational therapists, physiotherapists and those working in the primary care sector. I am wondering what is going on. I know that it is difficult and that there are so many aspects and layers to the health care and its budget, but these facts that I am bringing to the attention of the Minister of State do not impress me much.

I do not see any benefit arising in my county from the new health care groups for those who need health care and the ageing population. They need these services. I would like to see some accountability on the part of the HSE for the 122 new grade VIII general managers. What is going on in Dr. Steevens' Hospital? They should not be fattened up. Other areas need the resources. We cannot attract nurses. Who would want to work in an emergency department, given the stress and pressure involved? A cousin of mine is a newly qualified nurse. She has all of the opportunities in the United Kingdom available to her. She would not dare come back to what she calls battle zones. This is complex. It is not just the Minister. The HSE has service level agreements. What is going on? I would like some answers.

I thank the Minister of State for being here and the Minister, Deputy Simon Harris, for attending earlier.

I wish to address a couple of points, the first of hwich relates to the rural Ireland document, into which I presume the Minister and the Minister of State had an input. It is disappointing in its vagueness on what is being done to address the issue of health care from a rural perspective. I will refer to a couple of matters in it relating to mental health. There is no realisation in it of the situation. It states: "In line with the Connecting for Life Programme, provide support for local strategies across rural Ireland to address suicide and ... mental [health and] wellbeing". I know that many people and their families who present at emergency departments with mental health difficulties but are sent home. Young people, in particular, are presenting. They may have been protected under the child and adolescent mental health services, CAMHS, system, under which they were sometimes residential patients. However, because the CAMHS criteria are so inflexible, once they reach the age of 18 years, they are kicked out and sent back into their communities. Time and again, they present at emergency departments and are sent home without any support or service. I am extremely concerned for them and those who are not being seen through the emergency department. I ask the Minister of State to address the matter in a real and proper way.

The document is too vague on health matters. While it needs more clarity and to be teased out, it is welcome that there will be extra investment - €435 million for 90 projects - in public nursing home facilities and district and community hospitals. My fear, however, is that this provision is just to address HIQA's requirements and that we might end up with fewer beds. Perhaps the Minister of State might clarify how many extra beds the investment will mean for rural Ireland. Does it address problems such as the closing down of bed spaces? Many of them, including some in my community, were closed by the Fianna Fáil Government. For instance, in 2009 and 2010 half of the beds in Belmullet District Hospital were closed. Is it the Minister's intention to reopen these beds with some of this capital investment? That is the way forward.

I do not like to use the word, but there is almost a kind of a schizophrenic attitude towards primary care services: we will invest in primary care servoces; no, we will not; we will centralise and privatise them; and then it is back to primary care services. It reminds me a little of when the Department with responsibility for agriculture used to have us put as many sheep as possible on the hills and then have us bring them back down. The primary care model was first mooted in 2000-01 when the pilot projects were carried out. The Minister of State knows that they were never resourced - even in the boom time - in the way that had been intended. There was never the investment in personnel or technology needed to run proper primary care centres. When the Government refers in the plan to 18 new primary care centres, it means nothing to the likes of me. That pilot primary care centres are not working because the investment has not been made, which is a huge failure.

There are many cancer patients who are not receiving treatment. They are ringing the hospital and being told to stay at home because it does not have a bed for them. That these patients are not receiving appropriate treatment is extremely serious.

I could raise many other issues, but I wish to raise one, in particular. Has the Department examined the possibility of an all-island approach to health care services? I see this as the way forward. Has any report or scoping exercise been undertaken? If not, will the Department oversee a consultation and scoping exercise on an all-island approach to health services? We, including our Ministers in the North, will co-operate and work with the Minister and the Minister of State in whatever way we can to bring it about. Huge benefits could be gained through an amalgamation, if one likes, of resources under the NHS and the HSE. There are only 6.5 million people on this island. We should be able to provide a proper, robust and sustainable health service based on need, not ability to pay.

I welcome the Minister of State and thank the Minister, Deputy Simon Harris, for his attendance earlier.

We all know that there is a huge issue with patients on trolleys. It did not happen today or yesterday, although I understand January's numbers are down on those for the same month last year, which is welcome. Listening to some, one would think the Government was happy with the situation and that its aim was to have patients on trolleys. It is obviously not. No one wants to see anyone on a trolley, particularly an elderly person. I also feel strongly that those involved in this issue should be offering suggestions on how we can make this better, rather than constantly criticising on the airwaves.

It is not just a case of throwing money and beds at the problem. This becomes clearer when we talk directly to those at the coal face. A multifaceted approach is required. One issue I wish to highlight - I often speak about it - is the need to develop a sustainable and effective model of geriatric care in the community. Last year on a given day, three quarters of the patients in the emergency department in a midlands hospital were elderly. They were presenting with various needs and some of them required intravenous medication, including antibiotics and basic hydration.

If there was more joined-up thinking within the HSE in the development of an effective community geriatric service model, many of these frail elderly persons would not have to be treated in hospital and could be treated at home. The services should also be available on a 24/7 basis because patients - elderly patients in particular - do not choose when to get sick. Connolly Hospital in Dublin is showing the way in that regard. I understand the consultant geriatricians based at the hospital visit all nursing homes attached to it and hold regular team meetings with family members. They also liaise with palliative care teams and engage in decision making processes with multidisciplinary care teams. This all adds up to preventing the needless transfer of patients to hospital by treating and caring for the elderly in the community, thus relieving pressure on the emergency department and the hospital in general. In November 2013 Ms Mary Burke of Nursing Homes Ireland, in a statement to the Oireachtas Joint Committee on Health and Children, said she believed the Connolly Hospital approach should be rolled out nationwide. She said it would prevent readmissions to acute hospitals. People might argue, rightly, that Connolly Hospital has patients on trolleys, but it has definitely reduced the number of frail elderly patients on trolleys.

A number of hospitals provide different models of geriatric care, including geriatric assessment units and outreach facilities. I would like to see community geriatricians teaming up with specialist nurses based in the community, visiting local nursing homes, community units and elderly patients in their own homes and treating them without the need to transfer them to hospital. As I said, this would not only help to reduce overcrowding, more importantly, it would also preserve the dignity of older people and reduce the stress on families brought on by the ordeal of having an elderly person admitted to hospital. I have asked on several occasions for such a model to be rolled out across the country and would appreciate a response from the Minister of State in that regard.

I welcome the Minister of State, Deputy Marcella Corcoran Kennedy. I was pleased the Minister for Health, Deputy Simon Harris, was present in the House earlier. It is important to have senior departmental representatives here to discuss the health of the nation.

One of the key points made earlier in the debate was we had not built a new hospital in Ireland since 1998. In that year the population was approximately 3.7 million. Today there is a population of 4.5 million. According to demographic profiling, the population will increase by a further 1 million in the next 20 years. This means that planning health services for the next 20 years and beyond will be very challenging. Major investment in hospitals and health infrastructure, including human resources, will be required. We must think outside the box and determine where such investment is needed. We will be looking at building new hospitals in places like Limerick, Cork and Galway. That will pose a very significant challenge for the Government, whatever its make-up. We also need to put a funding strategy in place to fund this investment.

In my part of the country the last new hospital to be built was Cork University Hospital which opened in 1976, the year I was born. There has been no change in the intervening period. We must look at where we will put the new infrastructure. This involves working with the local authorities and local people to ensure any new hospital would be capable of dealing with projected population growth and built in an appropriate location. We must develop a 20-year strategy for the development of health infrastructure. One of the biggest challenges will be to find the best locations. If one looks at Cork, it has the potential to increase its population by 200,000 to 300,000 people in the next 20 years. A housing estate being developed in Carrigaline will have 1,800 houses on completion. We need to have the infrastructure following such developments and that will be a core issue in planning.

The largest waiting list for gynaecological services in the country is in Cork. I attended a meeting with the Minister and every consultant in the maternity hospital three weeks ago and the statistics with which we were provided were frightening. Action is required on this and many other issues. The Minister gave a commitment to revert to us on it and I hope he will give us a date for when he will provide the details of the review of what is happening in this area. One hospital in Cork accounts for 50% of those waiting in Ireland for gynaecological services That is mismanagement and it should never have happened. We must deliver on these major key issues.

The biggest issue is that there will be an additional 1 million people in Ireland in the next 20 years. We must have a plan in order that we can deliver core hospital infrastructure in every major urban centre in the country. That will be the real challenge for the Government and the next three or four that will follow.

I thank the Cathaoirleach for giving the Minister for Health, Deputy Simon Harris, and me the opportunity to speak about our health priorities.

I thank Senators for their sincere and passionate contributions on a broad range of issues. They included mental health, local and national service issues, bed capacity, difficulties with emergency departments, the ageing population, chronic disease and challenges in the areas of respite care and home help services. Senators have also referred to the analysis of the hospital groups and the services they are delivering, the increase in the number of grade VIII administrative positions in the HSE, difficulties in filling clinical vacancies, the all-Ireland approach to health care, home care packages and dementia care services. The debate was broad and wide-ranging. Providing responses to many of the specific questions asked will be a matter for the HSE and I will ensure Senators receive answers to their questions.

I the opportunity to assure Senators of the Government's commitment to improving the experience of patients and their families using health services. Improving the health service requires a concerted effort. It is important to highlight the fact that the delivery of health services is the responsibility of the HSE. It implements Government policy, with the budget negotiated for the executive by the Minister. As he pointed out, health issues go beyond political affiliations. We all share the same goal. I am glad that there is a willingness to build a consensus in this House. We all want to develop a health service in which people feel valued, respected and cared for. However, we cannot and should not underestimate the challenges we face.

Overcrowding in emergency departments is unacceptable for patients, health care workers and policy makers. The Minister spoke abpit the various initiatives and efforts to tackle this problem. I echo his sentiments about recognising that when we talk about trolley numbers, we are talking about people. People must be at the core of everything we do. While there are many challenges, we cannot lose sight of the progress we are making. This year we have the highest health budget ever, at €14.6 billion. This represents an unprecedented investment which will make a real difference to the services we can deliver. Of course, the delivery of health services by the HSE is not just about resources; this year's budget allocation demonstrates the Government's commitment to investing the gains from our recovering economy in improving the health service. We must maintain our focus on the way services are organised and delivered and reducing costs. We must strive to work with the HSE to maximise the ability of the health service to respond to growing needs.

In respect of my own brief, we must focus on health promotion initiatives. We need to put greater emphasis on the prevention of health problems before they arise because the majority of chronic diseases are preventable. We also need to increase the uptake of various HSE screening programmes. The HSE's website contains a wealth of information on screening programmes for cervical breast cancer and bowel cancer, among others. The HSE also provides wonderful support for those who are trying to quit smoking on www.quit.ie, an excellent website which is well worth visiting.

The Healthy Ireland framework is a Government-led initiative which aims to create a society in which everyone can enjoy physical and mental health and in which well-being is valued and supported at every level. The framework arose from concerns that the health status of people living in Ireland, including lifestyle trends and health inequalities, was leading to a future which was dangerously unhealthy and, very likely, unaffordable for us as a society. Healthy Ireland seeks to provide individuals and communities with accurate information on how to improve their health and well-being. It seeks to empower and motivate them by making the healthy choice the easy one to make.

For example, last year the national physical activity plan was launched, while the previous year we launched the national sexual health strategy. We are on course to significantly reduce the consumption of tobacco in society by 2025.

I was also delighted to launch A Healthy Weight for Ireland, the obesity action plan up to 2025. The action plan has 60 specific actions to improve the nation's health and reduce the burden of obesity across society. This policy and action plan aim to reverse obesity trends, prevent health complications and reduce the overall burden for individuals, families, the health system, wider society and the economy.

We all have a role to play in the health and well-being agenda. No one action in isolation will reduce the increasing burden of chronic disease we face in the health service, but if we reduce the consumption of alcohol and tobacco, as well as fat, sugar and salt in the food we eat, increase our physical activity and have ourselves screened, we will improve the overall health and well-being of everybody in society. Often the small and sometimes the not so small changes in lifestyle and behaviour will make a big difference. It can be challenging, but that is the difference we should aim to make.

Sitting suspended at 2.35 p.m and resumed at 3 p.m.