Health Service Executive (Financial Matters) Bill 2013: Second Stage

I move: "That the Bill be now read a Second Time."

I am pleased to introduce the Health Service Executive (Financial Matters) Bill 2013 to the House. The Bill provides for the disestablishment of the Vote of the Health Service Executive and the funding of the executive through the Vote of the Office of the Minister for Health. It also provides for a new statutory financial governance framework.

The Government is reforming the health services and it is reform of unprecedented breadth and depth. It is radical and will ultimately see the introduction of universal health insurance. In November 2012, I set out the building blocks for this reform in Future Health: A Strategic Framework for Reform of the Health Service 2012-2015. Many of the initiatives, such as the eventual replacement of the HSE, will require further legislative changes. The Bill is, therefore, a transitional measure, building on earlier changes provided for in the Health Service Executive (Governance) Act, which was passed last year.

The Health Act 2004 provided that the HSE had its own Vote and that the Minister for Health had no legal role in setting its budget. The House will understand that the intention was to give the HSE greater operational autonomy from what, at the time, was characterised as a politicised decision-making system. In my view, it crucially weakened the accountability of the HSE to the Minister for Health and the Department of Health, and thus this House.

The Bill seeks to rectify that situation by restoring the Vote of the HSE to the Office of the Minister for Health and thus re-establishing appropriate and proper accountability for the HSE to Government. It is also another step on the reform journey, including the dissolution of the HSE, the establishment of a health commissioning agency, new community care structures and the establishment of hospital trusts.

It is appropriate that I take this opportunity to tell the House that we have been progressing our reform since the publication of Future Health just over a year ago. We published reports on establishing hospital groups and on the future of smaller hospitals. Since publication, we have appointed chairpersons for each of the seven groups and we are currently in the process of appointing the chief executive officers. In March 2013, we published Healthy Ireland, our strategy for empowering people in Ireland to get healthier. As part of Healthy Ireland, we published Tobacco Free Ireland, our strategy for making Ireland tobacco free by 2025. I am aware that the Members opposite were at the Oireachtas Joint Committee on Health and Children at which this important issue was discussed with the tobacco industry and the Law Society of Ireland. We have also published a package of measures to tackle alcohol misuse in the form of a Public Health (Alcohol) Bill. We are moving to tackle obesity through the special action group on obesity. We have also published an e-health strategy and will be progressing work on that through 2014. Shadow funding for selected hospitals under the "money follows the patient" system commenced in 2013 and it is being rolled out to all hospitals this year.

In addition, a draft of the White Paper on universal health insurance is being completed and I anticipate that this will be published shortly. Deputies will also be aware that there have been a number of reports highlighting the need for changes in the way the health services are financially managed. The successful implementation of the reform programme requires a fundamental change in the financial management systems in the HSE. To this end, a financial reform programme has been initiated within the executive with the establishment of a finance reform board to oversee the programme and, in particular, to oversee the establishment of a national financial management and procurement system in the HSE.

The Bill provides for the disestablishment of the Vote of the Health Service Executive from January 2015 and from that date the funding of the executive will be mainly through the Vote of the Office of the Minister for Health by way of grants paid to the executive. The executive will itself continue to collect the income it generates through statutory charges, superannuation contributions and other miscellaneous income. The director general of the HSE will become an accountable person rather than an Accounting Officer and the Bill sets out an alternative statutory framework to govern the funding of the HSE and ensure that proper controls, in regard to its expenditure, are exercised by the director general. The Bill also makes consequential changes to the service plan process to align it with the new budgetary arrangements.

The Bill is divided into three Parts. Part 1 provides for preliminary matters. Part 2 contains the amendments to the Health Act 2004. Part 3 contains transitional provisions which are required to enable the change from the current statutory regime to the new regime and ensure continuity in accountability for the expenditure of the executive. Part 1 has three sections which are technical provisions covering matters such as the Title, commencement, definitions and repeals. They are standard provisions. The only provision being repealed is section 34 of the 2004 Act , which required ministerial sanction for any capital project in excess of an amount determined by the Minister. This provision is redundant as a new process for approval of a capital plan is being provided in a new section 33B as inserted by section 11.

Part 2 contains the body of the Bill, which is designed to amend the 2004 Act, as amended by the governance legislation, to put in place the new statutory framework. It amends a number of sections and inserts a number of additional sections. Section 4 amends section 5A of the 2004 Act. Section 5A provides that expenses incurred by the executive are payable out of moneys provided by the Oireachtas subject to the approval of the Minister for Health and the sanction of the Minister of Public Expenditure and Reform. The amendment limits the application of this provision up to 1 January 2015. This is because the provision is being replaced by a new provision, section 33A, which is being inserted by section 11, which I will outline shortly.

Section 5 amends section 16G, which was inserted by the 2013 Act. Section 16G sets out the general functions of the director general. The section specifically provides that the director general is responsible to the directorate, as the governing body, for the performance of his or her functions, except where he or she is acting as chairperson of the directorate. The amendment provides an additional exception where the director general is required to report to the Minister for Health if he or she is of the view that the actions of the executive are likely to lead to a breach of its budget limits, which is provided for in section 34A, as inserted by section 12 of this Bill.

Section 6 amends section 28 of the 2004 Act, which provides specific definitions for Part 7 of that Act. Part 7 sets out the accountability framework for the Executive. This section adds further definitions which are required arising from the other provisions of the Bill. The main ones are in regard to net determinations - budgets - an approved capital plan and related matters.

Section 7 inserts a new section, section 30A, enabling the Minister to determine a net budget for the HSE and sets out the process for doing so. Essentially, the Minister is required to notify the HSE of its budget no later than 21 days after the publication of the Estimates for the Public Services, more commonly known as the Abridged Estimates Volume, or AEV. In practice it is likely that the net determinations will be issued on the day the AEV is published or the next day. The section also allows the Minister to adjust a net determination for the HSE in the course of the year.

Section 8 amends section 31 of the Act, which provides for the executive to prepare and submit a service plan to the Minister for his or her approval. The amendment is consequential on the insertion of section 30A and requires the HSE to submit its service plan 21 days after receiving notification of its budget from the Minister. The section is also amended to require the HSE to submit an estimate of its income and expenditure as part of the plan and ensure that the plan complies with the budget notified to it by the Minister.

Section 9 amends section 32, which allows approved service plans to be amended. This is a consequential amendment to the insertion of section 30A(3) and sets out the process for amending a service plan if a Minister amends a net determination during the year.

Section 10 inserts a replacement section for the existing section 33, which requires the HSE to manage services in a manner that is in accordance with the approved service plan. The section is being expanded to require the executive to manage the services within the net determination notified to it by the Minister. Subsection (2) reintroduces the concept of first charge principle. Under this principle if the HSE exceeds its budget in one year that deficit is a first charge against the following year's approved budget. If the Executive has a surplus it would be allowed to carry over the surplus into the following year. In the interests of proper governance and accountability, I will be bringing forward an amendment on Committee Stage to make the latter provision subject to the agreement of the Minister for Health and the consent of the Minister for Public Expenditure and Reform.

Section 11 inserts two new sections. Section 33A is a technical provision allowing the Minister to issue grants to the executive, with the agreement of the Minister for Public Expenditure and Reform. This effectively replaces section 5A, as I already mentioned. Section 33B is also inserted by this section. It provides for a separate process for approving a capital plan and provides for the governance arrangements regarding the approval of such a plan.

Section 12 inserts 2 new sections regarding the functions of the director general of the HSE. The new section 34A gives the director general the statutory responsibility to ensure that the HSE operates within its budget, both in respect of capital and non-capital expenditure. It also obliges the director general to notify the Minister if actions being undertaken by the executive are likely to lead to it breaching its financial limits. A new section 34B provides that the director general shall be accountable to the Committee of Public Accounts in respect of the HSE's annual financial statements and any other reports made by the Comptroller and Auditor General. This provision is required as section 40G of the governance legislation making the director general the Accounting Officer of the HSE is being amended so that he or she ceases to be the Accounting Officer with effect from 1 January 2015.

Section 13 amends section 40G and makes the director general the Accounting Officer for the HSE for the years 2005 to 2014. This means that the director general is still accountable for the appropriation accounts for those years and that the HSE has to produce appropriation accounts for 2014.

Section 14 amends section 401, as inserted by the 2013 Act, which sets out the functions of the Audit Committee of the HSE. The existing subsection (3)(b) reflects the current statutory position of the director general as being the Accounting Officer. It is being amended to delete that reference and replace it with an obligation on the audit committee to ensure that the executive is complying with the implementation of the service plan in accordance with the net determination and the capital plan in accordance with the limit set under section 33B.

Part 3 provides for the transitional arrangements to enable the change over from the current system to the new funding arrangements. Section 15 provides that the HSE's Vote shall be abolished on 1 January 2015 and that funding will be arranged through the Vote of the Minister for Health in 2015.

It also provides funds in the Vote of the Minister for Health for 2015 so as to enable the Department to provide grants to the HSE, pending Dáil approval of the Minister's office's Vote. The provision will cease to have effect when the Dáil approves the Estimate for the Minister for Health for 2015. Section 16 is a technical amendment to the Valuation Act, designed to ensure that the buildings of the Health Service Executive continue to remain exempt from rates.

As I have outlined, this Bill is another step on the reform journey, the ultimate destination being universal health insurance. The central aim of the health reform programme is to improve equity and access to services. The Bill is an essential, if somewhat technical, part of that goal. Transparency and accountability around service delivery are fundamental tenets of the health reform programme. I believe the Bill, together with the other changes I am making, will help ensure more accountability during the time the HSE continues in existence. This is yet another very important building block in achieving our goal of universal health insurance and better outcomes for patients and for our citizens. I commend the Bill to the House.

I welcome the opportunity to speak on the Bill. The consensual arrangement we had earlier in regard to the sunbeds legislation has to stop at this stage and we have to go into a more adversarial mode. I do that in the best interests of the need for us to have a very open debate on how we fund our health services in the years ahead.

Reference was made in the Minister's opening speech to universal health insurance, which is the Holy Grail of his policy in terms of how we are going to fund the health services in the years ahead. There has been an element of slippage with that commitment and, for example, the Minister is now talking about 2019 for the full implementation of universal health insurance, as envisaged by him. Our difficulty is that we are not actually sure what the Minister envisages because we are still waiting for the publication of the White Paper on universal health insurance. I know it is imminent because the Minister has informed the Dáil of that and the Taoiseach has also informed us it will be published in the very near future. However, because we are still waiting for it, we are speaking in the dark in terms of the funding model, whether that is a sustainable model and how we will fund the health services in the years ahead.

Our concern is that the Bill transfers substantial powers to the Minister of the day. I am obviously critical of the Minister of the day at present, and there will be other Ministers in the years ahead. I am not always critical, however, but on the funding of the health services I have been consistent because I look at the record and adjudicate in a fair manner. I believe that, to date, a strategic plan with regard to how we fund the health services has been lacking.

I am aware there is pressure on the public finances and the Minister is always trying to remind me, as if I need to be reminded, of why we are where we are. Of course, there is an inquiry to be set up in a non-biased way to assess that, but that is for another day. In the meantime, the obligation on the Minister for Health is to ensure there is a sustainable health service that is adequately funded and that can provide patients with the services they need in a safe environment. I do not believe that is in place at present.

One only has to listen to the reports today from Tullamore Hospital, where a large number of people are waiting on trolleys, trying to access the hospital, and it is in almost a crisis mode. I do not use such wording lightly from this side of the House. However, it is a fact the health service has huge pressure points. We are informed from time to time that there are seasonal factors, such as flu epidemics, adverse weather and so on, and this can have an impact and can build pressure points into the system, for various reasons. However, there is almost a consistency beginning to emanate in terms of pressure on our emergency departments and concerns about the fact that the recommendations of the Tallaght hospital report on overcrowding in emergency departments have not been fully rolled out across the country.

The point that will be made by the Minister is that this is what he is trying to resolve and that he is trying to take ownership from the HSE and bring it back into the Department under the auspices of the Minister of the day. However, I am not sure that will be beneficial to patients in the longer term. In my experience, while we all come in here with the best of intentions in terms of seeking a mandate from the public for our policies to be implemented, I believe the over-politicisation of our health services has had a corrosive effect on their delivery for many years. There has been an over-politicisation of the health services by every Government and every Opposition, which is, inherently, a difficulty we will further face if we go down his route of vesting further authority and more powers in the Minister of the day.

I have listened to and read many debates in this House over the years. I find that much of what is said is irrational in many ways. It is drummed up and what it advocates is not necessarily in the best interests of the patients but rather in the best interests of political parties and individuals. We must acknowledge this is clearly something that has had a damaging effect on the ability of the State to provide health services to the public.

The old health boards system was abolished in the context of developing the HSE in 2004. That was the first step in trying to bring forward a national health service that would have uniformity across the country, and that would provide and allocate resources based on what people needed in particular areas, as opposed to being based on the whims of politicians. When we have limited resources, it is clearly imperative that this money is provided for patients and the delivery of health care, as opposed to being provided for political purposes.

I have made accusations in the House before of pork barrel politics. It is not the first time that accusation has been made as it has been encountered many times across the floor of the House. However, I believe that when we actually vest all of this in one individual, it can have that impact, either intentionally or unintentionally. For example, on this matter the Bill states:

Insertion of sections 33A and 33B in Act of 2004

11. The Act of 2004 is amended by inserting the following sections after section 33:

Power of Minister to make grants to Executive 33A.

On and from 1 January 2015, the Minister shall, with the consent of the Minister for Public Expenditure and Reform [there are now two of them in it] out of moneys provided by the Oireachtas, make grants to the Executive.

Determination by Minister of capital funding and submission by Executive of capital plans

33B. (1) The Minister shall—

(a) subject to subsection (9) and with the consent of the Minister for Public Expenditure and Reform, in respect of each financial year of the Executive, determine the maximum amount of funding that the Minister will make available to the Executive in that year for capital expenditure, and

(b) notify the Executive in writing of that amount as soon as is practicable.

If we go down this road of allowing State funds to be distributed in a way that is not necessarily conducive to the delivery of health care itself it can happen in the context of Cabinet collegiality, for example, where Ministers may assist one another in terms of the provision of funding - in other words, I scratch your back and you scratch mine. There has already been evidence of this in terms of funding of hospitals located in the constituencies of certain ministerial colleagues. I am concerned that we could now have this corrosive element being brought back into our health services.

The suggestion is continually being made that the HSE and the Minister of the day would be a political puppet in the sense that there would be no real accountability to this House. The HSE has its own board of governance and is accountable to the Houses of the Oireachtas through the committee system but, at the end of the day, the Minister does not have full oversight of the HSE, which limits its accountability to this House. That is a valid point.

Certainly that is an area where amendments to the 2004 Act could have been made that would have obliged the HSE to report on a more regular basis. However, the committees had the authority to bring in the HSE. The HSE was obligated under the 2004 Act to explain decisions in the context of its budget, financial arrangements, management, planning and policy. All of those things were part and parcel of the Act. Perhaps Oireachtas committees and individual Members did not exercise that power to its fullest extent previously but there was certainly accountability in that form.

The Minister was at one remove and very often was the political figurehead but unable to decide the policy. One could argue about whether this was a good or bad thing. I have reservations about the Minister having absolute control over the health service for the reasons I have outlined today and on previous occasions in respect of decisions that are made without any clear reason as to why they were made. A Minister of State resigned because of the issue of favouritism towards constituencies. That is a fact. It actually happened in the context of a motion of no confidence in the Minister tabled by Fianna Fáil at the time. The Minister of State resigned on foot of the fact that she had such concerns about interference in a process that had been clearly established to identify and address a health need. Certainly, some health centres were expedited. We have tried, but we will never get to the bottom of it. I highlight this because it will happen again. There will be another Minister who may also have a tendency to decide things based on political reasons as opposed to absolute need in terms of health. That is why this Bill is of concern to us.

In respect of the broader issue of health and where we are regarding the provision of health care, the Minister says he has made reasonable efforts to address outpatient and inpatient waiting lists and the number of people on trolleys, that we are providing a reasonable service with €4 billion less and fewer staff and that everything is fine. However, everything is not fine because as late as last year, the Minister acknowledged that everything is far from fine when he tried to secure additional funding. At one stage, he told his Cabinet colleagues that he would be seeking almost €1 billion extra in the context of the budget deficit that was being carried forward and the requirement to provide an additional figure of over €600 million to maintain safe health services and guarantee patient safety. That is a fact. The Minister did not secure that funding so that is not being spent around the country this year but we already see evidence of difficulties in the provision of basic care through our emergency departments and in moving people from hospitals to step-down facilities and into community care settings. That is evidence.

It is better than it was in the previous Government's day but it is still there.

I am highlighting the problems and would like to highlight the solutions some day. In the meantime, there is no point in me coming into this House and pretending, as the Minister is doing, that everything is okay. Everything is not okay.

Nobody ever said that everything was okay.

The point we make is that this legislation will not add anything to patient safety and the delivery of health care.

There were a few planks in the Minister's manifesto. The key one was the development of primary care and the other one was to move to universal health insurance. We are certainly putting the cart before the horse in this legislation in respect of the abolition of the HSE, the establishment of hospital groupings and then trusts and the roll-out of universal health insurance. One thing is certain. We know that the funding model the Minister wants to bring forward is along the lines of private health insurers providing health cover to those who can afford it and a subvention from the State to those who cannot afford private health cover or a purchase by the State of private health cover for those people. I assume that this is the basic principle, that there was a suite of services that health insurers will be obliged to provide at certain rates and that competition between health insurers will find the level in terms of the market itself. Of course, there are a few major flaws in that. The first is that we do not have a very vibrant health insurance market in this country. There will be a massive subvention from the State to the private health insurance market because the numbers of people covered by private health insurance are tumbling. This is evidenced week in and week out by the massive numbers of people who have dropped out of private health insurance further burdening the public hospital system. While we continue down the road of speaking about universal health insurance, we are forgetting that the central plank that underpins it - the foundations on which it will be built - is a vibrant private health insurance market. Every policy that is being pursued by the Minister, the Minister for Finance and the Government collectively undermines the foundations on which the Minister wants to build the funding model of health.

The Minister absolves himself of it because he says it is a taxation matter and I agree it is a taxation matter but surely the Minister for Finance would be conscious of the fact that a policy is being developed by the Minister for Health that aims to promote a vibrant private health insurance market. What did he do? He waltzed into the Dáil last October and with one swoop of his pen decided to inflate the cost of private health insurance for ordinary families throughout the country. Reference was made at the time that the change only related to gold-plated policies. If every private health insurance premium taken out by ordinary families throughout the country is gold-plated, let the Minister say that. The bottom line is that it was an intentional sleight of hand or word to insinuate that somehow it would only affect a few premiums. It affected the average family plan offered by health insurance companies in this country. That is a fact and is happening as we speak when families get their renewal notice and bill from the private health insurance companies telling them that the policy has now gone up by "X" amount. It has gone up multiples of health inflation. The key reasons result from policies pursued by the Ministers for Health and Finance.

Full cost recoup for private patients in public beds is another area that will have an impact on the cost of health insurance. If the Minister or Government was serious about trying to provide a sustainable model of private health insurance, they would pursue policies that would attract and encourage as many people as possible into private health insurance to underpin the entire concept of inter-generational solidarity where the youngest and healthiest support those who are older and require more treatments. The basic principle of insurance is that one spreads the load and burden across as many people as possible but the Government's policies are doing the exact opposite. There is now an almost obsessive attempt to drive younger people out of private health cover. I cannot understand the rationale behind it and I think, deep down, the Minister for Health probably does not support that policy either but has been hung out in Cabinet and is now scratching around everywhere for funding to support the health services and the funding of same. It certainly does not make sense to charge full cost for private patients in public beds when facilities are not available through the private hospital system. These patients are already taxpayers, are making an effort through their own means to fund their own health care and are already entitled to that care anyway under the 1970 Act.

We need the White Paper soon. If it is delayed further, it will just be fanciful. A vibrant, private health insurance market that provides cover for 4.3 million people who either purchase it directly or on whose behalf it is purchased by the State will not happen. That system will not be sustainable if something is not done quickly. This is another key area in respect of which we need a full debate.

The Minister stated that he would welcome our input into the universal health insurance White Paper. We will have views on it, but my instinct is that this process is going down a poorly thought out route. The Minister claims that he achieved a mandate for the implementation of universal health insurance. It was undoubtedly a central plank in Fine Gael's policies, but its lines have become unclear. We must elucidate the policy dramatically.

The provision of care that is both safe and costs the State the least amount is often discussed. This will be done through primary care centres, general practitioner, GP, practices, public health nurses, community and home care packages and home helps. The aim is to keep people out of acute hospital settings. Given the budget and its individual elements, however, primary care is being underfunded considerably. Chronic illnesses are to be moved from the acute hospital setting into primary care where GPs will be expected to take it on. They have the expertise and the willingness, but there must be quid pro quo in terms of resourcing and support. The Government cannot keep stripping away supports while expecting to maintain the traditionally strong relationship between GPs and patients, customers or whatever one wants to call them. It will erode the services provided by GPs. As the Minister stated, they are doing work that nurse specialists could do and nurse specialists are doing work that care assistants could do. Would it not be a good idea to provide resources in order to address this deficiency and ensure that patients are treated by the most appropriately qualified clinicians? Clearly, this should be done, but the Minister has done the exact opposite. He has undermined primary care and eroded the ability of GPs, nurse practitioners and others to provide care in the community setting. This will create significant difficulties in the short and medium terms.

Last year, the Government decided to proceed with providing free GP care for five year olds and under. It was a good idea on the face of it. It would also have been a good idea to provide adequate funding and resourcing, but this is seemingly only being done by removing resources and supports from vulnerable people. The budget arithmetic in the HSE service plan as announced last October leaves one in no doubt about the Government's decision to target discretionary medical cards on a consistent basis. In fact, they have been so well targeted by now that the Government has decided to remove the word "discretionary" from the HSE service plan. When I submitted a Dáil question to the Minister of State, Deputy White, he told me that there was no such entity as a discretionary medical card. At one stage, there were nearly 96,000 of them. How they disappeared overnight is a mystery.

What has happened has had a major impact on the lives of the many people who struggle daily with illness, disease and disability and have been doing their level best to continue with family supports, etc. Those supports have been stripped away by the callous decision to undermine the discretionary medical card system, which had been built up over many years. Although it contained geographical inconsistencies, its principles were humanity and fairness. The suggestion that medical cards can no longer be awarded on a discretionary basis - the Health Act 1970 says otherwise - is simply not right. It is within the gift of the HSE and the Minister to ensure the availability of discretionary medical cards to people with long-term and life-limiting illnesses and disabilities. Financial hardships arise because of their circumstances. Removing discretionary cards is an incredible decision by the Government and the Minister in particular.

Health funding has been vested in a Minister who can callously cut services from the most vulnerable. When the Department of Health, the HSE and the Minister's office panicked in recent years, home helps, home care packages, disability supports and discretionary medical cards were the first services to be cut. I am not confident about giving more control to a Minister who can make such decisions. This is another reason for our opposition to the Bill.

Myths have grown up about the establishment of the HSE. It brought the health boards and all areas of health under its umbrella. The Minister makes great play out of the fact that we retained all staff, but his predecessor as Fine Gael's health spokesperson, Deputy Twomey, insisted at the time that there be no forced redundancies, only voluntary ones, and that packages be put in place. He stated:

The view of workers must be respected. Although the Minister said there will be no forced redundancies, many of the employees of the health service are extremely concerned about what their roles will be.

Fine Gael asserted the need to retain all employees, but it has now decided to vilify that decision. Consistency is scarce around this place, particularly given the comments made then and those being made now because the Government wants to abolish the HSE. The Government will regret its decision to politicise the health services again. It will regret its decision to give the Minister more power over capital expenditure. More importantly, the people who depend on services will be the ones who see whether there is fairness and impartiality in the decisions on capital expenditure and resourcing. This legislation will bring decision making and accountability back under the Minister's umbrella.

For these reasons, we need a sincere debate. Yes, the HSE was cumbersome and posed difficulties, but are we now saying that we should revert to a system of competing rather than complementary trusts scattered throughout the country that try to undermine one another in the provision of health care? This decision has not been fully considered.

If it was fully thought out, the Minister would have published that White Paper already. Four years ago, he had an idea in his mind about the Dutch model, but now that model has been moved off the catwalk completely and we are somewhere completely different, still waiting for a funding model we can analyse in the context of the Irish market. We do not have a population of 18 or 19 million people, unlike the Netherlands. We do not have 18 or 19 health insurance providers. We have a population of 4.3 million and we have only four health insurance providers, with one very dominant player. We now see that the whole edifice of the health insurance industry is beginning to crack and crumble. That is primarily down to policies that are being pursued by the Minister. Consistency about how to go about rolling out the Government's health policy does not even exist in the first place. That is why I have little confidence that we are going to see a model that is sustainable and fair, because the decisions the Government has made to date to rein in spending have been mainly unfair. In fact, they were downright lousy in terms of the areas targeted.

However bad the Minister may say the HSE was, let us have an honest debate about what way we will fund the health services and how we will fund them. The Government should publish the White Paper, but I must question going down a road into a cul-de-sac where we end up with an unsustainable funding model for a health service that will not be fit for purpose and that will be torn apart into trusts. That is why we will not be supporting this Bill.

This Bill follows almost exactly a year after the introduction of the Health Service Executive (Governance) Bill 2012 and is part of the Government's claimed programme of change in the public health services. When the HSE was first established, we in Sinn Féin claimed it represented bureaucratic change rather than real reform. It was not the replacement of the inequitable and inefficient two-tier system with a truly equitable and efficient universal system based on need alone, something which we certainly want to see in place. We stated last year that the Health Service Executive (Governance) Bill 2012 represented more bureaucratic change, perhaps delivering a more streamlined bureaucracy but nothing more. We stated that that Bill might increase accountability to, and the powers and responsibilities of, the Minister. However, we asked at the time whether this particular Minister and this particular Cabinet were worthy of such responsibilities, and whether it would make the Minister more accountable to the Dail and to the people. Sadly, the past year has demonstrated that we were correct in answering "No" to both questions.

We have seen the debacle over health funding in the budget and in the HSE service plan, and the inevitable Supplementary Estimates as a result of underfunding, year on year. We have seen the memorandum to the Cabinet from the HSE director, admitting the reality that the 2014 budget funding means it will be impossible to provide the necessary services over the course of the year. Of course, this memorandum was suppressed and changed to try to disguise the unsustainability of the cuts being imposed this year. It is essentially a technicality whether budget funding for health services is voted, as it has been up to now, in separate HSE and health Department Votes, or as it will be under this Bill, in one Vote. What matters is that there is sufficient funding and that such funding is used to best effect. On both counts this Government is failing like its predecessors. By the end of 2014, under the HSE service plan, almost €4 billion will have been taken out of our public health services 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 that have gone since 2007.

Under the recently published HSE divisional plans, hospitals are expected not only to function as last year, but to perform better with a reduction of €200 million in their budgets. Already struggling acute hospitals face an average reduction of 4% in their funding. Front-line care is being affected, even by the HSE's own admission, with a projected drop of 25,000 in the number of day cases and 3,000 in the number of inpatient treatments during 2014. An example of how unrealistic these plans are is the target to reduce the delayed discharge of patients from acute hospitals by 4%. We addressed this issue in the House earlier today. However, the allocation for nursing home beds has been reduced this year, which will mean many more older people will spend longer in scarce hospital beds because there are insufficient nursing home places for those requiring residential care.

This Bill, therefore, is essentially technical legislation as it provides for the ending of the HSE's separate Vote in the budget. In future, it is to be funded through the Vote for the office of the Minister for Health. We have no issue with that. In reality, it amounts to the same thing. However, in light of what I have pointed out regarding budget underfunding in 2013 and the resultant necessary Supplementary Estimates and the underfunding in 2014, section 10 is a cause for concern. It would mean that an overspend in any one year would be carried over to the following year as a charge on the HSE budget. Is it the case that this would mean no more Supplementary Estimates in the health area? Perhaps the Minister can address this when summing up on Second Stage.

As with the Health Service Executive (Governance) Bill, we are debating this Bill in a vacuum of knowledge as far as the Government's overall health reform plans are concerned. The promised White Paper on financing universal health insurance has still not been published, even though it was supposed to appear early in the life of this Government. The Government's document, Future Health, stated the White Paper would be published in 2013. It has been reported in the media in recent days that a draft of the White Paper is in the Minister's hands and that he will circulate that draft to the Government in the coming weeks. Can he confirm that? It has also been reported that the Government is planning to consult the public through a citizens' health assembly about its health insurance plans. Is that the case? Is it also the case, as reported, that the White Paper refers to universal health insurance being introduced by 2019? The programme for Government states: "A system of Universal Health Insurance ... will be introduced by 2016, with the legislative and organisational groundwork for the system complete within this Government’s term of office." Is that now being pushed beyond 2016, which is the crucial watershed of a general election?

It is long past time we had clarity on the Government's plans for health reform. From the quite detailed media reports we have seen this past week, it seems journalists have had access to the draft White Paper on universal health insurance.

If that is the case, it is disgraceful. It is the elected representatives of the people in this House, not journalistic recipients of leaks, who should receive that information in the first instance.

This is essentially a technical Bill, which may well be a piece in a jigsaw. If so, it remains a puzzle to me as I cannot yet see a picture. If the Minister has such a picture, it is long past time that he made it known to the Opposition spokespersons on health.

Debate adjourned.