Health Services: Motion [Private Members]

I move:

That Dáil Éireann agrees that the 2014 national service plan of the Health Service Executive is inadequate to meet fully all of the growing demands being placed on the health services and that the lack of sufficient resources will not be in the best interests of patient care and this is already evident in accident and emergency departments.

I wish to share time with Deputies Keaveney, Browne and Cowen.

The reason I put down this motion is quite clear. The last three Estimates that have been presented for the HSE service plan have been inadequate in providing funding to maintain the services in a manner that is safe for patients and that allows front-line services to provide the care that they want to give to patients not just in accident and emergency departments, but also in ambulance services, acute hospital setting and care for the elderly. Looking through the HSE service plan, it is quite evident that it does not have sufficient resources to ensure that we can deliver services to the people who need them. Time and again, we have listened to eminent professionals - senior clinicians, front-line staff - saying that they simply cannot maintain safe services in emergency departments in our broader hospital system throughout this country. That is why we decided to put down this motion.

I would like to put on the record my distaste at the decision by the Government not to allow for a full debate in the plenary session of this Parliament on the HSE service plan. That was signalled by the Government last week. This was in Government time. Fianna Fáil decided to table a Private Members' motion, and then the Government decided that it would pull the six hour debate on the HSE service plan tomorrow. That will deny many Members in this Chamber the chance to contribute to the debate on the HSE service plan and the lack of services that will flow from it. The Government has decided, in an arrogant way, to remove any form of debate from this Chamber on the HSE service plan. The Minister knows as well as I do that Private Members' time only allows for three hours of debate this evening and tomorrow evening. Due to Standing Orders, a large number of Deputies will not be able to make a contribution. The HSE service plan deserves scrutiny because it outlines the blueprint for spending in the year ahead. We already know in January that services will be cut back in 2014 and as we get to the end of 2014, as happened in 2012 and 2013, we will see a cut in services that are primarily targeted at the most vulnerable in our society, so that we can live within means.

The Minister has said that he has his spending indicators on a monthly basis right through the year, but since he has taken charge, every year there is panic by August, cuts in September and pain in October for many people whose services have been withdrawn. This is why we have put down the motion tonight. More importantly, the Government has decided to withdraw six hours of debate tomorrow which would have allowed Deputies on all sides to make a meaningful contribution, to go through the HSE service plan for 2014 and to highlight their concerns and the deficiencies in it. The deficiencies are quite stark, and it is not just me, the Fianna Fáil spokesperson on health, saying this. The director general is also making the same point. He said that it would not be possible to meet fully all of the growing demands being placed on the health services. He also said that, in particular, some service priorities and demographic pressures may not be met. We already know that this is a sanitised version of what the director general wanted to say, but when the HSE service plan was submitted to the Cabinet by the Minister, his colleagues jumped up and down and said that they had to politically sanitise the director general's statement. The director general was saying quite emphatically that the funds being presented for the Estimate in October were not sufficient in any way and it would not be possible to provide a safe system of health in this country. This is why we believed it was appropriate to have a debate in Private Members' time, but also for all Deputies to be able to contribute to the debate on the HSE service plan in this Chamber tomorrow for six hours. It was a shameful decision by the Government, the Minister or the Chief Whip, or all of them.

For a number of years, expenditure and savings in discretionary medical cards were itemised in the HSE service plan. However, there is no reference in this year's service plan to discretionary medical cards. When I put down a Dáil question recently to the Minister of State, Deputy White, he was clear in stating that there is no such entity as a discretionary medical card. I cannot understand how there can be no such entity as a discretionary medical card, because we have been debating the issue for some time in this Chamber, and the Minister has been contradicting the fact that there has been a targeted attempt at removing and reducing the number of discretionary medical cards in the system. Now we find that they do not exist at all and there is no such entity, but there is such an entity. Over 90,000 people had discretionary medical cards at one stage, and I can assure the Minister they are a very important entity to those people who rely on them to deal with their illnesses and disabilities.

I know what is happening. The Government wishes to erase the word "discretionary" from its accounting practice. It wants to be able to reduce the number of discretionary medical cards awarded every year. Great play has been made by the Minister about the fact that many of the people who had discretionary medical cards are now moving towards being awarded a full medical card under the Health Act 1970. That may be the case, but many more people should be qualifying for discretionary medical cards because of the precedents that were set over many years. These are precedents that were based on basic humanity and decency, and on assisting people through a very difficult time in their individual lives or in their family lives, dealing with financial issues and also sickness, disease, disability and so on. Erasing that word shows that there has been a fundamental change in policy regarding discretionary medical cards. People will be let sink or swim. If they qualify under the financial guidelines of the 1970 Act, they will get a medical card, but if they do not, then the other aspects of their circumstances will not be taken into account. I believe there is a targeted approach, and the fact that it is not mentioned in the HSE service plan and the fact that the Minister of State claimed that there is no such entity as a discretionary medical card, is an indication to me that there has been a major change in policy on this issue.

Whether we count them in the accident and emergency department, or in the corridor outside the emergency department, or in the ward where it is not in a designated area, there were 410 people on trolleys today in our hospitals. I remember in the past when the Minister would be apoplectic with rage and indignation on this side of the House if we had those figures. He said it was a central tenet of his stated policy to eradicate waiting times in emergency departments and to reduce dependency on trolleys in emergency departments for excessive hours.

That was the Minister's stated policy.

Most criticisms I level at the Minister are reasonable and I heartily endorse all measures he introduces with which I agree. In adjudicating his efforts to address the problem of people waiting on trolleys, however, one need only examine the figures for January. More important, recent data show a 2% increase in the number of people on trolleys in 2013 compared with 2012. The Minister's policies have led to a reversal in this area.

The special delivery unit established under Dr. Martin Connor created some impetus and resulted in a brief respite in terms of the numbers on trolleys. However, recent developments indicate that the unit is quickly losing momentum for a number of reasons. The embargo on recruitment to front-line services continues and staff continue to operate under serious pressure. Furthermore, the HSE decision to reduce the number of people who can access long-term residential care and respite care means patients are being kept in hospitals for longer than is necessary. Having repeatedly stated that a person should only be in hospital if he or she needs hospital care, the Minister should know that this is the wrong approach. Many of those who are in hospital should be at home or in step-down facilities. The absence of a determined effort to increase capacity in after care indicates that the Minister is not prioritising step-down facilities, home care packages, home help supports and so forth and his policies in these areas are not having the desired effect.

Senior clinicians, consultants in emergency medicine and representatives of the Irish Emergency Medicine Trainees Association have pointed out that patient safety is being jeopardised daily in our emergency departments. The Minister appears to dismiss these concerns as if clinicians are making them up. I have met and listened to the concerns of nurses, doctors, non-consultant hospital doctors, janitors and members of every other profession working to make our emergency departments function under extremely difficult circumstances. I suggest that rather than dismissing their concerns, the Minister should listen to those who assist the people who are admitted daily to our accident and emergency departments. They will tell him that there are major problems with the system. If he chooses not to believe them, he need only examine the Irish Medical Organisation's trolley count figures for January, which show we have a major problem in our emergency departments. The provision of care in emergency units is a key aspect of the Minister's policy on the Health Service Executive.

Having read through the HSE service plan, it is clear we must wait for the detail of the regional plans because the meat will be in the provision of services at local level where the impact of cuts will be felt in services for the disabled, elderly and others.

When I raised the issue of general practitioners with the Minister previously, he stated that global comparisons show that Irish GPs are well paid. He also denied there was a crisis in primary care and general medical practice. I beg to differ; there is a major problem in primary care. If, as the Minister claims, general practice is a lucrative area, why do many general practitioners view boarding an aeroplane as a career option? The answer is that they have been left with no choice. I am not advocating directly for general practitioners - the issue at stake is primary care, another central plank of the Minister's mission statement both as an Opposition spokesperson and a Government Minister. He has failed in the past three years to pursue a meaningful policy that will have a significant impact on the provision and expansion of primary care. He speaks, for example, about the roll-out of primary care centres. This is tinkering at the edges because the bottom line is that general practices, one of the critical components of ensuring the delivery of primary care, are under serious stress. If the Minister does not wish to listen to the concerns of general practitioners, he should listen to their patients who will soon find it more difficult to see their general practitioner on a same day basis and may have to wait for one or two days for an appointment.

While the motion is welcome, it should be taken in conjunction with the six hour debate promised by the Government for tomorrow. It is shameful that the debate will not take place because the Government could not be bothered to listen to the views not only of the Opposition but also of Deputies on the Government backbenches.

It cannot have escaped the notice of the Government Deputies that the wording of the motion is taken, almost word for word, from a recent statement by Mr. Tony O'Brien, director general of the Health Service Executive. It is worth placing Mr. O'Brien's words on the record for the attention of Government Deputies. He stated that "it will not be possible to meet fully all of the growing demands being placed on the health services. In particular, some service priorities and demographic pressures may not be met". The Government's amendment proposes to flatly contradict the director general of the HSE.

I will return to Mr. O'Brien but I propose first to address the substantive part of my contribution to the continuing failure to secure appropriate resources for the mental health sector. This comes at a time when levels of mental ill health are increasing and many communities are experiencing serious, tragic and shattering levels of suicide. Sadly, the mental health services continue to be Cinderella of the health service. There has been a fundamental failure to build on the progress made by previous Governments, including in the Mental Health Acts of 2001 and 2008 and the full adoption of A Vision for Change in 2006. Instead, the Government is cherry-picking from A Vision for Change, selecting those aspects that save money and ignoring and dragging its feet on those aspects that require resources.

The ongoing closure of St. Brigid's Hospital in Ballinasloe is a perfect example of this approach. Recently, a sum of €3.1 million was spent on providing a state-of-the-art facility that will now be closed. Patients are instead being moved to Galway before an adequate unit to accommodate them has been identified. The accommodation chosen is in a unit that only last year was criticised by the Inspectorate of Mental Health Services. This pattern of failing to link capital spending with current spending is to be found throughout several areas of the health service.

The decision to close St. Brigid's Hospital was taken on the back of a highly curious process that seemed designed to deliver on a decision that had already been made. This approach is typical of nearly every consultation process undertaken by the Health Service Executive under this Government. It simply ticks the boxes as part of an exercise that does not constitute a genuine engagement with communities, medical professionals or service users. Members of the public see through this tactic, the outcome of which is the destruction of faith and trust in local HSE management.

The Government has actively undermined the ethos contained in A Vision for Change, a strategy that is built on a recovery model that recognises the necessity of a collaborative relationship between service users and medical professionals. Furthermore, the policy envisaged that service users would be included in policy formation and decision making. The National Service Users Executive, which was established under A Vision for Change to represent service users, recently recounted to me how it has been bullied by the HSE to the point that it can no longer function. Last October I received a letter from the HSE clearly stating that service users participating in meetings with the HSE would not be treated as equals alongside medical professionals or other public servants. This approach flatly contradicts the letter and spirit of A Vision for Change and fundamentally undermines the parity of esteem essential to the recovery model.

I recently met representatives of Mental Health Reform who expressed frustration at the delays in the delivery of promised mental health funding for 2013. The HSE National Service Plan 2014 indicates that certain initiatives, including the appointment of new staff for community mental health teams allocated for 2013 and 2014, will be "specifically targeted towards the latter half of 2014 to allow ... savings to be utilised on specific services on a timing delayed basis".

As stated by Dr. Shari McDaid, director general of Mental Health Reform:

Unfortunately, mental health needs do not operate on a timing delayed basis, and the decision to delay until the latter half of 2014 the appointment of next year's promised 250-280 new staff and the remaining staff due from 2013 will have a real human cost. Yet again, we are seeing mental health services suffer the drip-drip effect of delays.

Only yesterday, I received a response to a question I tabled to the Minister for Health in September 2013, which confirms the Government's deliberate policy of delaying the recruitment of new staff in the mental health sector. As of 30 November last year, only 137 of the 459 promised posts had been filled. The question of how many of these staff are actually working on the ground remains unanswered. These posts form part of the commitment in the programme for Government to ring-fence €35 million a year for mental health services. This promise was betrayed in budget 2014 when a cut of €15 million was imposed on the service. There is still no clarity in regard to how much of the €35 million allocated in 2012 and 2013 was actually spent. Having spoken to those working in our mental health services and from information provided to me in response to a parliamentary question, I strongly suspect that it has not been spent. The reduction by €15 million to €20 million in last year's budget in the amount ring-fenced may simply be the Government recognising the magnitude of the under-spend that has already occurred in mental health services.

Mental health services are struggling and are being starved of resources. Only recently those working in the mental health service in east Galway told me that HSE expenditure on services in that area were €3 million under budget at the end of October last year. They fundamentally believe that not one red cent of this money will be spread across the mental health budget. The Minister needs to confirm if this is so and to provide an explanation for it.

At the end of September 2013, some 413 children were more than a year on a waiting list for a first appointment. This means that 413 children in some level of mental distress were waiting more than a year to be seen. The demand on child and adolescent mental health services is running at 13% above the anticipated level. At the same time, research published this year by the Royal College of Surgeons in Ireland shows that the rate of children and young people with a mental disorder in Ireland is higher than anywhere else in Europe or the USA. There are individual and collective tragedies waiting to happen. This issue needs to be addressed urgently by whoever is running the Department of Health.

I believe the issues arising in the mental health service area, and in the health service generally, are the result of two key but related causes. First, the Department of Health is weak, unable to properly manage the budgetary process, suffering from a lack of confidence and support from Cabinet and lacking the ability to manage and control spending. The back-of-an-envelope approach taken to the budget and the HSE service plan has severely undermined public confidence in the service. The farcical nature of the so-called probity measures targeting savings from the medical card scheme, the reduction from €113 million to €23 million, and the miraculous appearance of €108 million in unspecified other savings from payroll are but examples from a catalogue of many in this regard. Second, and most significant, we do not know to whom the Minister is listening. He is not, given the creative editing of the commentary of the director general of the HSE, Mr. O'Brien, listening to him. To be fair to Mr. O'Brien, he appears to have that rare gift for telling it as it is. He bluntly told the Cabinet: "It will not be possible in 2014 to fully meet all of the growing demands placed on the health services." However, as someone decided that this might alarm the public, when the service plan was published the next day, this had been changed to, "It will be very challenging in 2014 to fully meet all of the growing demands."

It is important the Minister listens to those on the front line. Observations or complaints from medical professionals, their unions and professional bodies, are, at best, being ignored and, at worst, the messenger is being attacked. It is not enough to send departmental officials to nod, smile and empathise with staff on the front line; we need to see action. However, this is not happening. The Minister, who I know is a listening man, needs to listen to what patients and service users are saying. I call on officials to demonstrate confidence in HSE management and the Minister by way of a process of engagement.

Morale within the health service is poor. This will eventually affect the quality and delivery of service and the patient. It is not good enough to only listen to people. We need action. It is essential in the public interest that the Minister engages properly with the service plan production and that we work together to ensure we achieve outcomes in the interests in the citizens of this country.

I too welcome the opportunity to contribute to the debate on this motion regarding the Health Service Executive. I agree with Deputy Kelleher's comments in regard to the Government's decision to withdraw the six-hour debate tomorrow on the HSE service plan, which would have provided more Deputies on this side of the House, and on the Government side, with an opportunity, to have an input into the service plan for 2014.

It appears to me that the Minister and director general of the HSE are poles apart in that while the director general has outlined the amount required for the provision of services in 2014 the Minister is not willing to make available the necessary funding to provide all of the services required to meet the needs of people throughout the country over the next year. As stated earlier, this was clearly spelled out by the director general when he stated: "It will not be possible to meet fully all of the growing demands being place on the health services." While the HSE national plan has been published, we have not yet had sight of the plans for the regions. The executives of HSE south would normally by this stage have explained the cuts and reductions to services in 2014 to the people on the ground. It is strange that this has not yet happened. I encourage the Minister to ensure that the service plan for HSE south is made available as quickly as possible.

While many issues are, perhaps, dealt with in the small print they are not set out in the overall detail of the HSE service plan. The Minister will be aware that the provision of speech and language therapy for children is one of the great scandals of recent years, with children waiting two and three years for services. I recently received a letter from a constituent, a mother of a child who is two years and eight months old, cannot speak and has many other problems, for whom she recently applied to the HSE for an assessment of needs in terms of his development. The response from the HSE was that her child may not obtain services for a year or 18 months, which caused her great concern. In my constituency of Wexford, as I am sure is the case in every other constituency, there are delays of two and three years in respect of speech and language service provision. The letter from my constituent goes on to state that she was told by the HSE that if she has the child privately assessed by a psychologist, this assessment will not be accepted by HSE south. It is strange that a psychologist's report, paid for by a parent, is not acceptable to the HSE. I ask that the Minister make available funds for the provision of speech and language services for children throughout the country.

I wish to raise the issue of the ambulance service, which is creaking at present but not only in my constituency. The Minister will be aware that throughout the country we have had major problems with the ambulance service. We have a situation whereby there is not enough manpower and vehicles are not in the appropriate condition. There have been many cases where gardaí and ordinary people have taken people to hospitals because the ambulance service has been delayed or has taken so long to come to meet the needs of the patient. I gather €130 million will be spent on the ambulance service in this country in 2014. Scotland is a comparable country but £240 million will be spent in Scotland on ambulance services during 2014. The ambulance service needs a leg-up and extra resources but I do not see this anywhere in the HSE service plan. Perhaps when representatives from the HSE south come to explain their services there will be an increase in money, but I doubt it.

The discretionary medical card is one of the major ongoing issues within the system. People come to our clinics on a daily basis suffering from cancer and other serious illnesses. It is practically impossible to get a discretionary medical card nowadays. There has been a major change in the attitude of the Minister and the HSE in this area. The Minister for Health, Deputy Reilly, is a general practitioner. I have had situations where a GP has put on the relevant medical letter "end-of-life situation". Yet we must fight, argue and make representation after representation to get a medical card for such a person. That should not be the case. It is a shame and, as Deputy Kelleher has pointed out, nowhere in the HSE service plan are discretionary medical cards mentioned.

Mental health was touched on by Deputy Keaveney. We all bought into A Vision for Change. As the Minister is aware, the old St. Senan's Hospital in Enniscorthy closed down. The walls have come down and nice new buildings have been built, which we welcome. Many people were sent home to the community. However, in recent months many of the nurses and staff who were working in the community have been withdrawn into the residential care houses because of a lack of staff. This is a genuine area of concern. People were very good at providing outreach services in the community. Now, we find that the staff are being withdrawn and the people in the communities are left without visits from the community nurse. The scheme had been so successful.

A Vision for Change was one of the enlightened decisions taken by politicians in this House and there was buy-in from all sides. It has been implemented by this Government. However, there is a lack of funding in mental health services at present. This was one of the major planks of the programme for Government. I remind the Minister that he said he would ring-fence €35 million annually from within the health budget to develop community mental health teams and services as outlined in A Vision for Change. That money does not seem to be coming on-stream despite the fact that the Minister of State, Deputy Lynch, has said on several occasions that the money is ring-fenced for extra staffing. However, the extra staff are not being provided. Now we have a situation whereby the nurses who were working in the community are now being withdrawn to the residential areas.

There is an issue with accident and emergency departments. A new accident and emergency department is being built in Wexford General Hospital. I understand an extra ten staff will be required to open the new accident and emergency department, which is coming near fruition. Will the Minister indicate whether an extra allocation of money will be made available to provide the extra ten staff for Wexford hospital? Will we see what has happened in other parts of the country, that is, new buildings remaining closed for months or years? I call on the Minister to ensure that the essential extra funding is made available for the new building at Wexford hospital.

We have long waiting lists at accident and emergency departments. People are on trolleys. As Deputy Kelleher said, the numbers increasing on trolleys in recent weeks are alarming. They disappeared for a while but we now have over 400 people on trolleys. We have a significant increase in the numbers on trolleys in Wexford hospital. Waiting lists are soaring at the hospital. They have increased by 57% in a year. Certain areas of the HSE service plan have not been working in 2013 and certainly will not work in 2014 when one considers the dramatic reduction of funds to be provided by the HSE.

I emphasise to the Minister the importance of the fair deal scheme. The fair deal scheme worked reasonably well. However, now when I inquire about the scheme or make a new application, I am told to send in the application but that the officials do not know when I will get the money. This means a significant number of people are taking up hospital beds when they could be out in the community and in nursing homes under the scheme. It is essential that extra moneys are made available for the fair deal scheme. Nursing Homes Ireland has stated clearly that the service plan is projecting a reduction of 939 persons to be supported by the nursing home support or fair deal scheme in 2014. That is a substantial reduction. It is not a wise decision for the fair deal scheme not to continue as heretofore.

The motion states categorically and plainly, as has been said by my colleagues, that the 2014 national service plan of the HSE is inadequate to meet fully all the growing demands placed on the health services. The lack of sufficient resources will not be in the best interests of patient care. This service plan provides for fewer people to be treated as inpatients, fewer people to be treated as outpatients and fewer people to be treated as day cases in hospitals throughout the country this year. The service plan means that far fewer people will have medical cards by the end of 2014.

Let us consider the discussion on the service plan that took place at the Oireachtas Joint Committee on Health and Children earlier this month. It was interesting to hear members of the HSE outline a series of measures that do not necessarily have a significant cost but are none the less absent from this service plan. They said they would like to have developed a national perinatal pathology service at a cost of €420,000 this year but they are not in a position to do so. They would like to have seen phase 2 of the intermediary care service at a cost of €4.4 million but they will not be doing that this year. They said they would like to have done more in the area of health and well-being initiatives at a cost of €1.5 million but will not be doing so. They were keen to roll out an extension of BreastCheck at a cost of €500,000 in the current year but they will not be proceeding with that. Nor could the HSE or the Minister secure Government resources for a €40 million proposal that would review home care and community support services, develop a new model of service delivery and maintain home help hours at 2013 levels despite the cuts. The proposal would provide home care packages and support for early discharge from hospital while reducing the level of entry to long-term residential care, but this will not materialise. They could not get an extra €25 million to meet the increased demand for dental treatment services and stop the growing loss of dental treatment services through the country and at various locations in my constituency.

One of the previous speakers quoted what the HSE chief executive, Tony O'Brien, had to say before a Cabinet meeting at Christmas. He said, "It will not be possible to fully meet all of the growing demands being placed on the health services".

After the meeting, however, the spin was in overdrive, with Mr. O'Brien stating that it would merely be "very challenging" in 2014 to meet all of the growing demands on services.

Colleagues have dealt with the pressures on hospital emergency departments. Will the Minister clarify what is happening in regard to the fair deal scheme and offer assurances regarding the issues we have outlined in this regard? Age Action Ireland has expressed concern about the impact the service plan will have on the sickest and most vulnerable, including older people. The plan acknowledges that waiting times for a nursing home bed under the fair deal scheme will increase in 2014. In fact, it states that 700 fewer beds will be funded under the scheme this year compared with the target for 2013.

Deputy Colm Keaveney outlined the issues arising in the area of mental health services provision, including the frustration on the part of patients that the delivery of the promised funding for 2013 and 2014 will be subject to delays. Deputy John Browne referred to the situation in the regions, where health service managers have a right to know the true extent of the cuts proposed in the 2014 plan. I understand the Midland Regional Hospital in Tullamore and the hospitals in Mullingar and Portlaoise have started the year in the dark in this regard. Will the Minister not do the honest and decent thing by publishing the full plan without further delay? We need to know what the full and real effect will be in terms of the ability of health service providers throughout the regions to deliver front-line services.

Deputy Browne mentioned the consternation that has been expressed in regard to ambulance services in Wexford. Similar concerns arise in respect of the service in Offaly, Donegal and throughout the country, as we have heard from various Deputies in recent weeks. The reconfiguration of staff and of moneys serves only to re-emphasise the fact that moving the deck chairs around does not address the underlying issue. If the risks associated with the policy of cuts and efficiencies are not addressed, there will be obvious and unfortunate consequences for ambulance services throughout the country.

The failure on the part of the Minister to provide adequate time for a debate of this magnitude has put paid to the prospect of the representatives of the people in this House obtaining a fair and adequate explanation of the situation as it stands and as proposed for 2014 in the context of the proposed service plan for the health services.

I propose to share time with Deputies Peter Fitzpatrick and Pat Breen.

I move amendment No. 1:

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

"agrees that the 2014 national service plan provides a comprehensive basis for the Health Service Executive, HSE, to continue to deliver safe and high quality health and social care services to the general public throughout the year;

notes that the overriding priority reflected throughout the 2014 national service plan, at a time of undoubted financial constraint, is the commitment to patient safety;

notes that the HSE has set the advancement and implementation of the Government's programme of health reform at the centre of its service planning for 2014; and

notes, in particular, the progress that has been made in reducing the waiting times for patients on trolleys in emergency departments, with a reduction of 8,814 in the year to 27 December 2013, down 34% from 2011."

I welcome the opportunity to address the House regarding the 2014 national service plan for the health services. As Deputies have pointed out, this is a time of significant challenge for the health system as a consequence of the emergency financial situation the State has had to address in recent years. Conveniently, all of the speakers opposite omitted to explain how we ended up in that financial morass. Fortunately, as a result of the hard work of the Irish people, we are now emerging from it.

Along with significant and sustained financial pressure on the health system and reductions in health and social care funding and workforce numbers, the health services have also had to respond to significant demographic pressures, with the population of the State increasing by 8% and the proportion of persons aged 65 and over growing by one fifth since 2008. Several Deputies referred to Mr. Tony O'Brien's statements before and after the Cabinet meeting in December. The differences in his second statement are reflective of the decision at that meeting to provide an additional €47 million, which makes the delivery of the service plan much more achievable. Nonetheless, we are facing a serious challenge in 2014. Indeed, it might well be the most challenging year so far for the health services.

The 2014 service plan outlines a comprehensive response to these challenges. Fundamentally, it is about patient safety, with the emphasis throughout on enhancing and improving measures in that regard. The plan also reflects our focus on reform and builds on the significant progress we have made in implementing our historic programme of reforming initiatives. The evidence of our success thus far in these two areas - reform and patient safety - can be seen in the year-on-year reduction in the number of patients on trolleys in our hospitals. Despite the significant challenges, we have not only ensured that the health services are responding to the day-to-day pressures of providing high quality care with reduced resources but have also begun putting in place the building blocks of a health service fit for the 21st century. Since the publication of our strategy for reforming the health services in November 2012, we have set about redesigning a health service that provides access according to need rather than ability to pay, enables best health outcomes for available resources, and treats patients at the lowest level of complexity that is safe, timely, effective and efficient, and as close to home as possible.

In 2014, we are implementing the money-follows-the-patient funding system in hospitals on a phased basis, building on the work we did in 2013. Participating public hospitals will be paid for the actual level of activity undertaken rather than receiving a set annual grant. This will support greater efficiency in hospitals and help to enhance patient safety. It will also ensure a patient-centred service. Simply put, if there is no patient, there will be no payment to the hospital. We will continue the work on hospital groups that we began in 2013, appointing new group chief executive officers where required and developing memoranda of understanding between the Health Service Executive and each group. In addition, we will be seeking new industry partners, including from abroad, in the areas of pharmaceuticals, medical devices and other areas of research. The objective is not just to improve health care but also to create jobs in these areas.

Embodied in hospital groups is the fundamental principle of system reform whereby care will be given at the lowest level of complexity and as close as possible to home. This reflects our desire to empower health service staff, within a robust system of governance, to make better decisions in the interests of patient safely. Alongside this reform of hospital groups, we will be working on the establishment of new community areas, with associated governance and organisational arrangements, following the completion of the review of integrated service areas. We will implement new internal management structures with specific programmes relating to shared services, procurement, human resources and information. This builds on the abolition last year of the HSE board and establishment of the HSE directorate, and will be complemented by reform of the Department of Health. Our shared goal is to enable the health sector to respond in a more effective way to patients' health needs and empower health service staff.

Signal among these reforms, as set out in the 2014 service plan, is the establishment of a patient safety agency, initially on an administrative basis within the HSE structure. This will represent a major step in improving safety and quality. The agency will have an advocacy role in regard to patient complaints, supporting patients by directing them to the appropriate provider or agency that can provide a response to the issues they raise. If patients do not obtain satisfaction, the agency will be able to help them to advance their complaint in another forum. Based on a detailed analysis of complaints throughout the system, the patient safety agency will provide national leadership for patient advocacy services, including the health service charter, You and Your Health Service. The agency will also focus on leadership and capacity-building for patient safety, clinical effectiveness, adverse-event learning and clinical audit.

Patient safety is our watchword and the number one priority in respect of both clinicians and health system management. It must be fully built into governance, management and accountability systems throughout the health services. In 2014, there will be a particular focus on the priority areas of medication safety, health care-associated infections, HCAI, and the national early warning score, NEWS. The plan also seeks to implement the recommendations contained in the reports of the Health Service Executive and the Health Information and Quality Authority regarding the maternal death at Galway University Hospital in 2012, by targeting necessary patient-centred improvements in maternity care.

Our programme of reform extends beyond the health services into addressing the growing incidence of chronic illnesses and the challenges of an aging population. In 2013, we published Healthy Ireland - A Framework for Improved Health and Wellbeing, which sets out a whole-of-government and cross-sectoral approach to addressing the demands placed on health and social care services.

The commitment in the 2014 service plan to the health and well-being reform agenda set out in Healthy Ireland is critical in terms of enabling the required shift in emphasis towards health prevention, promotion and improvement in the years ahead.

The Government is not unfamiliar with the need to achieve savings. It is reflected in the service plan in the shape of €619 million worth of savings measures, which reflect an additional €47 million in health funding provided by the Government in the Revised Estimates. As already outlined, this target is challenging. The House will be aware that as part of budget 2014, I sought an objective verification process to focus on medical card probity, for which the original budgetary target was €133 million. The outcome of the verification process is that €23 million, rather than €133 million, has been targeted in medical card probity. This takes account of the progress already made on probity and of the Government's commitment that everyone who is entitled to a medical or GP-visit card will have that entitlement guaranteed. I reiterate for the benefit of the House and the public that no person who meets the eligibility conditions for a medical card will be affected by this measure. In fact, the 2014 service plan provides an additional €35 million to meet the cost of new applications for medical and GP-visit cards this year. The Government will ensure that those who are entitled to medical cards will continue to hold them.

The implementation of the Haddington Road agreement is now well advanced in most sectors and is delivering on its objectives. The agreement involves a demanding set of targets for the health service, which accounts for approximately one third of the overall public service workforce. The focus and responsibility of HSE management is on the delivery of the necessary savings and a HSE national assurance and support team is working with managers to ensure that measures to deliver these savings are implemented. Under the service plan, the €108 million in pay-related savings form an integral part of the overall savings target. This will be subject to a separate process and will, of necessity, remain unspecified and be held centrally by the HSE until measures to realise these savings have been agreed between the Departments of Health, the Taoiseach and Public Expenditure and Reform.

Of course, we are going to achieve significant savings from reference pricing and generic substitution. Price reductions of the order of 30% per item reimbursed have been achieved since 2009 and the average cost of items reimbursed is now running at 2001-02 levels. It is anticipated that reference prices will be set for 80% of the off-patent market by the end of this year. We introduced the first reference price in November of last year for atorvastatins and the HSE now pays 70% less for these products compared to what it was paying last May. This will ensure that the medicine prices in Ireland fall towards European norms. This year will also see continuation of the HSE's preferred drugs initiative to facilitate the most cost effective prescribing, particularly in respect of high-cost medicines and the continued full-year impact of pricing agreements concluded with the Irish Pharmaceutical Healthcare Association, IPHA, and the Association of Pharmaceutical Manufacturers in Ireland, APMI, which will result in savings of €28 million in 2014.

For people and patients, a key barometer of the success of our reform programme must be the performance of emergency departments and waiting lists. I am proud to report that there has been a 34% reduction in the number of accident and emergency department patients waiting for ward bed accommodation when one compares 2013 to 2011. That is almost 30,000 fewer patients waiting on trolleys. The figure for the number on trolleys in accident and emergency departments today stands at 327. The remainder are on wards, some on trolleys and some in beds. Two points need to be made in this regard. One cannot compare today's figures for those of years past because Ward Watch did not exist then and the trolleys and beds in wards were not counted. More importantly, outcomes for patients are absolutely proven to be much better when they are on wards and regardless of whether they are on trolleys or in beds. It is patient outcomes with which I am concerned.

The House will be aware that surges in demand occur around the new year and Easter. Such surges cause difficulties for everyone in the health services, especially patients. The key point is that health service staff are aware of these increases in pressures and, in conjunction with the special delivery unit, are working on measures to address them. This sustained focus and effort has seen a 3% reduction to date in 2014 compared to 2013. This, of course, is not of much comfort to patients who have been caught up in the situation and I acknowledge that. However, it should also be acknowledged that we have worked to address the ongoing problem of trolleys. We have made - and will continue to make - progress and we will continue to work to address this matter. Our commitment to addressing the situation is underlined by the targeted funding of €30 million available to better address areas of acute services which are likely to experience increased service demand. With this funding we will specifically seek to assist demand-led services such as emergency departments through the identification and utilisation of additional capacity and capability across the system.

When we came into government, there was no information available in respect of outpatient waiting times. Ours is the first Government to count the number of people on the relevant waiting list and in March of 2013 we indicated that over 384,000 people were waiting for outpatient appointments. Some of these individuals have been waiting for their appointments for more than four years. Some 103,000 of the 384,000 patients to whom I refer were waiting longer than a year for appointments. I have requested that no one should be waiting for longer than 12 months by the end of the year. I am pleased to say that despite the 10% reduction in staff, the 20% reduction in our budget, the 8% increase in population and the 20,000 additional people per annum who survive past the age of 65 - which is great but which increases the pressure on the system - in just nine months over 98,000 people have come off the list. That is an extraordinary achievement by the men and women who work in our health service and I take this opportunity to salute them.

More needs to be done-----

-----and it will be done. However, what I have just stated shows the great progress that can be made by means of reform.

The Deputies opposite were involved in a Government which had access to unprecedented amounts of money. However, that Administration did not take advantage of this and institute the reforms that were so badly required. From 1997 to 2007, health spending quadrupled but accident and emergency departments became increasingly crowded and outpatient lists became longer and longer. We have also reduced the target for inpatient treatment from nine months to eight. Some 99.99% of the 41,287 adult patients on the elective waiting list were seen within eight months. That is also a very positive achievement, particularly in light of the downward revision of the target. A total of 95% of children awaiting inpatient or day-case surgery are waiting for under 20 weeks and 99% of patients awaiting routine endoscopy procedures are waiting for fewer than 13 weeks. This means that some targets have not been met and we have a plan to deal with that. We will deal with it.

I wish to bring to the attention of the House the significant service developments that are provided for in the 2014 service plan. In line with the commitment in the programme for Government in respect of universal health insurance, a GP service without fees at the point of use will be provided to an estimated 240,000 children aged five and under in 2014. Additional funding of €37 million was provided in the budget to meet the cost of this measure. This is critically important as a building block on the road to universal health insurance. A further €20 million has been earmarked to meet the commitment in the programme for Government in respect of mental health services. This funding will allow for continued strengthening of community teams, increased suicide prevention resources and clinical programme development and implementation and will support an extra 250 to 280 posts. These posts are in addition to the approximately 900 posts approved to date under the programme for Government commitment to mental health service development.

The 2014 HSE service plan includes provision of an additional €178 million for vital service developments, including €35 million for new medical cards and €30 million to meet increased demand across the acute service areas to which I referred earlier. Other priority service areas addressed in the plan at my specific request include additional funding of €4.5 million for the continued roll-out of diabetic retinopathy screening and treatment - thus ensuring that many people who would otherwise have gone blind will not do so - and €3.2 million to provide a service to undertake bilateral cochlear implants, with particular focus on five and six year olds in order that no one will pass his or her seventh birthday without having such implants inserted, if necessary, and thus miss out on the opportunity for near normal hearing.

A total of €10 million is being provided for young people with disabilities leaving school and training and requiring emergency and residential needs placements so that their parents are not forced to spend the summer worrying about where their children will find a place in the autumn.

Almost €3 million is being provided for additional organ donation and transplantation resources to benefit patients and their families, in particular to allow for more live kidney donations. A total of €1.2 million will allow the discharge from hospital and required care in the community for special care children who have undergone tracheotomies in order to allow such children to grow up at home and not in hospital.

The primary focus of the HSE throughout this year will be to deliver the same level of front-line services with a reduced budget while ensuring that quality and safety are paramount. In this regard, the director general has highlighted that the Haddington Road agreement provides an important mechanism for delivering the service plan. I fully endorse those comments.

Speakers referred to the fair deal scheme. There has been a transfer of €23 million which will mean 700 fewer people in long-term care and not 900 fewer as stated. This will allow more than 1,000 extra people to stay at home as a result of the introduction of new supports. More people will be availing of free GP care with more than 2.2 million entitled to and in a position to access free GP care during the course of this year.

The refrain from the other side of the House is that the health service is in chaos and that it will collapse. Chaos is 569 people on trolleys on a day in January 2011; chaos is not even knowing the extent of an outpatient waiting list; chaos is having no idea how long a patient must wait to have an operation, a wait which could run to one, two or four years. Despite the constraints, the system can now look after patients in a far better way. There has been a massive, 95% reduction in the numbers waiting longer than one year for an outpatient appointment, a reduction of 34% in the numbers enduring long waits on trolleys and all adult patients are being treated within the eight-month period set down for inpatient procedures once seen by a consultant.

Having seen the consultant.

Yes. In the past we did not know how long they had been waiting to see a consultant.

Exactly. Deputy Cowen and his party were afraid to count them. They did not want to know - "sweep it under the carpet and say it ain't so". That has always been the Fianna Fáil way, going right back to Charlie Haughey; say it often enough and it is so. That is not the way this Government is going to behave and that is not the way we are going to run this health service. We are open and transparent and we engage with the front line. I warrant that no Minister has been to more hospitals in his first three years than I have been. I continue to engage with the system, I continue to support them and I salute the Herculean effort they make on our behalf every day.

This year remains an extremely challenging one for the health services. The scale of savings to be achieved remains considerable. However, the health service has already risen to the challenge of delivering significant savings while maintaining and improving the health services. Since the onset of the recession, there has been a 20% reduction in the health budget, amounting to over €3 billion, a reduction of 10% in staff numbers, amounting to 10,000 staff, and an increase of 8% in the population.

The Minister for Health expressed concerns about the number of savings targets set for the health services in the recent budget. He requested that a validation process involving the Secretaries General of the Departments of Health, the Taoiseach, and Public Expenditure and Reform examining these targets. Following this process, the savings in the medical card scheme has been reduced from €133 million to €23 million. The Government has agreed to provide an additional €47 million for the health budget for 2014. This additional allocation was made possible because of the recovery in the labour market. Projected levels of unemployment next year are lower than projected at the time of the budget. The remaining €63 million in savings is being provided for on an interim basis from pension provisions.

A core objective of the health service plan is to maintain front-line services and prioritise safe, quality treatment for patients in a timely manner. Safety monitoring is a key priority. A comprehensive set of quality and safety indicators will be developed and monitored. Key reforms to be progressed include the establishment of a new patient agency to promote good safety practices in the health service and to provide advocacy support to patients; the establishment of a health care commissioning agency; a national pricing office; phased implementation of a money-follows-the-patient approach in acute hospitals; the establishment of hospital groups; a focus on actions to promote health and well-being; and the transfer of responsibility for child and family services from the HSE to the new Child and Family Agency.

A total of €35 million has been provided for an additional 60,000 medical cards. Approximately 420,000 children aged five years and under will benefit from free GP care as part of the move to universal health insurance. More than 90% of those aged over 70 will remain covered by either a medical card or a GP visit card.

Disability services will receive additional funding of €14 million and 130 additional staff have been provided to address priority needs in disability services. A total of €7 million is being allocated to provide an estimated 1,200 additional places for school-leavers. A total of €3 million is allocated to provide emergency placement for people with disabilities whose family circumstances have changed and who require an immediate and unplanned service response. A total of €4 million will deliver the required increase in services for children with disabilities, including autism. There will be no cuts to the level of home support and personal assistant hours. The target for the number of home service hours provided to people with disabilities in 2014 is 2.4 million. The target for the number of personal assistant hours provided to adults with a physical or sensory disability in 2014 is 1.3 million. The level of respite care will also remain the same as the 2013 level.

The priority for services for older people is to provide comprehensive home care and community support in order to maintain older people in their own homes and communities for as long as possible. The HSE provides home help and home care packages to approximately 56,000 people at any one time within an overall budget of €315 million. A total of 10.3 million home help hours are to be provided in 2014 and 10,870 home care packages.

The nursing home support scheme will continue to support over 22,000 people in long-term residential care at a cost of €939 million. An additional €20 million has been ring-fenced for 250 to 280 posts in the mental health services in 2014 to enable the strengthening of community teams, increased suicide prevention resources and clinical programme development and implementation.

The service plan provides funding for key service priorities in 2014 which include funding of €3.22 million to undertake bilateral cochlear implants; funding of €1.48 million to deliver patient-centred improvements in maternity care; an extra allocation of €8.3 million for cancer services; and €2.92 million for organ donations and transplantation services. Funding of €30 million has been provided to address waiting lists by increasing access to accident and emergency departments, day care and outpatient services. Funding of €3.1 million has been provided to implement a sustainable approach to the recruitment of non-consultant hospital doctors and to progress compliance with the EU working time directive.

The biggest threat to the health service of our nation is the doom and gloom merchants on the Opposition benches who constantly question the Government's record on health, despite their party's dreadful record in that Department.

It is acknowledged that 2014 will be another challenging year for the health services, in particular, taking into account the savings of €619 million which must be achieved. In spite of the fact that the HSE must operate with fewer resources and fewer staff, it has managed to make real progress. For example, the mid-west hospital group in my region has seen a number of positive developments such as the commencement of the colorectal screening programme in Ennis and the neonatal screening programme in Limerick. A total of 7,472 additional in-patients and 11,094 outpatients were treated in the system. There is no denying the bottle-neck at the accident and emergency department at the Mid-West Regional Hospital at Limerick.

It is particularly acute at this time of the year when, traditionally, there is a peak in the number of people attending emergency departments. Hospitals in Northern Ireland and the UK have witnessed similar increases since Christmas. However, the situation in the Mid-Western Regional Hospital in Limerick could be alleviated by reducing the disruption and extending the hours of operation of the services in Ennis. The idea of developing local injuries clinics and medical assessment units was to reduce the need for patients to present themselves at emergency departments.

The medical assessment unit in Ennis was closed for three and a half days earlier this month when the senior doctor who was scheduled to be on duty in the unit was off sick and there was nobody there to replace him, forcing Clare patients to travel to Limerick and putting the service there under further pressure. I am glad the HSE intends to promote greater use of these units this year. However, in order to do so, it is important it puts a staffing procedure in place in Ennis which will minimise any further disruption. In addition, the medical assessment unit in Ennis should be open on a seven-day basis which would eliminate the need for some patients to travel to Limerick at weekends.

The problems in the accident and emergency department in Limerick are causing a lot of distress and upset for patients and their families and for the staff who are working there. The solution is to have a new emergency department up and running as soon as possible. I understand that while work is well underway on the new facility, it could be 2016 before it is operational. It should be fast tracked. I put that question to Ms Ann Doherty and I know they will do their very best to open the new emergency department, hopefully, at the end of 2015.

I constantly receive complaints from constituents about the length of time they have to wait at accident and emergency departments. Given that this facility will not be opened in the short term, I urge the HSE to open additional beds in the interim to alleviate the situation.

I have always argued that a separate paediatric emergency department should be available in Limerick hospital given that paediatric services are no longer provided in Ennis. It is not acceptable that sick children who are attending the accident and emergency department must wait in the same area with adults, in particular at night and at weekends when the accident and emergency department is overcrowded with people coming from pubs and nightclubs being treated. I understand the HSE plan for 2014 envisages the development of an interim paediatric accident and emergency department and I urge it to proceed with that facility as soon as possible.

The Minister has an ambitious plan for our health service. He does not have the luxury of resources which the previous Administration had but in spite of this, he has embarked on a programme of reform which is delivering real and tangible results and I commend him on his work. I urge the Opposition to end the charade of political opportunism and to work with the Government to deliver a better health service to our people.

Yesterday, I attended a briefing by HSE mid-west in Limerick. I understand the local service plan hopes to keep the same service this year. We were told by the director that it was an ambitious project. Given the limited resources and reduction in funding, it has put a plan in place which will try to keep the same service we had in 2013. I commend the local HSE in that regard.

I welcome the opportunity of this Private Members' motion to address the situation in our public health service and the total inadequacy of this Government's budget for health and of the HSE's 2014 service plan. Sinn Féin will support the motion in the name of the Fianna Fáil Deputies as far as it goes. We agree, as the motion states, that the 2014 national service plan of the HSE is inadequate to fully meet all of the growing demands being placed on the health service. We also agree that the lack of sufficient resources will not be in the best interests of patient care and that this is already evident in accident and emergency departments.

That said, we are disappointed the motion does not go further. It makes no demands on the Government and puts forward no proposals for improvement and for the fundamental change, which is needed. This is disappointing but not surprising given that it was the Fianna Fáil leader, Deputy Martin, as Minister for Health, who set up the HSE in the first place. He maintained the unequal two-tier health system with its top heavy bureaucracy and its inequitable delivery of services both in terms of the public private division and in terms of regional disparities.

The current Fine Gael-Labour Party Government and the Minister for Health have talked much about reform but with little result. The reality has been that they have continued with the year-on-year cuts to our public health service which were begun by the last Fianna Fáil-led Government. A number of our Deputies have requested meetings with clinical directors in their areas to discuss the impacts of the health service cuts but some have been very slow to in coming forward to facilitate these meetings. For elected Deputies that is not good enough.

As I pointed out at the Select Committee on Health and Children today when we were dealing with the Revised Estimates for health, by the end of 2014, under the HSE's service plan, almost €4 billion will have been taken out of our public health service since 2008. In terms of staff numbers, a further 2,600 whole-time equivalents are to go in 2014 on top of the 12,500 which have gone since 2007. As the HSE admitted in the suppressed memo to Cabinet in advance of publication of the HSE service plan, the cuts being imposed in 2014 are unsustainable.

The statement earlier this month by the Irish Emergency Medicine Trainees Association that overcrowding in hospital emergency Departments is unequivocally dangerous for patients is a wake-up call for the Government. The trainees pointed out that over the previous two weeks, trolley numbers had exceeded 300 per day, and this came after the Irish Nurses and Midwives Organisation highlighted the increase in trolley figures in 2013 over the previous year.

The health cuts imposed by this Government, and reflected in the HSE service plan, are set to make the situation worse over the course of 2014. Hospitals are under severe pressure and the bed shortage is acute. This is compounded by the decision not to provide additional funding in the service plan for nursing home places, leading to more older people occupying acute hospital beds for longer as they await ever scarcer nursing home places.

Under the heading of care of older people and community care, the Fine Gael-Labour Party programme for Government states:

Investment in the supply of more and better care for older people in the community and in residential settings will be a priority of this Government. Additional funding will be provided each year for the care of older people. This funding will go to more residential places, more home care packages and the delivery of more home help and other professional community care services.

This Government is clearly reneging on its commitment in its programme for Government to ensure the supply of more residential places for older people who need them. By its failure to live up to its own commitments, the Government is condemning older people, especially those with dementia, and their families to the misery of long stays in our public hospitals as they await nursing home places. This is first and foremost a terrible ordeal for those older people. Crucially, given the crisis in our hospitals, it means that acute hospital beds are being occupied by people who need long-term residential care and not long-term acute hospital care.

The first State-wide audit of dementia care carried out by Dr. Suzanne Timmons, consultant geriatrician at UCC Mercy Hospital, has just been published. It shows that one quarter of inpatients in our hospitals are affected by dementia. That is a huge percentage. The audit also shows that our health system is ill-equipped to deal with dementia. I cited this at the Select Committee on Health and Children today and I stress it again. The figures in the audit show that 91% of hospital wards have no access to psychology services while more than one third of wards have unfilled health care assistant vacancies. Dr. Timmons stated that the low standard of dementia care in hospitals continues to affect the overall well-being of patients. She also stated that for a person with dementia, it must be much more challenging and frightening and that if one is used to being at home with someone one recognises and is used to one's own routine, the acute hospital must be a very frightening place and that is why everyone who works in a hospital needs to improve their practices.

This will be growing problems which will need to be addressed but clearly Government policy is going in the opposite direction, as the service plan confirms. I urge the Government to change direction on the care of dementia, which is affecting increasing numbers of people as our population lives longer.

I want to take the opportunity presented to me by this health care debate to raise the imminent closure of Mount Carmel Hospital in Dublin. This hospital is being allowed to close with hardly a murmur from the Minister for Health. While it is privately owned, we have been told by the Irish Nurses and Midwives Organisation that at the time of last week's shock closure announcement, some 80% of the hospital's patients had been referred directly to it by the HSE from our public hospitals. Mount Carmel Hospital is not simply a private maternity hospital, as reported in the media. It has been providing a wide range of services and taking pressure from hard-pressed public hospitals. We are talking about 130 beds and 330 staff - 200 of them nurses - being removed from our health system. Why is this happening? Is it the case that the owners of Mount Carmel Hospital petitioned the High Court for liquidation at the behest of NAMA because their loans are in NAMA? This requires more detailed address by the Dáil and a detailed response from the Minister. I hope the Ceann Comhairle will accede to the request of Deputies for a Topical Issue debate on this pressing matter tomorrow or on Thursday. If something is not done in the next few days, this health facility will close, 130 beds will be lost and 330 experienced, qualified and dedicated staff will lose their jobs.

I wish to say a little more about the service plan. It has to be said that despite the untiring efforts of health workers, our service is not fit for purpose. The cuts introduced by Fianna Fáil, the Labour Party and Fine Gael have devastated front-line care. Some €4 billion has been taken out of our health services since 2008, while our people continue to pay the enormous debts of bankers and financial speculators. Thousands of people, including seriously ill and disabled children, are facing the loss of their discretionary medical cards this year. Accident and emergency services in hospitals throughout the State are under threat. Funding for nursing home beds is being cut. The knock-on effect of this is to put pressure on hospital beds. Prescription charges have been trebled by a Minister who condemned them when he was in opposition. All of this sends a clear message to the sick, the disabled, the elderly and anybody else who depends on the health service that they are far less important to the Government than investors, speculators and the markets. This is a grave injustice. Any Government that persists with such a policy is morally bankrupt. Sinn Féin is telling the Government that health care is a basic right and that the health service must not be diminished any further. It is beyond time for radical changes in the Government's health policy. We need a change of direction and we need it now.

Apparently, some Members of this House are disappointed that the media has been focusing on the Committee of Public Accounts in recent weeks. It has been suggested that the committee in question, rather than this Chamber, has been at the centre of parliamentary discourse. I do not know what Members are annoyed about, given that no Fianna Fáil Deputies are present for this part of the debate on a Private Members' motion that was tabled by their party. They have not had the courtesy to remain to hear contributions to the debate on their own motion. Equally, neither the Minister for Health nor the Ministers of State at the Department of Health are in attendance. I have stayed here until the very end of this evening's session to raise an issue that pertains to this motion, but the Deputies from the party that proposed the motion have not bothered to stay. The relevant Minister and Ministers of State are not here either. How can this place be taken seriously in that type of scenario?

The Minister, Deputy Reilly, has just left because he has an appointment.

Surely one of the three Ministers or Ministers of State could have stayed.

I will pass the Deputy's remarks on to the Minister.

Deputies cannot complain about the Committee of Public Accounts when we have that kind of scenario in here.

I ask the Deputy not to invite argument.

Fair enough. Who would I be to argue with the Chair?

I hold the Chair in high esteem.

The Deputy and I could spend the whole night arguing about this, but we would be wasting the Deputy's speaking time. We would not want to do that.

I assure the Chair that I am happy to use one minute of my time to make that point.

As a representative of Donegal North-East, the best example I can give in dealing with the substantive issue in this debate is the case of Letterkenny General Hospital. As Deputies will know, a serious flood last year affected the hospital's new three-storey building as well as the older part of the hospital. Approximately 40% of the hospital's floor space was contaminated by flood water. It was an unprecedented level of crisis for a hospital in this State. The response of the hospital's management and staff to that incident, both on the night it happened and during the clean-up in the days that followed, was absolutely heroic. It has been a substantial challenge for them to hold the place together since that time. However, the hospital's accident and emergency department has been overwhelmed in recent weeks. Contrary to what some people have suggested, this is not solely as a result of the impact of the flood. It is a reflection of the historic neglect of the hospital.

Letterkenny General Hospital is the seventh largest hospital in the State. Each year, it takes in approximately 21,000 inpatients, which is considerably more than some hospitals that have higher budgets. It is remarkable that it is designated as a general hospital rather than a regional hospital as it should be. It deals with 21,000 inpatients. It has the lowest budget allocation per inpatient and the lowest allocation of staff in the State. That has been the case for many years. It has been suggested to me that last year's flood and the response to it took the spotlight from the hospital's inevitable medical staffing crisis. The hospital has approximately six medical registrars, measured as whole-time equivalents, when it needs 16 of them. There is a real crisis in terms of that key component. It is not possible to sustain all the specialties in a hospital and man a 24-hour accident and emergency unit in the absence of the required number of medical registrars.

I would like to conclude by speaking about the historic neglect of certain hospitals in various parts of Ireland. I refer, for example, to the manner in which junior doctors are allocated from the training hospitals. It is right that the taxpayer, through the HSE, subsidises those training hospitals. However, there does not seem to be a means of ensuring these key staff are allocated fairly to other hospitals. I want to use this debate to call for that to change. This is not some parish pump thing. The facts are the facts. It is a fact that Letterkenny General Hospital has the lowest budget allocation per inpatient and the lowest allocation of medical staff in the State. That was the scenario before the flood. We want to see the full restoration of Letterkenny General Hospital. I am not just talking in terms of capital. We need to ensure the hospital has enough staff to run effectively. I will make three recommendations in that context. First, Letterkenny General Hospital needs to be upgraded to regional hospital status. Second, there needs to be a fair allocation of staff and budgetary resources to the hospital, based on its number of inpatients. Third, and most immediately, there needs to be an allocation of medical registrars to the hospital, especially given that we have heard from the most senior staff at the hospital that it is facing a staffing crisis in this key area. I call on the Minister of State to pass this urgent message on to the Minister and Ministers of State at the Department of Health. The staff of the hospital should be met half way. The Government should respond to the heroism of the staff and management of the hospital by giving them what they need to do their jobs.

Before the House adjourns-----

I understood I had five minutes.

If we could prevent the cutbacks in the health services as easily as we prevented the cutting short of this debate, it would be a good turn of events. I welcome the opportunity to contribute to the debate. Deputy Breen referred to the doom and gloom merchants on the Opposition benches. I wonder whether he considers the chief executive of the HSE, Mr. O'Brien, to be a doom and gloom merchant, given that he has said that this year's HSE funding cuts may not be in the best interests of patient care.

I wish to give two examples of the impacts of the cuts in funding to the HSE on my community in County Donegal. It ties in with the example given by Deputy Mac Lochlainn of the difficulties in Letterkenny General Hospital. Killybegs community hospital has 48 beds dedicated to respite care and long-stay care for elderly patients. However, today eight of those beds are closed because of the embargo the Government has applied in the health service. Those eight beds are closed because management will not replace staff, who have retired or are on sick leave, which would allow the hospital to operate to its full capacity. This means that many elderly patients are scattered around County Donegal, many of them 40 or 50 miles away from their homes in nursing home care because they cannot access a bed in their own communities.

That shows the impact the cuts in the health services have had in recent years. Those cuts are continuing because there is no sign of the embargo being lifted. If we want the health services to work for the benefit of the community, we need to ensure that beds in community hospitals are kept operational. Staff should be allocated on a temporary basis to ensure that happens. This ties into the problems Letterkenny General Hospital is having because patients cannot move out of the general hospital into community hospitals where many beds have been closed because of staffing shortages and the ongoing embargo. That indicates the crisis we have in community hospitals.

In the past week the community on Arranmore Island was faced with the loss of its public health nurse. This is an isolated community of 500 people - ten years ago more than 1,000 people lived on the island. As a result of the withdrawal of services and the difficulties in this recession, people have moved away and emigrated. This community had a vital link in having a public health nurse available full-time on the island. The HSE in its wisdom proposed to move this nurse from the island and replace her with a part-time nurse. Thankfully, the community mobilised and today that decision was reversed, which I welcome. However, the community should never have had to do this. The community should have been comfortable in the knowledge that despite all the threats it faces, the threat of the removal of health services should not have been one. It should have been able to look to rebuild the population on the island in the confidence that it would have the services for people. That decision was only reversed because the community mobilised and fought for a service to which it is entitled.

Those two examples give an idea of the crisis that many people face every day because of a lack of investment in our health services. In launching the HSE's service plan, Mr. Tony O'Brien stated that his overriding priority was patient safety and his next priority was treating patients in as timely a fashion as possible given the constraints the service is under. It is a sad indictment of a health service in 2014 that the best we can hope for is to treat patients safely and then in a timely fashion. We should be looking to invest in our health services and develop them so that they can provide for the people who need them most.

I wish to highlight some items that have been dropped from the HSE's service plan, including a reduction of €53 million in services for older people. In the next ten years the number of people over 65 will double and in hospitals such as Killybegs Community Hospital we will need to double the number of beds - not closing beds because of an embargo. We need an investment programme to double the number of beds available over the next ten years for that ageing population. There has been a reduction of €3.9 million in the colorectal screening programme. That is an investment that would save money in the long run and it indicates the Government's short-sightedness in the HSE service plan. BreastCheck has been cut by €500,000 preventing the further roll-out of that programme, which is also an investment that would save money.

The health services need investment and increased funding as opposed to this constant mantra of more for less, which is absolute rubbish.

Debate adjourned.