Dáil Éireann díospóireacht -
Tuesday, 25 Oct 2011

Vol. 744 No. 4

Health Services Delivery: Motion

Deputy Joe Higgins

I move:

"That Dáil Éireann:

noting that:

the ‘FairCare' health reform plan of the Minister for Health, James Reilly T.D., is in chaos as a result of health cuts and that as a result there is a spiralling crisis in health service delivery and accident and emergency (A&E) services across the country;

this crisis in our public health system is particularly manifest in the following areas:

Limerick: The closures in 2009 of 24 hour A&E departments in Nenagh, Ennis and St. John's hospitals have resulted in acute overcrowding in Limerick Regional Hospital and promises that additional resources would be made available have not materialised;

Loughlinstown: The plan to downgrade A&E in St. Colmcille's will inevitably put pressure on St. Vincent's Hospital which is already overcrowded and has had to go ‘off call' on a number of occasions over the last weeks;

Blanchardstown: The funding cut from €104 million in 2009 to €84 million in 2011 while there is an almost 10% increase in both the local population and the amount of patients treated during this period will inevitably affect patient safety. Twelve beds in Laurel Ward and 16 in the inpatient surgical day ward are set to close. A costing for running the A&E on a 12 hour basis has been performed. This is causing grave concern among residents in the hospital catchment area of 330,000;

Cork: Planned cutbacks to emergency services in Cork, which include closing Victoria South Infirmary A&E in April, Bantry minor injury assessment unit and unspecified dates for downgrading Mallow and Youghal, will put unacceptable pressure on Cork University Hospital and Mercy Hospital. The downgrading of Skibbereen Ambulance Service to an 8 a.m. to 8 p.m. service leaves west Cork with a wholly inadequate ambulance service: it is already a regular occurrence on weekend nights for no ambulances to be available. West Cork will be dependent on the ambulance in Clonakilty (which serves Rosscarbery to Kinsale) which can take 30 minutes on blue lights to reach Skibbereen and 90 minutes to Castletownbere;

Roscommon: The downgrading of A&E services in Roscommon represents an unacceptable cut in the level of health services for the people of Roscommon/Leitrim, putting additional pressure on Galway University Hospital where, on 20th October, 37 people were on trolleys;

South Tipperary: The recent announcement of the closure of the acute psychiatric unit in South Tipperary Hospital;

Letterkenny: The recruitment embargo means that staff have to be pulled in from other essential services to ensure that the hospital can function as an essential healthcare facility, adversely affecting community and other services; and

Tallaght: Tallaght Hospital has been historically underfunded. It is the busiest hospital in the State but ranks lowest of the top five hospitals in Dublin for funding. Its catchment area has been expanded from 350,000 to 500,000. The Health Service Executive has identified the need for step down beds and improved primary care as major contributors to increasing pressure on the acute hospitals; recently, however it announced the closing of the Crooksling nursing home in Brittas. Tallaght and Clondalkin have twice the average number of people per general practitioner in Ireland and three times the average in France and Germany;

the loss of almost 5,000 beds since 1980 and the more recent closure of more than 1,700 beds due to budget cuts and the recruitment embargo means there is a crisis of capacity in our public hospitals that is the immediate cause of the problems in A&Es. There are fewer than 3 acute hospital beds per 1,000 population in Ireland compared to an EU average of 4 beds per 1,000; and

since 2008 there are 6,000 fewer health-workers in the health service because of the recruitment embargo. These are overwhelmingly frontline staff including 1,000 nurses. The Chief Executive Officer of the Health Service Executive, Mr. Cathal Magee, admits there will be 7,000 more staff lost by 2014, a total loss of 13,000 or 11.7% (2008:111,000; 2011:105,000; 2014:98,000); and

resolves to:

lift the embargo on recruitment to the health service and to reverse the policy of closing hospital beds — reopening, as a matter of urgency, the 1,700 recently cut beds;

abandon the policy of closing or downgrading local and regional hospitals;

safeguard the 24 hour A&E of Blanchardstown Hospital and reverse the bed closures in the Laurel and day surgical wards;

reverse the downgrading of 24 hour A&E in Nenagh and Ennis to relieve pressure on Limerick Regional Hospital;

reverse the plan to downgrade the A&E in St. Colmcille's in Loughlinstown preventing further pressure on St. Vincent's Hospital;

reverse the downgrading of 24 hour A&E in Roscommon relieving pressure on Galway University Hospital;

reverse the announcement of the closure of the acute psychiatric unit of South Tipperary General Hospital;

abandon planned cutbacks or downgrading in emergency services in the Cork area specifically, at Victoria South Infirmary, Bantry, Mallow, Youghal or the downgrading of the Skibbereen ambulance service;

lift the embargo at Letterkenny Hospital to ensure that the hospital can function as an essential healthcare facility; and

impose no further cuts in the health budget 2012."

I am sharing time with Deputies Richard Boyd Barrett, Seamus Healy and Catherine Murphy.

This motion is in the name of the United Left Alliance Deputies and supported by other Deputies. Our motion lists in a comprehensive way the huge range of attacks on our hospital services particularly and on the health service generally throughout the country. Unfortunately, these attacks are intensifying which bears witness to the fact that instead of the change the Labour Party-Fine Gael coalition Government promised it has continued on where Fianna Fáil and the Green Party left off in terms of the savaging of our public services, in this case health, while at the same time continuing the disastrous policy of austerity begun by its predecessors.

It is incredible that our motion outlines crucial and devastating cuts to areas of our health service, and hospitals particularly, throughout the country and at the same time in two weeks' time €700 million will be paid to unsecured Anglo Irish Bank bondholders and, if this Government continues to have its way, €3.5 billion by the end of June. That is a devastating condemnation of this coalition of Fine Gael and the Labour Party.

I will concentrate particularly on the effects on Connolly Hospital in Blanchardstown. Connolly Hospital has undergone debilitating cuts in recent years including a cut of €20 million in its budget, from €104 million to €84 million in the past two to three years alone, with consequences for reduction in beds and other difficulties. That comes down to more suffering for people on waiting lists and huge pressure on the frontline staff at Connolly Hospital who, by common consent and the testament of the people who use the service, are model workers in the health field.

In terms of these new cuts to Connolly hospital, incredibly, this week provision is made and is being implemented for the removal of 26 surgical beds from Connolly hospital. The surgical day ward is closing for two weeks and when it reopens only eight beds will continue to operate with another 12 beds being removed from the Laurel ward, making a total of 28.

These new cuts are being implemented without a murmur of opposition from two Ministers who represent the catchment area of Connolly Hospital, namely, the Minister for Transport, Tourism and Sport, Deputy Varadkar, and the Minister for Social Protection, Deputy Burton. These two Ministers exhibit the most acute cynicism and hypocrisy in their attitude towards Blanchardstown hospital. On 5 October last year, the Minister, Deputy Varadkar, who was then Deputy Varadkar, was withering in his criticism of the most recently announced cuts at that stage which included the closure of 24 beds in Connolly hospital and a total of 118 across the northside hospitals in Dublin. The then Deputy Varadkar stated:

With 118 beds closed, hospitals on the northside will be a war-zone this winter. I have worked in the Emergency Departments in both Beaumont and Connolly Hospital and also on the wards during winter time. I know how busy it gets during the winter as the number of cases of pneumonia, COPD, heart failure and chest infections soar. With over 100 beds closed, we are facing into an A&E trolley crisis the like of which we have never seen.

That was the Minister, Deputy Varadkar, speaking as a simple Deputy 12 months ago but two weeks ago at a public meeting in regard to the new cuts at Connolly Hospital, Blanchardstown, he baldly declared: "These new cuts will remain and there must be more cuts". What changed in the past 12 months? The only thing that changed is that the Minister assumed high office in Government and then cynically betrayed the people whom he claimed to stand for previously.

The Labour Party Minister, Deputy Burton, is equally cynical and hypocritical in her attitude to the new cuts in Connolly Hospital. Last year, the then Deputy Burton declared: "With proper investment, James Connolly Memorial Hospital will develop into a world class medical facility". She outlined among her five key priorities for Dublin West making Connolly Hospital a world class medical facility. Now the Minister, Deputy Burton, is silent on the effects of the €20 million cuts in the Connolly Hospital budget and the new cuts just announced. How can she make a world class medical facility and how can she stand for investment in that against the background of the massive cuts to the budget and these new cuts taking out dozens of surgical beds? Like the Minister, Deputy Varadkar, the Minister, Deputy Burton, has displayed the most acute cynicism and hypocrisy.

The people of the catchment area, however, are acutely concerned about these most recent cuts. The closure for a few weeks of the surgical day ward and the huge reduction in beds in the surgical day ward will mean dozens fewer procedures on a daily basis for those now on waiting lists to have their conditions ameliorated. We can be sure that for them it will mean cancellation and rescheduling well into next year, with all the stress and suffering that goes with that, yet two Ministers who represent the area and claim to be champions for Connolly Hospital, its patients and staff are not just silent but are condoning this new round of cuts.

The people of part of the catchment area in the constituency of Dublin West will have an opportunity in two days to make a judgment, through the ballot box, on this monumental cynicism and hypocrisy. I am sure they have already drawn the conclusion that sending another Fine Gael or Labour Party backbencher to this House following their vote next Thursday will simply intensify these draconian cuts and the Government's determination to continue them, whereas sending a representative of the campaigns that have genuinely fought and continue to fight for the hospital, particularly my colleague, Councillor Ruth Coppinger, would be a massive warning to this Government that these cuts will not be tolerated.

We want investment back in the hospital, the cuts reversed and the Government's disastrous policy of austerity changed. We need and will have, after Thursday, genuine champions for the hospital, its staff and patients, not fair weather friends for whom it is politically convenient at certain times to support them but who, on getting into positions of power, immediately forget the allegedly solemn promises they made to protect and defend our health service in this area.

Deputy Richard Boyd Barrett

As with so many issues before the election, Fine Gael and the Labour Party were full of fine words, noble sentiments and not a few specific promises when it came to the protection of our health services, accident and emergency services and hospitals in general. The Fine Gael pre-election document spoke about having the most ambitious plan for the health service since the establishment of the State. Fine Gael was going to increase access and make the system much fairer, dismantle the dysfunctional HSE, created by Deputy Micheál Martin, and end the efforts of Fianna Fáil and the former Minister and Deputy, Mary Harney, to privatise the health system by favouring private over public care. With regard to accident and emergency services, the document stated boldly that no accident and emergency services would be withdrawn unless a demonstrably better service was put in place and was seen to work. It also talked about addressing the manpower crisis within the health service and said that Fine Gael would initiate a long-term manpower strategy to tackle the chronic front-line staff shortages.

Not only have all those fine words and noble sentiments been dissolved and the promises broken, but what the party is doing is exactly the opposite. The ambitious plan for reform is now beginning to look like a very ambitious plan to massacre the public health services, slash the number of beds and front-line health services and to prepare the health system for full-scale privatisation. The evidence can be seen everywhere.

There are people from Skibbereen and Bantry in west Cork in the Visitors Gallery tonight. Throughout the country, people are out on the streets protesting against plans to cut the number of hospital beds, cut budgets and downgrade accident and emergency services that are reeling under the impact of the recruitment embargo which is slaughtering the number of front-line health workers who are able to deliver the services. In west Cork, Donegal, Roscommon, Nenagh, Ennis, Blanchardstown, Loughlinstown, Dundalk, Drogheda and any area one cares to name the services are being slashed.

The figures in that regard are quite shocking. The number of people on trolleys is worse than ever. A total of 344 people were on trolleys today. In Cork University Hospital there were 23 people on trolleys, in Beaumont Hospital it was 37, last Friday in Galway University Hospital it was also 37, in Drogheda today it was 30, in Wexford it was 22 and in St. Vincent's Hospital it was 24. In fact, in the case of St. Vincent's Hospital that figure was low compared with the figure on some days last week. On five consecutive days two weeks ago St. Vincent's Hospital had to go off call for two hours because it simply could not cope. That is the reality. A total of 2,317 beds have been closed, 1,000 nurses have gone from the health system since 2008 and 6,000 other health workers, mainly front line, have also gone. Furthermore, according to the HSE, another 7,000 health workers will be gone by 2014. That is the reality of what the Government is doing to the health service. According to the Irish Nurses and Midwives Organisation, INMO, the number of people on trolleys in the past year has increased by 33%, but the Minister still persists with the attacks, downgradings and cuts in the health service.

All of this is covered and justified with spin and, frankly, lies about reconfiguring services, health and safety issues and, the one I like best, centres of excellence. The Government is busy creating centres of excellence. The truth is, as the Minister, Deputy Varadkar, predicted when he was just a humble Deputy, the centres of excellence are war zones. They are like scenes from horror movies except that, unlike the movies, they are real. Accident and emergency departments are overrun, overwhelmed and unable to cope. The Minister is trying to tell us that downgrading or closing accident and emergency services in Roscommon will not make the situation worse in Galway, that doing so in Nenagh and Ennis will not make the situation worse in Limerick, that doing so in west Cork will not make the situation in the bigger hospitals in Cork city much worse or that closing Loughlinstown hospital will not worsen the already overwhelmed situation in St. Vincent's Hospital. It just does not add up. If one cuts budgets and the number of front-line workers, closes down beds and downgrades services, it is obvious that one will not get centres of excellence but disaster zones which simply cannot cope with the volume of cases coming to them. That is the reality of the so-called fair care policy.

What is really going on behind the spin and the pre-election noble sentiments and promises? We got some indication from the revelation that the Minister is considering bringing in outside private contractors to manage some of our hospitals. That gives the game away. When one wishes to run down a health service or public amenity, the oldest trick in the book is to starve it of resources, claim there are health and safety issues and cause a crisis in that service to terrify people into moving to private providers. This also justifies a more general privatisation onslaught on the health care system. In this manner the Minister can open health care to the same type of privateers and corporate vultures who have wrecked our financial system and who, through speculation and gambling in the financial sector, have crashed our economy. He wishes to hand over our vital health services to those types of people.

This is all linked to the EU-IMF austerity programme. We all know, and no sane person disputes it, that it was greed for profit and the unregulated privatised nature of the financial system that led to the economic catastrophe that is now gripping Europe, yet the EU-IMF demanded privatisation in Greece, Ireland and Italy in these so-called bailout packages. That is what they want. Standing behind them are the general agreement on trades in services and the round table of industrialists in Europe who see services such as health and education as previously protected areas that they can prise open and get their greedy, profit-hungry hands on vital services that people need and from which they can make money. The Government is collaborating with them in destroying our public health services in order to open the door to these corporate vultures who are being assisted by the troika, the EU-IMF-ECB, in demanding austerity cuts and privatisation of our vital services.

I hope the big protests that are beginning to take place in Bantry, have taken place in Roscommon and are planned for Loughlinstown this weekend, and which we saw in Limerick in recent weeks, will link together into a national movement that will resist this vicious, unjustified, brutal, unfair assault that is going on in our public health services and force the Government to reprioritise people and the most needy over bailing out bankers and opening things up for corporate vultures.

Deputy Seamus Healy

Any reasonable person looking at the health service will know and appreciate it is in crisis, particularly the hospital services. My colleague has just outlined the reasons for that. What we have is the implementation by the Government of the policies of the previous Government. The three key areas creating that crisis in our hospitals and health services are bed closures, of which there were 1,700 in the past 12 months — 5,000 since 1980 — and the moratorium through which we have lost 6,000 staff since 2008. Another 7,000 will be lost between now and 2014, giving a total of 13,000 staff gone from the system. The third element, as the Minister is aware and which is clearly shown in the case of Blanchardstown hospital, is a budget reduction from €104 million to €84 million. That is a huge reduction but there is an expectation that the same number, if not more, patients will be treated. The throughput is higher, staff are under enormous pressure and the consequences for patients are huge. We know the consequences because we see them every day. Today, there are 344 patients on trolleys and that is happening in every acute hospital throughout the country.

Yesterday, an individual came to my clinic who was unwell and has been waiting for a barium meal for six months. It is unfair that any person should have to wait that length of time for a procedure which is crucial for that person's health. That is not an isolated case; it is happening in every acute hospital. Despite the best efforts of staff from the top to the bottom, who work above and beyond the call of duty on a daily basis, they simply cannot cope because those three elements are putting the health services in crisis.

The Minister is the political head of the health services. His amendment to the motion refers to the delivery of safe care closer to local communities and freeing up capacity in larger hospitals. I agree 100% with that statement. All international research and professional evidence suggests and proves that is the way to go, that health services should be delivered locally. The same independent international research proves that 95% of all health treatments can be provided locally in safety, as the Minister has described in his amendment. Is it not time the Minister instructed the HSE to implement that policy throughout the health services because it is doing the exact opposite? The Health Service Executive is implementing, by any other name, the Hanley report. It is implementing centralisation and specialisation on a daily basis.

It is time the political head of the health services instructed the HSE to follow the policy he claims to espouse in his amendment which states that it supports the Government's policy of developing the role of smaller hospitals to their full potential rather than closing or downgrading them; welcomes the Minister's intention to publish a framework for smaller hospitals which will include plans to transfer appropriate services from larger hospitals to smaller facilities; and supports the process of local consultation that will help inform future decisions on the organisation of acute hospital services. That is the kind of language we have been listening to from the Health Service Executive for years. What it means is the downgrading and closure of local hospitals, more Nenaghs, Ennis', Monaghans and Cavans.

The Minister speaks about the transfer of appropriate services from larger hospitals to smaller facilities but he has to transfer some services from those hospitals to do so. That is the key. What happened in respect of Monaghan, Cavan, Nenagh and Ennis is what this paragraph means and it is totally at variance with the proper delivery of safe services locally. I would be absolutely delighted if he was supporting the process of local consultation to help inform future decisions. However, we all know, including the Minister, that is not happening, that the Health Service Executive is a bully boy and makes the decision first without any consultation. After the event, to try to pull the wool over people's eyes, it involves itself in discussion with some stakeholders not about the decision or the service, but how its decision is to be implemented so there is no local consultation. There should be a real process of local consultation with stakeholders, whether staff, members of the public, service users or patients, before decisions are made. There is no point in having consultation after a decision has been made because the HSE will only have consultation on the basis that it wants to implement the decisions made.

I know that is the case because I have seen it at first hand in south Tipperary where the Health Service Executive made the decision to close the acute inpatient psychiatric unit at South Tipperary General Hospital without any consultation whatsoever. The decision was announced overnight and the first staff knew about it was on the local radio the following morning. Now, after the event, the Health Service Executive will discuss the issue, but it will not discuss the appropriateness of the decision. It will not discuss having a proper options appraisal nor will it discuss a proper cost-benefit analysis of the decision. It will only discuss the implementation of the decision. That will not work.

The policy being pursued by the Health Service Executive is the policy of the Hanly report. It is a policy of centralisation and specialisation. It is a flawed and misguided policy that is not providing a good service to patients in this country. We have seen that at first hand. What else is the reconfiguration of hospital services in Monaghan and Cavan into the hospital in Drogheda? What else is the reconfiguration of hospital services in Ennis and Nenagh into Limerick hospital only the implementation of the Hanly report? That has been an absolute disaster in both cases.

International, independent, professional research shows that medium-sized hospitals of approximately 200 to 300 beds provide the best quality of care, good value and proper access. The suggestion that biggest is best is simply wrong. It is leading to a situation where we have a major crisis in the health service, in particular in hospital services in this country. I support the motion.

Deputy Catherine Murphy

I thank the United Left Alliance for tabling the motion. The Government terms the health care service it intends to build as fair care. It is difficult to visualise what in fact the Minister has in mind. I accept we must build a health care system that gives us the best possible care that is affordable. I do not think any of us would dispute that, but I do not get any sense that this is what is occurring.

It seems that the Department of Finance is running the health service or the mandarins with the financial purse strings in the Health Service Executive. Many of our institutions — educational, health and local government — were largely constructed in the 19th century and we further fragmented and complicated them. It does not seem that we are capable of building the kind of institutional arrangements that are needed for our public services. It is not just about institutional arrangements but the principles under which those arrangements are in place, namely, equality of care and its delivery on the basis of need, and the question of social solidarity where people make a contribution so that everyone has the ability to receive fair services.

The health service is a mixture of voluntary hospitals, public hospitals, private hospitals and co-located hospitals. It is dysfunctional. The overarching dysfunction is complicated by the Health Service Executive, the design of which was flawed from the outset. It does not function for those who work within the system and it certainly does not function for those who require services. There is no doubt that those who can afford to pay for private health care do so because they can expect better outcomes. Essentially, they purchase private health care largely because they are afraid of depending on the public system. When people get into the public system they get very good care but the problem is to get in.

The list of hospitals in the motion and the problems they face is not exhaustive but it gives a snapshot of what is going on. We need to see a map of hospital services nationally and the functions they perform, what hospitals are linked, how many beds are available and how that relates to the population. The census indicates we have a growing population. The greater Dublin area shows consistent growth. Demographics play a part in health care needs. We must see that kind of mapping of the health service.

We have been told that it will take more than one Dáil term to reform the health care system but we need to have some sort of indication of what is intended and the sequence of what is intended. Currently, there is a reduction in spending and a reduction in staff. The closure of hospitals always has a knock-on effect on the hospitals to which they are linked. For example, when one closes the hospital in Navan, one puts pressure on Blanchardstown hospital. When Blanchardstown hospital is under pressure the Mater hospital is under pressure. When the Mater hospital is under pressure, Beaumont hospital is under pressure. It is a linked system. We are told that when services in Navan are reduced, the other hospitals will pick up the slack if that is necessary, but at the same time one sees the budgets of those hospitals being reduced. It does not appear that a system is being put in place that will be able to deliver.

We talked to some nurses who were outside Leinster House some weeks ago. They begged us to go and look at what they face every day in accident and emergency services and wards. They are told to postpone appointments for people who choose elective surgery. One might not see that as being serious but having spoken to the nurses concerned, it appears serious. They are at the coalface trying to deliver a service in a difficult situation.

Beds are being closed in hospitals and people are being left on trolleys in the same hospitals. The Health Information and Quality Authority, HIQA, has indicated that the situation, for example, in Tallaght hospital was unsafe. There are knock-on problems in terms of infection control when one tries to shoehorn too many people into a small space. It cannot be described as anything other than a crisis.

The recruitment embargo is a crude instrument. Agency nurses are a much more expensive way of delivering health care but they are being used to fill gaps where there is inadequacy. The implementation of the changes is not targeted. That will be problematic when it comes to February when more people leave the system. Those who retire are often at the top end who have been in place for a long time. They are the most experienced and will be the most difficult to replace, in particular those who are on the front line. Adequate consideration has not been given to what will happen in that regard. The lack of step-down facilities is another concern.

I was interested to read something to which this country signed up in 2006. I refer to a TASC report, Eliminating Health Inequalities. It states on page 26 of the report that:

In 2006, the Irish government, together with its EU partners, agreed a statement of common values and principles that underpin EU health systems and provide the framework for an explicit statement of national health policy in this country. Following the decision to exclude healthcare from the scope of the Directive requiring competition in the provision of health services within the EU, the member states acknowledged that health systems are a central part of Europe's vision of social protection and make a major contribution to social cohesion, social justice and sustainable development.

In their statement, the European health Ministers pledged to protect the values of universality, equity, solidarity and access to good quality care. It is worth elaborating on what these values mean:

Universality — no one is denied access to medical care;

Equity — there is equal access according to need regardless of ability to pay;

Solidarity — the cost of medical care and health systems is borne fairly across society and in such a way that accessibility to all is guaranteed;

Access to good quality care — medical care is safe, of a high quality and responsive to patients' needs.

I know the world has changed dramatically since 2006. The Lisbon treaty enshrines the Charter of Fundamental Rights. We had two Lisbon treaties. After the financial crash, people came to Ireland to tell us we needed to sign up to the Lisbon treaty. What does the treaty say about health care? It says:

Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities.

We hear nothing now from the European Union about solidarity or the Charter of Human Rights. We hear only about financial matters. We must get back to the point where solidarity, equality and people mean something. We must put Europe under pressure to deliver on these matters.

There is a direct relationship between the €700 that will be transferred to Anglo Irish Bank in the next week and what is happening in the health services. It is astonishing that tens of thousands of people are not out on the street, given what is happening at present. This is a crisis and it needs to be faced up to.

Minister for Health (Deputy James Reilly)

I move amendment No. 4:

To delete all words after "Dáil Éireann" and substitute the following:

"welcomes the decision of the Minister for Health, Deputy James Reilly, to establish a special delivery unit in his Department, which has already commenced working intensively to reduce unacceptable waiting times in accident and emergency departments, and for access inpatient, day case and outpatient care;

supports the Government's policy of developing the role of smaller hospitals to their full potential rather than closing or downgrading them;

welcomes the Minister's intention to publish a framework for smaller hospitals which will include plans to transfer appropriate services from larger hospitals to smaller facilities, thereby delivering safe care closer to local communities and freeing up capacity in the larger hospitals;

supports the process of local consultation that will help inform future decisions on the organisation of acute hospital services;

notes that the number of inpatient beds is no longer the best indicator of capacity to meet patients' needs, and that the majority of patients treated in hospitals are now day cases or outpatients;

welcomes the initiatives being taken by the National Ambulance Service to improve pre-hospital emergency services, both in the Cork region and nationally;

supports the Government's policy on implementation of the mental health strategy, A Vision for Change, through the provision of a range of community based patient-centred modern quality mental health services for the Carlow/Kilkenny/South Tipperary area;

notes that it is not realistic to exempt the health sector from public expenditure, and associated public service employment, consolidation measures required to restore Ireland's economic sovereignty;

welcomes the co-operation and flexibility shown to date by health service staff which has ensured that, within the staffing and financial resources available, the health service has increased overall outputs and has continued to meet the health care needs of the population in an appropriate and sustainable manner; and

supports the need for fundamental reforms of the health service in order to mitigate the impact on services of the required fiscal consolidation measures, including the implementation of universal primary care and the introduction of universal health insurance which will remove two-tier health care and greatly improve access to services for all citizens on an equitable basis."

Regarding comments made by the Ministers, Deputies Varadkar and Burton, Deputy Joe Higgins asked what happened in the last 12 months. The IMF came to town and we lost our economic sovereignty. If that does not make sense to Deputy Higgins, perhaps he will have a look again.

Deputy Boyd Barrett is now in competition with Deputy Higgins for hyperbole. He talks about massacre and slaughter. I ask him to look at the figures for Tallaght hospital. He mentioned all the other figures. Two weeks ago four people were lying on trolleys in Tallaght hospital. At one stage last week, no one was lying on a trolley there. Today's figures are as follows. This morning 13 people were on trolleys, 11 of whom were there for less than six hours and two of whom were there for between six and 12 hours. At 2 p.m., according to INMO figures, there were five people on trolleys. It is not all doom and gloom. I admit it is not great, but it is not all doom and gloom.

My primary concern as Minister for Health is for the safety of patients. I cannot stand over unsafe services and I will not stand over a return to untenable, unsustainable and irresponsible service provision. I am working tirelessly with my Government colleagues to make sure every service we deliver is of the highest quality for the patients who need it.

Changes in acute hospital services for vulnerable patients always give rise to public concern. This concern is understandable. Nobody wants to feel that their service is being taken away and no one wants to see what they think is a downgrading of their service.

However, we are not doing any of these things. What we are doing is seeking what is best for patients, and then how best to achieve it. My interest is in how we improve the services we provide to patients and how to achieve this as quickly as possible. The Opposition would like to have people believe that this is a system in chaos. That is not the case. Change is always difficult but change is necessary and we must not step back from that imperative. There is nothing clearer. The Government is working to clear policies aimed at delivering coherent changes to provide better structured and better managed, safer care in a very difficult budgetary situation.

As Minister for Health, I want to guarantee equal access to health care for all in our country. It is my view that this can only be achieved through a single-tier system, supported by universal health insurance, which ensures access based on need, not income. There are a number of important stepping stones along the way. These include hospital reform, including the work of the special delivery unit on waiting times and "money follows the patient" funding, with hospitals established as independent trusts. Work is already under way in this area.

Primary care reform is another key step. The Minister of State, Deputy Shortall, will address that issue in a few moments. We will improve and expand the capacity in the sector on a phased basis to allow for gathering of staff and other resources. This will allow us to move from the old hospital-centred model, with its episodic, reactive and fragmented health care, and to deliver a more proactive, joined-up approach.

Once the building blocks are in place, we will be ready to proceed with the introduction of universal health insurance. This system will give patients a choice of health insurer and will guarantee that everyone has equal access to a comprehensive range of curative services, both primary and hospital care.

The reform programme is a significant undertaking and should not be underestimated. With the scope and complex nature of what is planned in mind, the Government has approved an implementation group on universal health insurance. This group will assist in developing detailed and costed implementation proposals and will also help to push the implementation of the reform programme.

The national clinical care programmes under Dr. Barry White, HSE director of clinical strategy and programmes, mark a very significant development for the health services. The clinical programmes have three main objectives: to improve the quality of care delivered to all users of public health services, to improve access to all services and to improve cost effectiveness.

The multidisciplinary, clinician-led approach of the clinical programmes is a particular strength. Clinical disciplines can work together and share innovative solutions for greater patient benefits. Great credit is due to those involved. The work in the programmes also shows that there can be an appropriate expanded role for smaller hospitals and for greatly increased community-based treatment.

One of my biggest concerns is about our emergency services. It is totally unacceptable that patients have to wait hours and sometimes days to be assessed and treated at an emergency department or to be admitted to hospital. I am also dissatisfied with waiting times for some inpatient and day procedures, and with the time some patients wait for outpatient appointments. Long waiting times and bed access cannot be resolved within emergency departments or hospitals alone. Emergency department difficulties must be addressed on a system-wide basis. No part of this health service operates in isolation.

Earlier this year, I established the special delivery unit in my Department. The unit's role will be to unblock obstacles that stop patients being seen and treated quickly. I have asked the unit to concentrate on a number of priority areas. In emergency departments, for example, admission waiting times are currently unacceptable. People waiting in emergency departments are the most ill and must take the highest priority. Inpatient waiting times have been rising. We are also focusing on this area. The time from GP referral to an appointment with a consultant is unacceptably long in many specialties. We do not even have accurate figures. However, we are working on this and should have a full handle on it by April of next year. Access time to diagnostics is also too long in many instances.

The special delivery unit is already working on the emergency department issues, visiting emergency departments and examining the data. It has identified 15 hospitals providing unscheduled care that require support. Eight of these require very high support and the HSE has been asked for action plans to address this. The unit will review these plans and will work closely with the hospitals to ensure that long waits on trolleys will be a thing of the past. This week, we will see initiatives taken in the hospitals that are most in need of support, such as Beaumont, Drogheda, Cork, Galway and a number of others.

The special delivery unit initiatives are designed to support medical and nursing staff in the important job they do. Similarly we must support management, and the recent initiatives in Galway and Limerick are to do this.

Smaller hospitals are to be a key part of an integrated hospital service. They will provide a range of services safely, efficiently and as close as possible to patients' homes. Smaller hospitals should be the cornerstone of local provision, with clear links to other services. They should provide a range of diagnostics and expanded elective day surgery and medical procedures. These need to transfer from the larger hospitals, freeing these facilities for more complex work. I have no doubt that when this comes to pass and the pressure comes on the larger hospitals to let this work go to smaller hospitals we shall see more protests from various interest groups and possibly from some of the Deputies sitting opposite.

Deputy Billy Kelleher

And from some Deputies sitting behind the Minister.

Deputy James Reilly

Smaller hospitals now treat small numbers of patients with complex or acutely life-threatening conditions. It is not easy for clinical staff to maintain their skill levels in these complex cases. As such, small hospitals have difficulties in ensuring best outcomes. However, where it is necessary to transfer more complex services from smaller to larger hospitals, the transition must be managed. We want to improve the quality of the service. Key to quality will be the HSE clinical programmes, HIQA small hospital framework recommendations and the programme for Government policy on acute hospital services, including independent hospital trusts licensed by a patient safety authority and a universal health insurance health system. Under the framework, growth in local hospitals will be in ambulatory care, including chronic disease management and day surgery, diagnostics and rehabilitation, with close links to primary health care for the local population.

Smaller hospitals can deliver faster access for patients by increasing elective services in selected specialties. In turn, larger hospitals need to utilise smaller hospitals to meet access requirements for the more complex care only they can provide. We can and will expand the services safely delivered in smaller hospitals, in particular in day surgery, ambulatory care, medical services and diagnostics. It makes little sense to retain all of these services and in so doing clog up larger hospitals. This framework is the first of its kind to describe a genuine and positive role for smaller hospitals. It will be developed further as our reforms take hold and local communities, health professionals and other stakeholders will continue to be consulted as it develops.

The transformation will not be easy and will not happen overnight. It requires good planning and positive engagement with communities. Successful implementation of this approach means we must also transfer the right services to smaller hospitals. Thus far, there has been the transfer of services to larger centres for reasons of safety. We must rebalance this approach in order that smaller hospitals can develop confidence about their future roles. The flow of activity needs to reverse for less complex work. I have in the past drawn the analogy of sending one's ten year old Volkswagen to a Ferrari testing centre which, while it will do a great job, is hardly necessary when the local garage would do the job just as effectively and a lot more conveniently. It is important that smaller hospitals continue to provide immediate and urgent treatment in less complex, non life-threatening cases. The expert advice available emphasises that urgent care centres can manage typical presentations to emergency departments, most of which are not complex or life-threatening.

In line with HIQA and international evidence, we are implementing the best care model for complex and emergency cases, to transport seriously ill or injured patients to the centre best equipped to treat them. Ambulance personnel are highly trained and skilled clinical staff. They treat patients immediately at the scene and get them to the most appropriate, not necessarily the nearest, hospital as quickly as possible. Putting in place urgent care centres with ambulance bypass protocols to bring seriously ill patients to larger hospitals is not about closing emergency services, rather it is about making services safe. I am committed to this approach so as to ensure very ill patients have the greatest chance of survival.

Emergency ambulance services are not being diminished. Traditional work practices within the national ambulance service are changing as stations move from on-call to on-duty status. This move to on-duty status means highly trained paramedic crews will be in the stations or their vehicles to respond to calls rather than having to be called out to the station, which is inevitably slower when responding to emergency calls. This is a better way to provide the service and better for patients. On-duty status allows a modern emergency response service to be provided, including paramedics, advanced paramedics, community first responders and GP out-of-hours services, working together to respond to emergencies. This approach is consistent with international best practice and will ensure compliance with HIQA response times and quality standards.

Apart from the strategic initiatives I have addressed, there is a series of positive developments to which I can point. The new unit at St. Vincent's University Hospital, comprising 100 single rooms and provision for cystic fibrosis patients, is on target to open in April next year. A few days ago I opened the new colposcopy unit at the Coombe Women's Hospital. Also, resources have been made available to upgrade the hospital's theatre and labour suite to bring it up to international standards. As I mentioned, Tallaght hospital is now operating within its monthly budget, with reduced numbers waiting in its emergency department. Management enhancements will shortly be put in place at Limerick and Galway hospitals. Much improved, more up-to-date information is available on waiting lists, with weekly reporting in most hospitals to the special delivery unit enabling the addressing of individuals waiting more than 12 months for procedures. As I said previously, we are for the first time driving not in the dark but with full headlights on. Before the introduction at Our Lady's Hospital, Navan of a money follows the patient system initiative, no patients were admitted on the day of procedure. Currently, 80% are admitted on the day of procedure, providing for much greater efficiency. Cappagh National Orthopaedic Hospital, in which much greater numbers are being seen, has increased its day of admission figures by 45%.

On Deputy Healy's contention about smaller hospitals, I ask him to consider Louth County Hospital as a case in point. While in 2009 there were no care of the elderly cases at the hospital, thus far in 2011 there have been 388. The figure for haemochromatosis patients treated with phlebotomy was 535 in 2009; thus far this year it is 1,783. In respect of colposcopy, the figure in 2009 was nil; in 2010 it was 2,083. The number of surgery cases is up from 3,400 to 3,600; in respect of radiology, it is up from 534 to 3,000 plus, while the number of outpatient assessments is up from 933 to 974. This is the future for the small hospital, namely, appropriate work carried out safely, rather than trying to be all things to all men, with dire consequences.

Regulations to allow pharmacists to deliver the flu vaccine at much reduced cost and with increased accessibility are now in place. Also, later this week I will sign regulations to provide for a fall in fees to GPs from €42 to €28.50. On the catch-up programme for HPV, the cervical cancer vaccine, all girls in secondary school will be vaccinated during the next three years.

The choice for the Opposition is simple: swim against the tide or join us in making the health service a place wherein patients feel safe and those who work in it can feel proud.

Deputy Jerry Buttimer

People matter. The motion is about reform and having a plan for the health service. However, on reading it, one would not know reconfiguration is taking place. Reconfiguration involves the expansion of some services and the opening of new services and facilities, a point cynically not made in the motion which is an attempt from some quarters of the Opposition to exploit people's fears in seeking a quick and cheap headline. We need to take a reasonable approach to the health service and use proper language. At the very least, we must recognise that we have a Minister for Health who is pioneering and wants to see change. I am confident that at the end of his tenure in office we will have a health system that will be a changed model from the one we inherited. The decision by the Health Service Executive to reconfigure health services in Cork city was made in November 2009, one to which my constituency colleagues, the former Minister, Deputy Martin, and the former Minister of State, Deputy Kelleher, acquiesced. Listening to the comments of the former Minister, Deputy Martin, one would imagine he was never in government or that he had abandoned the concept of collective Cabinet responsibility. Since the HSE announced its reconfiguration plans for Cork city, many of my colleagues and I have engaged with it. We have arranged meetings with HSE managers and listened to them. Many of us expressed concern about the proposed changes and how they were being communicated. I have been told by HSE management in Cork that there will be an independent assessment of the new services to determine if they are delivering improved health care.

The motion refers to the closure of the accident and emergency department at the Victoria South Infirmary Hospital. What it does not mention is the opening in December of an acute medical unit in Cork University Hospital, the opening in 2012 of a surgical assessment unit in the same hospital, the opening of an urgent care centre at St. Mary's Orthopaedic Hospital, the opening in December of a regional pain management service at the Victoria South Infirmary Hospital, the doubling of orthopaedic surgery capacity at Cork University Hospital and the return to that hospital of paediatric orthopaedic surgery services, which service was abolished by the previous Government.

Deputy James Reilly

Hear, hear.

Deputy Jerry Buttimer

The plans outlined by the Minister indicate a clear and comprehensive restructuring of health services in Cork. As a member of the south-west regional health forum, I am aware that reconfiguration has left people less confident about the health service and that there is concern about HSE management at local and national level. The lack of political leadership during the past 14 years has eroded trust and confidence in the ability of the HSE to deliver change. That is why we will see change under the Minister's stewardship. We need to see independent verification of any changes and independent verification of claims by the HSE that proposed changes will result in improved delivery of services.

I have concerns about the creation of centres of excellence, in particular in regard to Cork University Hospital, which is overstretched. However, I am willing to listen. HIQA should get involved in this process as it would offer people much needed reassurance on the quality of services provided.

The Minister has been in office for just over seven months. It is politically wrong to blame him for every problem and earlier we heard rhetoric about war zones and crises. The Minister understands that reform of the health service is needed and he is driving that reform. That is why he has proposed radical changes in how the health service is delivered. Those opposite may be cynical and make smart comments but they should give the Minister an opportunity to drive that change, which has not happened for 14 years. We had a series of Ministers who sat at the Cabinet table, hid behind collective responsibility and did not deliver change.

I am happy that change will occur. It will not happen overnight or in seven years. If one talks to health care professionals and people working in the health service, they will tell one that morale is low and that change is needed but they are confident that we have a Minister who, and a Government which, will drive that change.

Everybody will not be happy. Stakeholders by their nature have vested interests and they will not all be happy because they will have to stand by their positions in their little kingdoms or fiefdoms. There will be opportunities for those opposite to jump up and down in their seats, to go out on the plinth and to lead delegations and mass protests.

The treatment of people and health matter. This Government is a reforming one. It has been in office since last March and not for 14 years. In 14 years time, we will have a different health system which has at its core quality health care delivered to the people who matter most.

Deputy Liam Twomey

It is very easy to play schoolyard politics when those opposite attempt to have a meaningful debate during Private Members' time. However, they are spanceled by an ideology which opposes but offers no solution. All this talk about anti-capitalism and so on from them gets a bit boring after a while. In case any Members opposite do not understand what I mean by being spanceled by ideology, I will explain. To spancel is to tie the two back legs of a cow when one is milking it by hand so she will not kick the bucket.

Deputy Michael Healy-Rae

We know what it means.

Deputy Liam Twomey

Deputy Healy-Rae should know what it means. That sums up how backward this motion is.

What are those opposite saying? They want to reverse the downgrade, reverse the plan and reverse the announcement. They are reversing themselves into a political cul-de-sac because they are offering nothing to the people who elected them to this House. They have no innovation or solutions.

Deputy Richard Boyd Barrett

Are downgrades good?

Deputy Liam Twomey

It is not always about money. The health service changes all the time. I know that because I worked in it for long enough. In case Deputy Boyd Barrett has not noticed, we do not have any money.

Deputy Richard Boyd Barrett

Can we have some upgrades?

Deputy Liam Twomey

I would like to know what those opposite believe we should do about the future of primary care. What changes should we make in disease prevention, health promotion and patient safety? Do they believe we should leave these nursing homes, which HIQA wants to close, open? Do they believe we should leave elderly patients at risk? Do they believe we should abolish HIQA? What is their view on patient safety besides using it as cliché? They must show us what they are about.

What do they believe is the role of paramedics or rapid response ambulances? Do they believe we should be reactive and react after something happens, like when an accident and emergency department closes or do they believe we should be proactive and get these ambulances, with the appropriate paramedics, to parts of the country where they can make a difference, as per what the Minister discussed? They have nothing to offer on an issue such as that and have nothing to say about air ambulances or about upskilling GPs to work in accident and emergency, as is happening in Ennis hospital currently. They have nothing to say about upskilling GPs to deal with emergencies on the side of the road——

Deputy Clare Daly

Deputy Twomey is not saying much about the Government amendment.

Deputy Liam Twomey

——or the emergencies we saw GPs deal with in the past in Donegal. They have absolutely nothing to say about those matters.

Neither have they anything to say about the way we are changing the role of pharmacists, GPs and practice nurses to deal with chronic care management. The Minister and the Minister of State, Deputy Shortall, have a vision in this regard but those opposite have nothing to say. These things matter to patients and the people they claim to represent.

Balancing the needs of local communities and access to urgent care with the expectation of how health care professionals believe their patients should be protected can be tricky at times. People who genuinely care about patients do not see the idea of an accident and emergency unit at every crossroad as a way forward. Medicine is changing quite rapidly and we must keep up with those changes, as outlined by the Minister in his contribution. These are the sort of things the Members opposite should be able to discuss.

None of the accident and emergency departments they discussed has any long-term future if it remains as it is now. They must change to have a long-term future. If they do not understand that, they do not understand the health service at all. They are changing dramatically as we speak.

If in a few years time when I am back in general practice, the things that will matter to me are those about which the Minister spoke, namely, admission waiting times in accident and emergency departments, inpatient waiting times, the time between a GP referring a patient for an appointment and the patient seeing the consultant and getting proper access to diagnostics. They are the sort of things I would like to talk about and not the rot we listened to earlier.

Minister of State at the Department of Health (Deputy Róisín Shortall)

I am glad to have the opportunity to contribute to this debate. As my colleague, the Minister, already stated, our main concern and that of this Government is the safety of patients. We will not stand over unsafe services. We have been clear about that from the very beginning. We are working hard within Government to ensure that safe and appropriate health services are delivered in the most appropriate setting.

This Government recognises the important role of smaller hospitals in local communities. We believe they represent, and will continue to represent, a fundamental element of an integrated health service in their regions providing as wide a range of treatment and care as possible. The future of health care delivery is about delivering appropriate care in the appropriate setting. This will mean that some services will move from smaller hospitals to larger ones but it will also mean that services will move from larger hospitals to smaller ones. In future, we will be sure that smaller hospitals will deliver appropriate and safe care for the communities they serve. Access for GPs to services and diagnostics will form a crucial part of the development of the role of smaller hospitals.

In considering the motion, it is important to state that apart from the very many reforms which are already under way and which the Minister outlined, primary care and its development is an essential component of health service reform and in the delivery of the most appropriate care as close to the patient as is possible. In a modern and responsive health care system, up to 95% of people's day-to-day health and social care needs can be met in the primary care setting. Deputy Healy made that point earlier, and that is our intention. They are the kind of reforms towards which we are working.

It is interesting that the motion refers to things that happened as far back as 1980 and in 2008 and 2009. We have a legacy of a lot of bad decisions which were made by the previous Government. We are setting about reversing them, addressing those past mistakes and introducing the kind of fundamental reforms our health service requires.

We intend to further develop services in the community so that everyone has direct access to integrated multi-disciplinary primary care teams of general practitioners, nurses, physiotherapists, occupational therapists and others. These primary care teams will be supported by a wider range of professionals, including pharmacists, dieticians, psychologists and chiropodists. That will all happen within a health care network.

We intend to develop integrated services in which patients have access to a range of primary care services within their communities, preferably in modern buildings. This is what the public wants and deserves. It makes sense from a health point of view and gives value for money. We are determined to deliver this type of modern, responsive health care system.

We want to develop and strengthen the number of primary care teams that are in place and I intend to build on the progress already made in respect of the primary care strategy. In addition, the programme for Government commits to the removal of cost as a barrier to accessing primary care services. The clear commitment is for the delivery of free access to GP care within the Government's term. This will be my main job as the Minister of State with responsibility for primary care. The delivery cannot be done overnight. Rather, it must be done incrementally so as to build capacity in the system. We are working in this regard. We also need a separate delivery structure for primary care within the health system so that it does not compete with other demands. We need a ring-fenced budget for primary care. Side by side with that will be key reforms, such as the roll-out of chronic disease programmes. These factors have the potential to transform our health services radically.

I am sorry to disappoint the Members opposite, but we will not be handing over the health system to the privateers——

Deputy Jerry Buttimer

Hear, hear.

Deputy Róisín Shortall

——or the corporate vultures about which Deputy Boyd Barrett is so fond of talking. We intend to reverse the privatisation of the health system introduced by the Ahern-Harney Government. This was our Government's first statement on health policy. It is naive and misleading of Deputies to suggest that money will solve the problems in the health service. If money was the solution, the problems would have been solved long ago. We need fundamental reform. We recognise the system's dysfunction to which Deputy Catherine Murphy referred and we are determined to bring about a fundamental reform to provide the modern and responsive health system that the public is entitled to expect.

Deputy Billy Kelleher

May I share time with Deputy Healy-Rae?

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Deputy Billy Kelleher

The Leas-Cheann Comhairle might tell me when I have three minutes remaining.

I welcome the opportunity to contribute on this motion, which highlights the challenges facing everyone in the provision of health care. There will be ideological debates and differences over how to provide that care, but the Minister and Deputies opposite referred to the fundamental issue, namely, that we should have an honest debate on what we are trying to achieve, how to provide primary care and how to fund health care, be it through universal health insurance or otherwise.

The Minister has only been in Government for a short period, some eight months, but his transformation and that of the parties opposite has been chameleon-like, given the differences between their remarks in the Chamber now and only a short while ago. We should have an honest debate on what was said previously and what is being said today. I filled in for Ministers for Health and Children and answered questions while I was on the other side of the House. Roles have been reversed, but I am listening to some of the same answers.

The closure of hospital beds is a fundamental issue. As recently as last year, the Minister stated that bed closures kept people on trolleys or at home in severe pain. Beds are being closed daily.

It has been suggested that the Opposition does not have a role to play in holding the Government to account, but we must hold the Government to account by highlighting the inadequacies in hospital services and health care provision. We must also hold people on the opposite side of the House politically accountable for their statements and decisions.

I am a fair person and will adjudicate on the longer term. In the short term, the Government has not made a good start. The Minister has rescinded numerous solemn commitments that he gave while on this side of the House and while traipsing across the country promising people the sun, moon and stars. If there are concerns in the country and an opposition to reconfiguration, they were sown by the Minister and no one else. He consistently promised that, if he was elected, accident and emergency services in all hospitals would be defended, there would be more beds and more hospitals would be built. None of this has come about.

Roscommon County Hospital is an example of an appalling U-turn. The people of Roscommon were given a cast iron commitment that their accident and emergency services would be retained and enhanced. Besides sacking the board of the HSE, the Minister's first decision was to close those services. He hid the closure under the guise of hospital safety, but when issues about Portlaoise hospital arose, the Government had a different view. It can rubbish one report but must commit itself to another. There are glaring inconsistencies in the policies emanating from the Government.

Patient safety is paramount, as the Minister of State, Deputy Shortall, stated. I assume every Deputy is for patient safety. If so, the Minister's commentary while on this side of the House was reckless. Everything he is doing now in the interests of patient safety is the exact opposite of what he stated he would do while in opposition. For example, he was going to retain accident and emergency services across the countryside.

Let us have an honest debate. I addressed the Seanad numerous times about the reconfiguration of hospital services in County Wexford. Are local Deputies now fully supportive of those proposals? Often——

Deputy Liam Twomey

For the record, there is no contradiction in what I am saying.

Deputy Billy Kelleher

The Minister will have something happen to him often, namely——

Deputy Liam Twomey

The Deputy should show us the record. He is making it up.

Deputy Billy Kelleher

——the opposition to reconfiguration will come from that side of the House where so far, the casualties of reconfiguration have arisen. The Minister does not need to worry about those of us on this side at all. At the very least we are obligated to hold people to account for the commitments they make during elections and the formation of Governments. This Government's start to date has not been great.

Cork was mentioned. I defended the reconfiguration of hospital services in Cork while in Government and I will defend them today, but I never slouched around Cork city making empty promises. The people of Cork were given a solemn commitment to the effect that orthopaedic services would remain with St. Mary's Orthopaedic Hospital.

Deputy James Reilly

Services would be maintained.

Deputy Billy Kelleher

I am afraid the commitment related to orthopaedic services. As a medical practitioner, the Minister knows full well the difference between those and other services. The commitment was that orthopaedic services would remain with St. Mary's on the north side of the city while all other health services would remain with the other hospitals. I knew at the outset that it was an empty promise, yet it was made by people who also knew. The rigamarole that followed saw an independent review group set up to examine the issue quickly. It threw its eye over the reconfiguration plans and recommended the removal of orthopaedic services to South Infirmary-Victoria University Hospital, which is now under way.

The suggestion is that we can now trust what the Government is telling us, but the parties' statements while in opposition differ wholly from what is occurring on the ground and the policies being implemented. There is considerable financial pressure, but I knew about it last January and February, as did the Minister. That he could go to Navan and promise to build a new hospital in the north east——

Deputy James Reilly

No one ever promised that. The Deputy is confabulating.

Deputy Billy Kelleher

The Minister clearly promised it. Even the Taoiseach denied——

Deputy James Reilly

Show me where I did. The Deputy should correct the record.

An Leas-Cheann Comhairle

Order, please.

Deputy James Reilly

That remark needs to be corrected. No new hospital was promised in Navan.

Deputy Billy Kelleher

No, the Minister made a promise in Navan about a new hospital in the north east——

Deputy James Reilly

Not in Navan, not by me.

Deputy Billy Kelleher

——in the context of the reconfiguration of hospital services.

Deputy James Reilly

A former Fianna Fáil Minister stated that not a red cent would be borrowed.

Deputy Billy Kelleher

It is difficult for people to take the Government's assertion that it will retain services in smaller hospitals seriously when the opposite is clearly the case. For example, strong, brave commitments were made about Mallow General Hospital. The Minister and I know that the accident and emergency department in Mallow General Hospital will not be retained but promises and commitments were made that it would be retained. The hospital will have a medical assessment unit and patients with serious injuries and illnesses will be transferred to the regional hospital in Cork. Promises were made at local level to retain the accident and emergency department and that undermines people's confidence in how health services are delivered.

On the broader issue of universal health insurance, we have heard a lot of noise about the merits of the Dutch model. What are the riding instructions and terms of reference of the implementation group established by the Minister to deal with the implementation of universal health insurance? The Minister said it is a long-term plan and the can has been kicked well down the road to the election following the next election. If it will be such a fundamental change to the manner in which health services will be funded in this State, it would be appropriate for us to have sight of the terms of reference given to the implementation group and to have a debate on this issue. Of all the provisions and pronouncements made by the Government, this is a fundamental issue regarding how our health services will be funded in the years ahead. No one other than the members of the implementation group, and perhaps the Minister, know the terms of reference and riding instructions, when it will report back and when implementation of the new universal health insurance will take place. The Minister should examine that and at least have a broader debate on the fundamental issue of the provision of health care in the country.

The Minister sacked the board of the HSE and took personal responsibility for it for a while, but that position has now changed in that in replies to parliamentary questions we are referred continually by the Minister to the HSE. I thank the Minister for that courtesy but he said he would adopt a hands-on approach to the provision of health care and that he would be running the HSE. We have now been informed we will have to wait a longer period than envisaged for legislation to be brought forward to change the governance structures of the HSE, but in the meantime who is running the health services? Is it the Minister, the Minister and the Department of Health, the HSE or who is it? This is allowing a drift to occur in the area of policy making, policy formulation and the implementation of Government decisions.

Deputy James Reilly

I can help the Deputy on that. There is still a board of the HSE with a chairman and a chief executive officer. Does that help the Deputy?

Deputy Billy Kelleher

It does, but the Minister said he would take a hands-on approach and, bar wearing a gown, he would be the person in charge, but that is not the case at present.

The health services have gone through a major transformation with the establishment of the Health Service Executive and the amalgamation of the health boards. Management change and changes of structures take seven to ten years to implement. The idea that we will go through a huge upheaval again in the health services will only undermine the capability of whatever organisation is there to provide health services to deliver what it is meant to do. In the meantime there must be clarity on the issue. I know from speaking to people in the HSE that they are unsure what policy direction will be taken and who is responsible for provision and delivery of health care in this country.

The national children's hospital project is a major issue to be decided on by the Government. Many people have had varying views on its location. The Minister expressed a view on it also and as a Deputy representing a Dublin constituency and a general practitioner, his view should be respected. An independent expert group was set up to establish whether the Mater site was the right one and to assess its cost effectiveness. It has reported that it is the most efficient site in terms of having a university hospital and a children's hospital on the one site. When will the decision on this project be made? I know it has gone before the public expenditure review group but this is a political decision. It is a decision the Government makes. It is not one for the public expenditure review group.

Deputy Róisín Shortall

It is at the planning stage.

Deputy James Reilly

It requires planning permission, as I am sure the Deputy understands.

Deputy Billy Kelleher

It requires planning but it also requires a political commitment, which can be made prior to planning in the context of whether the Minister is committed to this project. I am concerned that this project has been allowed to drift. It is at the planning stage. The Minister could state that if its gets planning approval, it will be built immediately, but that commitment has not been made and we are still waiting for clarity on that. The planners should be let do their job but if the project is granted planning permission, will the building of it commence immediately? Many people are concerned that there is not a strong political commitment to this project.

I welcome the opportunity to speak on this motion. Every area of the country has been touched by what is proposed. I would like to speak on this matter again in time to come but I want to allow my colleague to contribute.

Deputy Michael Healy-Rae

I thank Deputy Kelleher for sharing his time with me. I thank the Minister and the Minister of State for being present.

The Minister said that he feels he is driving with the headlights on and that we are no longer driving in the dark. He should say that to the people in Cahersiveen who have lost their ambulance service during the hours from 8 p.m. to 8 a.m. The people there will not have an ambulance service during those hours, they will not have headlights and they will be in the dark. This region is like no other in terms of the vastness of the area the ambulance service covers. I appreciate what Deputy Twomey stated about a first responder service and he is correct that we will have a first responder service. The Minister should note that during the hours the ambulance service will not be available in Cahersiveen, if an accident or an incident occurs or a person becomes ill on Valentia Island, Ballinskelligs, The Glen or Portmagee, the nearest ambulance base will be in Kenmare, Killarney or Tralee. The quickest time an ambulance can travel that journey is an hour and 45 minutes. The first responder will go out and, one hopes, stabilise the patient, but it will take the ambulance an hour and 45 minutes to arrive on the scene of whatever has happened. That cannot be right. The Minister's solutions are not applicable to the entire country because of the nature of the geography of the area. The Minister is right in his praise of the on-duty versus the on-call service for some cases but he is blatantly wrong in regard to other cases. This is a case in point where we should retain our ambulance service at night in Cahersiveen. We certainly do not want to see it suspended.

I support the motion and thank the Technical Group for bringing it forward. The dental clinics in Kenmare are under threat. We have already lost the one in Dingle. The Sláinte na Gaeltachta group would not be long telling the Minister what they think of the health service in that at a time when we have a new hospital in Dingle, we are losing our dental clinic which means that the people living in the Dingle Peninsula will have to travel to Tralee, as will the people in Kenmare and Cahersiveen. That is wrong because the distance people have to travel for treatment is ridiculous.

We are losing our call centre in Tralee and in Cork because the service is being centralised in Dublin. We got a bad enough fright when we saw what happened to the processing of medical cards once that service was moved from Tralee.

Deputy James Reilly

It has improved.

An Leas-Cheann Comhairle

The Deputy will have to raise those issues some other way. His time is up and I must call Deputy Ó Caoláin.

Deputy Michael Healy-Rae

I make that point that while the Minister may be right in his vision in certain areas, he is wrong in others and it is definitely wrong in the constituency I represent. We have major problems that need to be addressed.

Deputy Caoimhghín Ó Caoláin

My amendment concerns the crisis situation in the north east and I support the amendment of my colleague, Deputy Tóibín, calling for an inquiry into the disgraceful overcrowding at Our Lady of Lourdes Hospital in Drogheda. We are facing into what may be one of the worst ever winters in our health services. If the Fine Gael-Labour Government does not act in accordance with the commitments it gave to the electorate prior to the general election, then the situation outlined at hospitals listed in the motion, and at other hospitals, will deteriorate rapidly.

There are over 1,900 public beds closed in our hospitals, yet the Minister for Health, Deputy Reilly, is in denial about this reality.

On 3 October last, I asked the Minister in the Dáil if he would commence a programme of reopening public hospital beds in view of the research by the Irish Nurses and Midwives Organisation showing that 1,947 public hospital beds are currently closed. I asked if he agreed that more beds closed means more patients suffering needlessly on trolleys and more patients waiting at home in pain due to cancelled operations. He replied: "I do not agree that more beds closed means more patients on trolleys and more people waiting". I then pointed out that in May 2010, after 33 beds were closed in Beaumont Hospital, Deputy Reilly, as an Opposition Deputy, stated: "More beds closed means more patients suffering needlessly on trolleys and more patients waiting at home in pain due to cancelled operations". After less than a year in office, the Minister is already parroting the words of his predecessor, Ms Mary Harney. Her words have become his words.

The Minister's words and those of his Labour coalition partners were all very different when he was in opposition. In The Irish Times, on 8 February 2011, Deputy Reilly stated: “We will put in place an emergency plan to accommodate the predictable surge in activity that occurs every winter”. In that same feature his colleague, then Labour Health spokesperson, Deputy Jan O’Sullivan, said: “In the first months of Government, we will lift the moratorium on replacement of frontline staff where beds or operating theatres are closed because of a shortage of nurses, etc”.

I would appreciate if the Minister paid a little attention to what I am saying.

Deputy James Reilly

I am listening to Deputy Ó Caoláin.

Deputy Caoimhghín Ó Caoláin

The programme for Government boasts that this is "the first in the history of the State that is committed to developing a universal, single-tier health service, which guarantees access to medical care based on need, not income". The reality is very different, as many other speakers have outlined here this evening, and as is set out in the Technical Group motion. Every Deputy in this House could add further information to the list already in the Technical Group motion about services terminated or cut back in their own constituencies.

Deputy James Reilly

Would Deputy Ó Caoláin achieve it in seven months? I doubt it very much.

Deputy Caoimhghín Ó Caoláin

The situation in the north east——

Deputy James Reilly

A Leas Cheann Comhairle, at what time is this over?

Deputy Caoimhghín Ó Caoláin

That is a disgrace.

An Leas-Cheann Comhairle

Sorry, Deputy Ó Caoláin has one minute.

Deputy Caoimhghín Ó Caoláin

I have never yet heard a Minister for Health seek to close down a Deputy outlining the facts of the situation in the health services.

Deputy James Reilly

I asked and inquired, as I am entitled to do.

Deputy Caoimhghín Ó Caoláin

With all her faults, Deputy Reilly's predecessor never attempted that.

An Leas-Cheann Comhairle

Deputy Ó Caoláin to continue.

Deputy Caoimhghín Ó Caoláin

The INMO has pointed out that 842 patients spent time on trolleys in the emergency department at Our Lady of Lourdes Hospital in Drogheda in September 2011 compared to 331 in the comparable month of the previous year, an increase of 154%. The INMO states that this situation will deteriorate even further in the coming months as the winter period is traditionally worse in emergency departments nationwide.

Pressure on the Lourdes and on Cavan General Hospital have been greatly increased by the so-called hospital reconfiguration process in the north east — the removal of services and downgrading of other services at other hospital sites in the region. This downgrading process totally contradicts the Minister's supposed strategy of giving smaller hospitals and primary care a greater role. The hours of the minor injury unit at Monaghan General Hospital are being cut. The rapid response vehicle has been withdrawn from the ambulance service covering County Monaghan and north Louth. Services have been taken away from the Louth County Hospital in Dundalk and from Our Lady's Hospital in Navan. Clearly, these services must be restored. Nothing less is acceptable.

We had our attention drawn recently to the growing chaos in the Mid-Western Regional Hospital in Limerick where nurses were driven to industrial action, not in pursuit of better pay and conditions for themselves but for the safety of patients. The downgrading of smaller hospitals at Ennis and Nenagh have contributed to that pressure in Limerick.

An Leas-Cheann Comhairle

I ask Deputy Ó Caoláin to move that the debate be adjourned.

Deputy Caoimhghín Ó Caoláin

May I conclude with this?

An Leas-Cheann Comhairle

Briefly.

Deputy Caoimhghín Ó Caoláin

I want a commitment from Fine Gael and Labour that they will not adopt, or even consider, the series of further proposals that are being mooted in regard to a freeze on new medical cards until 2012, the slashing of home-help hours by 600,000 and the removal of 400,000 personal assistant hours. All of these proposals are under consideration and they are a further indication of what some of those within management in the HSE are prepared to do. The Minister has taken on responsibility. He has taken on accountability. Those were his own words. I ask him now to be both responsible and accountable.

Debate adjourned.