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

Question again proposed: "That the Bill be now read a Second Time."

I am happy to contribute to the debate on the Health Service Executive (Financial Matters) Bill 2013 which, as outlined to the House by the Minister, has been designed to disestablish the HSE Vote and take it back into the Department of Health as part of his planned reforms leading to the abolition of the HSE and the introduction of universal health insurance in his overall grand design for the health service. There have been questions raised that the legislation may reduce the democratic accountability of the HSE in financial planning because under the current system, it is the subject of a separate Vote which means that its expenditure has to be provided for separately in the Estimates and which will now be subsumed into the Department of Health. I can see that this change has the potential to create obscurity about what happens within the HSE and the finances of the health service in general. That needs to be identified by the Minister as something that will not occur. He needs to outline how we will see financial accountability to the Houses and how the Estimates process will work in the future because that is a real concern.

There is another concern. The Minister outlined on Second Stage that much work needed to be done within the Department of Health to ensure it could strengthen its financial control and planning capacity. The questions arising are whether this will be done and when will it take place. There is a real risk that we will pass this legislation and disestablish the Vote and the Department will not be capable of providing for the financial oversight that the Minister stated needs to happen. He needs to clarify whether that financial planning process is in place and what steps are being taken to ensure it is in place because the hallmark of the HSE has been that its financial management has been abysmal. One of the big criticisms of it is that it has not been able to plan and stay within budget, although there is another reason for this.

The HSE commissioned a report on its financial planning and financial services from PA Consulting which was critical of how finances were operated within it. Probably, it dates back to its establishment when its administration was maintained along old health board lines. One of the big criticisms made in the report was that financial planning and control of expenditure was engaged in across the board in the HSE, with local offices being instructed to achieve a reduction of, say, 5% or 10% across the board, rather than targeting areas where there might be wastage and over-expenditure. I do not know how the Bill will change this. Mr. Tony O'Brien of the HSE stated the executive was attempting to put in place structures to allow that planning to happen, but it has not yet happened. In a couple of years time will we still be wondering when we will get to the stage where there is proper financial control and financial planning?

The Bill provides for the carryover of deficits from one year to the next and that the first call in the budget for one year will be to meet the deficit in the previous year. In one sense, this is prudent, but in terms of the cuts from which the health service has suffered in the past few years, it will create significant difficulties and we will continue to see emergency Supplementary Estimates to bridge the gap.

That leads me to have a little sympathy for the Minister in the sense that one cannot take any more out of the health service. I do not believe the Government can continue to reduce the budget for it year on year and continue to roll out the mantra of more for less. What we will see this year is less for less. We cannot continue on this road. We have to accept that if we want to have a functioning health service and a health service that will provide for an ageing population who will need more expensive treatment to help people to recover, we have to invest in it. We cannot continue along the road of constantly cutting expenditure. From that point of view, I have a little sympathy for the Minister, but in other ways I have no sympathy for him because he is the one who laid out this plan and stated there were inefficiencies and that so much more could be done for less. We just cannot do this. We need to have that debate.

It was interesting to read the reports in the media over the weekend on the letter from the Minister for Public Expenditure and Reform to the Minister for Health complaining about the projected cost of universal health insurance which could end up costing the Exchequer an extra €5 billion. We should probably be looking at spending an extra €5 billion to ensure we have a health service that can treat patients in a timely fashion and in which patients can access the services and treatment that they need and to eliminate waiting lists in a timely fashion. If it costs an extra €5 billion, we should provide for such expenditure and be looking at increasing taxation to provide for it. We must have a debate that is about more than cutting costs and ensuring the HSE sticks within its assigned budget. We must have a debate on the type of health service we want and the treatment we want to provide for citizens.

It was interesting to read the Minister for Health's opinion piece in one of the newspapers after the weekend on his plans for universal health insurance.

I sat down to read it wondering just how often the Dutch model would be mentioned. Lo and behold, there it was in the middle, saying that the Dutch model is the one the Minister wants to pursue. I wonder, however, why the Minister continues to trumpet the Dutch model as being a panacea for the health services in Ireland.

I have friends living in Holland who are familiar with the Dutch model, and they do not believe it works. The individual cost of health cover in the Netherlands has almost doubled since the model was introduced. Although the Netherlands, with a population of almost 20 million, is four or five times the size of the Irish market, the number of insurance companies operating there has decreased. There is therefore less competition in health insurance in the Dutch market. Is that the road we want to take? I can foresee a situation, if universal health insurance is introduced here, in which we will go from having three health insurance companies to having only two - that is, the VHI and one other company. People will not have a choice and we will see premiums increasing. In addition, we will not get the effect we want from universal health insurance.

Will we be capable of putting in place a system whereby oversight bodies for the health insurance market will be able to determine what level of treatment people can get? I do not think so. We will hand over control of the health market to insurance companies and will thus lose political accountability and control. In addition, citizens will lose the right to access treatment in a timely fashion.

We need to debate the whole concept of universal health insurance in the context of what type of health services we want to provide for our people in future. That is the discussion we should be having. Each one of these Bills is incrementally bringing us down the road to universal health insurance without having such a debate. When we wake up and have a discussion about it, it will be too late because all the various pieces will have been put in place. It will then only be a matter of introducing universal health insurance into the system.

It took more than 20 years of development to implement the Dutch model, yet the Minister wants to do so in five or six years, or in the next term of office if the current parties are lucky enough to get back into government. There are serious implications from this, so we should be having a serious discussion about the type of health service we want. We should examine the possibility of providing more funding for health services based on increases in taxation, because that is the only way we can do it.

It is difficult for people to access private health insurance due to significant cost increases, but it is also interesting to note the numbers cancelling their private health cover. One aspect that is never discussed here, however, is that costs are increasing because the State is reducing its subsidies to private health insurance. The State has provided tax breaks for those who buy health insurance, while hospitals have not been charging the economic cost of private beds. Private companies are now complaining when they are charged the economic cost. When we go to universal health insurance the economic cost for everything will be charged by the hospitals to the insurers, which will put costs through the roof. We must stop subsidising private health services.

There are definitely parts of the health service which could not be cut back any more and which need extra money. However, when it comes to capital spending, it seems the worst possible thing that could happen to a hospital or health facility is for the Government to upgrade it. In the 1970s the government upgraded the maternity unit in Roscommon Hospital, and guess what? They closed it before the 1970s were over. In the noughties they upgraded the accident and emergency unit in Roscommon and - guess what? - it was closed.

In County Galway, €3 million has been spent in Ballinasloe on a high-class unit with unbreakable windows and toilets and a ligature-free environment for geriatrics. We certainly are short of money, but there are two reasons for that. One is that we have socialists such as Senator Lorraine Higgins who have a problem deciding whether we should tax more or cut services. The other reason is that money is being wasted.

Like everyone in the Dáil, I have attended many meetings over the years. The meeting I attended last Friday night, however, was probably the most emotional one I have ever attended in my life. We heard of a situation in the psychiatric unit in Galway, which is where the Minister is planning to shoehorn people in from Ballinasloe when he rips the beds out and closes it. We heard a tale from a clinician there that 31 people were expected to share three showers. It was not that bad, we were told, because they also had one bath, but guess what? The bath does not work. All that comes out of the bath taps is scalding hot water. We heard stories of how patients shiver in corridors waiting for a shower. I have seen the film "One Flew Over the Cuckoo's Nest" on quite a few occasions and the only hope I got from Friday's meeting was that at least it is not like that any more. At that meeting we heard many such stories, but apparently we are just NIMBYs for saying this. Dr. Barton, who was at that meeting, is anything but a NIMBY. I can criticise him for one thing though - he ran for Fine Gael at one stage, but no one is perfect.

At Friday's meeting we heard from a clinician with no political axe to grind who only cares about patients. On two separate occasions, when he was explaining why he was so distressed by the closure of the unit in Ballinasloe, he broke down and had to wipe tears from his eyes. This was obviously a NIMBY at work, according to the Minister of State, Deputy Kathleen Lynch, who is a latter-day Margaret Thatcher. She did say she hoped she would never sound like Margaret Thatcher, but now she does.

We can talk about finances all day long, but a good unit is being closed down although it is working perfectly well. In addition, people are being shoehorned into a place that has a duck pond on the roof because so much water is building up on it. The water is being held up by rolled steel joists, so people are waking up in wet beds. We are told that this happens everywhere because it is raining all over the country and everyone's house is leaking. I am sorry, but I do not live in a dump and my house fortunately does not leak. I would love to know where these HSE officials live if they think that is normal. I imagine they are saying these things to shut us up. I hate saying this because it discourages people from using that unit. As someone who had mental health problems in the past - and coming from a family that suffered from the black dog visiting their door regularly - I do not like saying this. I went to the hospital the morning after that meeting to try to see the unit. I was wary of going because the last thing one wants to do is impose on people. However, when we arrived there we were not allowed to see the unit due to patient confidentiality. That would be a legitimate excuse if there was anyone in there, but we were not allowed in. We were told that five showers were working in this glorified "One Flew Over the Cuckoo's Nest" institution, but we were not allowed to see inside. It is like dealing with a child who hides something behind its back but refuses to show it when asked. One becomes suspicious that perhaps it does have something behind its back. What were they hiding at that unit? If they are sure it is that good, why would they not let us in? Anyone who says we have a cheek to go there should remember that a year ago we were being asked to go to this unit to see how wonderful it was.

Now, when we want to see it, we are not allowed to see it. What the hell is the Government hiding? We have a system working perfectly in Ballinasloe and the Government is closing it down. Last night, an extraordinary event took place. I was on my way to Castlerea to visit my family and I discovered a protest taking place outside the gates of St. Brigid's Hospital. Fair dues to the people who had gathered in numbers to physically stop the removal of beds from the unit. The HSE saw fit to call the Garda Síochána. We can hardly call this respect for the issue of mental health. For those calling these people NIMBYs, they were parents and relatives of service users, along with staff, to defend what rightfully should have been defended.

We met Deputy Kathleen Lynch a couple of months ago and I was fooled by her for a while. She sounds like she empathises and I believed her for a while but I stopped believing this latter-day self-described Maggie Thatcher. She told us the reason they spent so much money on the unit was that patients could not hang themselves, throw themselves through windows or smashed toilet bowls. She said that it was for elderly people. I asked why she spent so much money on an inappropriate unit and I was told with a straight face that the elderly deserve the best. If the elderly deserve the best, we could have saved money there and had more services instead of spending it all on capital funding and then not using the unit. We also have an empty unit in Galway because we cannot afford to staff it. Every time someone commits suicide, we read it in the newspaper and people are rightfully saddened and shocked but at this point we say conclusively that the tears being cried by the Government are crocodile tears and nothing else. If the Government cared about this, it would keep what works and get rid of what does not work.

What is the Government planning for the future? It is planning to move everyone to Galway city. Apparently, it will build a new 50-bed unit. I do not believe that. Even if it was done, it places another facility in a place where there is no room. I and my family had to go through the anguish of queuing to get into a car park, wondering whether my mother would be dead by the time we got a parking space. I am not exaggerating, this happens on a regular basis. Now, the master plan for people with mental illness is to bring them into a crowded area and a stress-inducing built-up area. If people are not stressed or do not have mental health problems going in, they will have one coming out. It is hell to get there. If we lived in Hong Kong or some Chinese city where there is no room, it would be fine to build on that site but we live in the least congested area in the whole of Europe and the best way to get someone better is to put them into an environment where they can breathe in the air and not the diesel fumes, where they can roam around the wild countryside, which they can do in Ballinasloe. It is not to put them into a place that will destroy their mental health. I say this not as a politician or a NIMBY but as someone who cares about these people. I have lost hope in the assertion that the Government cares. At this stage, it is not politics and war must be declared on the Government for what it has done to these people.

The Bill is part of the plan of the Minister for Health, Deputy Reilly, to introduce universal health insurance. This is based on a Dutch model, which from my reading is not one I would examine. I would have thought that a Government with a significant number of Labour members should be looking for a service based on the national health service in Britain. This initially came from the needs of people in the communities and their need for proper maternity hospitals and hospitals for sick people. To provide those services, society can then decide that if it wants to provide these services for the elderly, the young and the general population, it must find the money. That comes down to taxing people who can well afford to pay more or setting aside some part of tax, as PRSI was supposed to be, to provide health services. That is the progressive way to provide services under a progressive taxation model. This must include people who work on the front line, Ministers, the people who use the service and the needs of the community.

I am sure all Members receive a report by the private nursing home sector, which is not an area I support. It gives figures and facts to the effect that, by 2021, the needs of the elderly, those over 65, will not be met on the basis of what we have and the amount of money the public service will put into providing long-term nursing home beds. Between 2009 and 2012, approximately 339 new nursing home beds were introduced, compared to an annual increase of 1,000 beds in the years prior to that. By 2021, we will need 221 nursing homes built to provide for our elderly, particularly those over 85 years.

This must be planned for. If society says we must look after the elderly in this fashion, we must see how we can fund it and we must have the debate. That is what politics is about. As a group of people or a party, we can set out that we will tax here or there to provide the service, increase tax or box off a certain amount of tax to provide it. The universal health insurance model will not work. As the previous Deputy said, it will service private companies.

The HSE has fallen apart. It is one of the worst models ever set up to service people's health needs. We hear horrific stories of people trying to get into the system. Once people are in the system, they feel they are getting a good service and that they are being looked after. This only occurs because of the will and the fact that we have well-trained nurses who give far beyond their time and energy in respect of what they get paid for. People in my family work in Wexford General Hospital and stay after they have finished their hours to assist people who are ill. They are under ferocious pressure. A member of my family in her early 60s feels she must leave because she does not have the will or the energy to face going into hospital every day and the pressure on her. She is an excellent nurse, one of the best one could ever meet. We are losing good people because they cannot take the daily pressure in hospitals and the extra work they must do. Work is falling on fewer shoulders every month and new people are not coming in because of the moratorium.

I do not support the context of the Bill because it is part and parcel of the universal health insurance model, which I do not support.

The chief executives at Tallaght and other hospitals have stated that any more cuts will bring us to a point at which hospitals cannot deliver the necessary care, as they have been cut to the bone. We have seen this first-hand at Tallaght, as there have been no spinal surgeons at the hospital for the past eight months. It has cost the HSE €350,000 to provide the required care at the Mater Private Hospital. I would be the first to argue that these patients should be seen in a timely manner but the HSE model should have provided the necessary surgeons in the first place. The information I have - it is not a definite fact - is that the surgeons left their posts because of the pressure in the hospital. The hospital engaged another surgeon, who also left quite quickly because of the pressure. If that is what happens in hospitals in one area, it is happening elsewhere in the health service.

This does not take into account the issues of maternity hospitals, the mental health needs of the population or other issues. We need to get a breakdown of the needs of our population into the future, matching that with funds and having a debate with people. We must have a discussion of what the cost will be and how to cut the fat so we can put more money into front-line services. That would procure the goodwill of the people, as they know that if that is what is required, it should come about. That would lead us to a good health service with a standard that our families need. There must be 221 nursing homes built over the next six or seven years to provide a service for people over 85, based on the figures that have been coming through.

Pharmacies do not seem to have passed on the reductions for generic pricing of pharmaceuticals. I do not know if the Minister of State knows that a report was published the other day detailing the costs of pharmacies throughout the country, and people are not seeing the effects of cuts.

There has been much progress in that respect, although we need more.

That is certainly not suggested by the figures given out the other day in the media. The information was broken down by area, including details of tablets and generic substitutions. The difference was only approximately 3%, which is not much considering we are meant to have seen a big reduction in the area.

There is much to be done, although I know this complex issue will not be solved in the next month or three months. There should be a change of mind and policy from the Government if we are to provide the health service we need. I will need it because I do not have private health insurance, as I never bought into the idea of it. We must have that political conversation but it must cut across the pantomime politics we have seen so many times. Do we want a national health service and how can we plan for it? We must also consider how to help provide finance for it.

The next slot is to be shared by Deputies Breen, Kyne, Fitzpatrick and John Paul Phelan.

I thank my colleagues for allowing me to speak now, as unfortunately I have official business and must get back to it. I welcome the opportunity to speak on the debate this afternoon. While the Bill is somewhat technical in nature, it 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.

The Minister for Health has embarked on one of the most radical overhauls of our health service in the history of the State and is driven by his determination to ensure equality of access for all patients based on needs rather than the size of their wallets. I commend the Minister on his work in the area. Previous attempts to reform the health system failed because the way health care was delivered was fragmented. During the period of greatest economic growth in this country, the disparity between those with private insurance and public patients grew, and as public representatives we have dealt with all cases and seen the unfairness of the two-tier health system. Real health care reforms require restructuring of health services and how they are organised. The restructuring is well under way and the various hospital groups have been established. The Health Service Executive (Governance) Bill 2012 provided for the new directorate structure and today's Bill provides for the financial structures. I also understand the White Paper on universal health insurance is due to be published shortly and I look forward to that and the following debate.

The changes have already had an impact. For example, a new governance structure has been introduced in the University of Limerick hospitals group, which comprises University Hospital Limerick, Mid-Western Regional Hospital Ennis, St. John's Hospital in Limerick, Nenagh Hospital and Croom orthopaedic hospital, and they are bedding down well. Under the new structure, 7,472 more inpatients and 11,094 more outpatients were seen in the system with a smaller budget. There are challenges, particularly in the accident and emergency department in Limerick, and, as I stated in this House, I am anxious to see that fast-tracked as soon as possible. Nevertheless, the new hospital structure is ensuring a better future for hospitals such as that in Ennis and will allow the University Hospital Limerick to focus on the areas in which it can deliver and transfer services to Ennis.

It was always envisaged that Ennis hospital would become the left arm of the regional hospital in Limerick, but until the Minister for Health assumed office, development was very much restricted. The opening of the new wing and the provision of a full range of services, as well as accreditation as a centre of colorectal screening, is allowing the hospital to expand the level of services. More can be done within the framework, such as maximising the use of the acute medical assessment unit by opening it seven days a week and expanding the range of day surgical procedures that can also be carried out. We cannot just patch up health services; we must transform the way they deliver.

Recently at a meeting in Limerick with HSE personnel, the absence of a model three hospital in the region was noted. There is one in Tralee and Clonmel but there is none in the mid-west regional hospital group. Limerick is a model four hospital and Ennis, Nenagh and St. John's hospitals are model two. The absence of a model three hospital in the region is putting pressure on University Hospital Limerick and I call on the HSE to consider Ennis hospital as a model three hospital. Much investment has gone into the hospital recently and the rooms have been upgraded and are state-of-the-art. Some further investment may be required but it would be a very small amount, and the only element that is really needed is a roster of consultants. I suggest that it would be well worth considering Ennis hospital as a model three hospital to alleviate the pressure in the system, particularly in that area. I will focus on that in future with the HSE.

We have an aging population so we must move away from treating people in hospitals to treating them in the community. I very much welcome the Minister's support for day care centres and the voluntary community initiatives which facilitate people in living longer in their homes. Priority is also being given to primary care and provision of preventative care. This health system offers the best way forward for the most important player in our health system, which is the patient. I support the Minister's efforts to drive reform. It is essential that functional structures are in place to support the new health care model, and today's legislation is another important step in this regard. I commend the Bill to the House.

I am happy to speak to this Bill, as it is an important part of measures being implemented to return overall responsibility for the health service to the Minister for Health and his Department. The Bill is somewhat technical in nature and contains the necessary provisions to bring financial governance of the HSE back within the framework of the Department of Health.

I can understand and appreciate the merits of creating the single health service, which merits presumably underpinned the creation of the HSE. A single authority replacing the various health boards made sense for a country of our size. While there were many missed opportunities in the past decade, with unworkable, ill thought-out policies such as co-location, the creation of the centres of excellence for cancer care against a backdrop of intense opposition has proven to be a correct policy with positive results for the people. However, time has also demonstrated that the creation of the HSE aided and abetted an evasion of responsibility. It became possible to blame a bureaucratic, unwieldy organisation for the ills that befell the health service. Charges of this nature were made regularly by various national and local public representatives.

The Minister for Health is introducing legislation and other measures that indicate clear points of responsibility and explicitly state objectives and how they are to be achieved. Most important, the Minister is taking responsibility directly for the reform of the health service. The establishment of hospital groups, a policy piloted in the west, is the most fundamental reform on the health services in decades and will ensure that hospitals in the regions work together to deliver care of the highest level and broadest range.

Despite the constant stream of negativity concerning health care, it is undeniable that tens of thousands of people across the country receive high quality health care from hospitals and primary care settings, provided by conscientious and dedicated health care staff. There have been tangible positive developments in the health service over the past three years, including a reduction by one third in the number of patients waiting on trolleys. There has been a reduction of over 90% in the number of people waiting more than a year for outpatient appointments. There has been a reduction of 99% in the number on the inpatient and day care waiting lists for eight months or more. There has been a reduction of 50% in the number of MRSA infections in hospitals, with 20 hospitals reporting no cases. Some €200 million was provided for the new children's hospital, with construction to commence next year and to be completed by 2018. The facility will provide world-class health care for generations of children.

These are developments that are drowned out, overlooked or ignored. These achievements are ones of which the many men and women working in the health care system, in every role, can and should be proud. However, to ensure that such provision of care continues, we need to implement reforms. A crucial reform is the abolition of the HSE. Another is the introduction of a universal health insurance system. Such a system, which will see all citizens having health insurance, will be rooted in the money-follows-the-patient model. No longer will block grants of public money be handed over with few, if any, conditions pertaining to standards or patient outcome. As the Minister stated earlier this week, care will be on the basis of need rather than one's income, a comment that should be the mission statement of every health system.

Another important measure about to be introduced is free general practitioner care for children under six. This is being viewed as a precursor to the introduction of such care for all citizens. Unfortunately, there are currently difficulties between the Irish Medical Organisation and HSE in negotiating this. We need to remember that all groups involved have the one aim, namely, the protection and promotion of the health of the people. There are certainly varying views on how we can achieve this but I appeal to the parties involved to commence meaningful and constructive talks and negotiations.

General practitioners have faced considerable challenges, as have most other professions and sections in society since the economic collapse. That said, I acknowledge that general practitioners, as with every other citizen, want to ensure that this measure is rolled out fully. I am confident that it will be.

There are a number of positive factors, particularly the children's hospital, which has been talked about for many years. I am delighted to see that work will commence on it next year and that it will be completed by 2018. The pilot scheme for reorganisation commenced in the west and it has been a success. More meetings have been held in public across the region, resulting in accountability. Oireachtas Members are fully briefed on issues of importance and we are fully aware and conscious of the decisions being made. We have powers to consult and engage with the officials; this is an important role. I commend the Minister of State, Deputy Alex White, and the other Ministers on the team on their work.

The Health Service Executive (Financial Matters) Bill 2013 fulfils a commitment made in the programme for Government on future health. The Bill is designed to disestablish the HSE Vote, have HSE funding come under the Department of Health's Vote and establish a statutory financial governance framework for the HSE.

The health reform agenda set out in the programme for Government includes a commitment to dissolve the HSE and transfer its functions to other bodies as part of a wider move towards the establishment of universal health insurance.

The Bill provides for the disestablishment of the Vote of the HSE and the funding of the HSE through the Vote of the office of the Minister for Health from 1 January 2015. It also establishes a new financial governance structure for the HSE. It gives the Minister power to set a net budget for the HSE and approve as part of the service plan the executive's gross income and expenditure plan. It also reintroduces the first-charge principle whereby if the HSE exceeds its budget in one year, it must discharge the liabilities arising as a first charge the following year. It imposes certain legal obligations on the director general of the HSE to ensure the executive operates within the financial limits imposed by the Minister. It provides for a new procedure for the approval of capital plans. This provision will come into effect on 1 January 2015.

The HSE was established in January 2005 under the Health Act 2004, and it was given statutory responsibility for the management and delivery of health and personal social services. The Act emerged from the long-standing perception that the then system of health boards was problematic from a governance perspective. The HSE replaced ten regional health boards, the Eastern Regional Health Authority and a number of other agencies and bodies. It was the first body in the history of the State to manage the health services as a unified body. In a sense, the establishment of the HSE marked the culmination of an inevitable revolutionary process of rationalisation over several decades that resulted in the number of administrative units being reduced from over 90 to one, a national agency.

A key intention behind the legislation was that the executive’s establishment would mark a clear division between responsibility for policy, which would rest with the Department of Health, and the responsibility for management of services, which would rest with the HSE. An additional outcome was that power was effectively removed from local elected representatives, although the Act did provide for regional health forums comprising elected representatives. These forums have representative rather than executive functions.

Since its establishment, the HSE has been subject to controversy and criticism of a high level. There was not a decline in personnel numbers on its creation. There was a continuation of separate financial and other structures from the health board era within the HSE. There was insufficient openness and transparency and a general lack of integration and coherence across the organisation.

There have also been criticisms of the specifics of the relationship with the Department of Health. The programme for Government committed to a health reform programme to achieve a universal, single-tier health service based on universal health insurance. As part of the reform process, the programme stated the HSE would cease to exist over time, and that its functions would return to the Minister for Health or be taken over by the universal health insurance system. The Minister for Health and his Department will be responsible for policy and expenditure. The HSE will cease to exist as its functions are given to other bodies during the process of reform.

The HSE hospital purchasing arm will merge with the National Treatment Purchase Fund to become a new purchaser of public patient care during the period of transition. HSE hospitals will become autonomous providers of care. With universal health insurance, public hospitals will no longer be managed by the HSE. They will be independent, not-for-profit trusts with managers accountable to their boards. The Patient Safety Authority will introduce a national licensing system for hospitals and will oversee the transition of hospitals from the HSE to independent local control.

I support the Health Service Executive (Financial Matters) Bill 2013. It is an awkwardly named Bill in the sense that it is really another step in the reform of the health service that will ultimately see the dismantling of the HSE. We are sometimes in the habit of naming legislation in a way that does not reflect its intent. I acknowledge there may be reasons for doing so.

Without going over the ground covered by previous speakers, the system of health service provision has been greatly transformed in the past 50 years. It moved from a system of county provision in which there were county and city health committees to a regionalised structure under the old health boards to the decision in 2004 of a previous Government to introduce the HSE and now to the decision last year by the Government and Ministers in the Department of Health to consider the provision of acute services based on the hospital network system mentioned by Deputy Fitzpatrick. It probably marks a return of acute services to a regionally based system.

The creation of the HSE by the then Minister and current Leader of the Opposition, Deputy Micheál Martin, promised much in terms of reform and the savings that could be made with regard to services that might have been duplicated under the old regional health board system. However, the system has not worked. The two parties in gvernment prior to the general election and in the programme for Government committed to a complete overhaul of the way health services were delivered. Last year's announcement on the hospital networks was part of that and this legislation which will see the Vote for the HSE being replaced by a Vote for the Department of Health is another significant step in the desperately needed reform of the health service.

One of the difficulties that emerged when the HSE was established was that it created a system that was so centralised that local decisions which had previously been and should be made on a regional basis could no longer be made at that level. I have always been a believer in empowering local democracy on different levels and believe that while the old health board system had many flaws and required reform, the fact that there was somebody in each region who was directly responsible and accountable for his or her region in terms of the service provided offered a level of accountability which the HSE never achieved. From its initiation, it was bound up in a level of bureaucracy that had gone mad. For that reason, this legislation which provides for the health service to be funded directly from the Vote for the Department of Health from January 2015 is a welcome initiative. The HSE has never properly functioned as an organisation. That is not to say there are not many incredibly excellent public servants working in it, be they on the front line or in administration. In many instances, the administrators had their hands tied under the system operated by the HSE and were unable to make the decisions they should have been empowered to make.

This legislation is another step in reforming the way the health service is delivered and, ultimately, in moving towards a universal health insurance system, an important development in which hospitals and acute services will be funded on the basis of the number of patients they treat rather than through the historical construction of budgets, as the system largely has been heretofore. For that reason, I welcome the legislation.

I welcome the Bill and the opportunity to speak about it. We must move forward with the reform agenda, by which I mean meaningful reform and change, transparency, accountability and, above all, a health service that works for its patients and service users in general. We must also be conscious of staff issues and the staff's role in creating a valuable health service that works for and in the interests of people, particularly patients. This debate and reform should be about trying to get the best practice for patients and service users and encouraging and developing best practice and professionalism among the staff who work in the health service. One regularly hears complaints about the health service, but many good quality people work in it, both on the front line and in administration sections. Yes, they have many problems and there are huge demands, but we must accept that many of them are working against the odds. We should accept that in this debate and within the legislation.

The Health Service Executive (Financial Matters) Bill has been designed to disestablish the HSE Vote, with funding for the service to come from the Vote for the Department of Health, and to establish a statutory financial governance framework for the HSE. It is also part of a series of legislative measures designed to provide for the dissolution of the HSE and reform of the health system. Again, the emphasis must be on reform. Before the last general election, candidates who called to people's doors were told that they had to reform and change the system. The big issues, of course, were jobs, the economy and banking but third or fourth on the list of concerns were the health service and the education sector. People want us to do something about these issues and the Bill is part of that process. I have concerns about aspects of it, but, in good faith, I consider the broader thrust to be positive. We must stop shilly-shallying and talking about reform and get on with the job.

With providing for the disestablishment of the HSE Vote, the Bill establishes a new financial governance structure for that body, which I welcome. It gives the Minister the power to set a net budget for the HSE and approve, as part of the service plan, the executive's gross income and expenditure plan. It also reintroduces the first charge principle, whereby if the HSE exceeds its budget in a year, it must discharge the liabilities arising as a first charge in the following year.

Also, the Bill imposes certain legal obligations on the director general of the HSE to ensure the executive operates within the financial limits imposed by the Minister. One must be concerned about this provision. We must emphasise that when dealing with the health service, one is dealing with a service for sick people, people with a disability and people in need. It is not necessarily a private company. That is very important. Sometimes one hears people say a business person could run the health service in such and such a way. The focus of health and education services is on providing a health service for patients and an education service for pupils, respectively. That is a key difference from a private business. For that reason, I strongly support some of the reforms being made by the Government. It might surprise the Minister, but if I, as an Independent Deputy, see sensible proposals from any quarter, I will always support them.

Those are the core issues in the legislation. When discussing patients, we must focus on best practice. One hears much talk about accident and emergency departments, waiting lists and patients on trolleys. There are still major problems in that regard. The Minister of State, Deputy Alex White, and the Minister, Deputy James Reilly, regularly produce figures to show that this or that has been reduced, but the bottom line is that if one goes to Beaumont hospital in my constituency tomorrow morning, one will see patients on trolleys. That is also the case in Galway hospital. I was in that hospital recently to visit a relation and saw the chaos there. That is the reality, with which we must deal also. Irrespective of what the situation we face is, be it an influenza epidemic or a bad weather event, we must have a proper plan.

It always fascinates me that countries with fewer resources than this country can have a top quality health service. A couple of years ago I visited Cuba when I visited the hospitals in Havana and the centres for people with disabilities. This is a country that has been hammered by the bullies in the USA through embargoes and blockades, yet it has quality front-line services.

I met young and student doctors who, as part of their training, went up into the mountains during the summer holidays to work with families and on maternity-related issues. If a country has a good health service, we should not be afraid to consider it. We should not run away from it and be bowled over by the politically correct right-wing view in this country about all of the negative things in certain countries. The reality is that Cuba has an excellent health service, against the odds given its resources. We must be brave enough to examine its system. I would love to see the Minister of State and the Minister go there to see examples of best practice.

I was fascinated to note the policy in Cuba on children with disabilities, in particular intellectual disabilities, from the cradle to the grave. The day a child is born in Havana or any part of Cuba he or she has a service until the day he or she dies. That is the vision and leadership I would like to see. It might not be politically correct to say it, but if something works, we should not be afraid to consider it. The same is true of other countries in the European Union that have examples of good practice. We should not run away from them, rather we should look closely at them.

I mentioned services for people with disabilities which are an important part of my election platform. We have a Minister of State with responsibility for people with disabilities, but I would love to see the appointment of a senior Minister with dedicated responsibility for disabilities inclusion. I would also like to see the prioritisation of the funding for disability services in line with the pre-election commitments given by the Government. In addition, I would like to see implementation of agreed measures, targets and timelines. That is the sensible approach I wish to promote. We need something fresh and new. Let us not run away from issues; let us get on with addressing them. For those who say it is a minority issue, I remind the Minister that there are 595,335 people with disabilities in Ireland, representing 13% of the population. They deserve a senior Ministry. That is something which should be considered when changes are made next year or whenever they are made.

We must consider front-line services which have seen a massive cut in recent years. Funding has been reduced by €159.1 million, which represents a 9.4% reduction in spending at a time when the need for services is increasing. Meanwhile, people in receipt of disability allowance have endured cuts of almost 8%, resulting in the loss of more than €847 in their annual income. There have been substantial changes to essential services and supports such as adjustments to medical card eligibility; a €60 million loss under the housing adaptation grant scheme since 2010; and a 90% or €325 cut to the respite care grant in 2013. The fivefold increase in prescription charges since 2011 has had a significant impact on the everyday lives of people with disabilities.

I raise these issues because they require discussion, in particular in the context of reform. In the context of health service reform, accountability and change, I wish to ensure people with physical and intellectual disabilities are part of the reform agenda, which is most important. I again emphasise the importance of the 595,335 people with disabilities, representing 13% of the population. These figures are based on a census carried out in 2011 and they do not include many other family members and friends who are also affected by a person's disability. I refer to carers, family members and others who are involved in looking after people with disabilities. It is important to refer to such matters openly.

The Bill gives the Minister the power to set a net budget for the HSE and approve as part of the service plan the executive’s gross income and expenditure plan. Under the new Vote arrangements, the HSE will mainly be funded by means of grants made from the Vote for the office of the Minister for Health. That is the standard method of the State to fund statutory bodies. It also reintroduces the first charge principle whereby if the HSE exceeds its budget in one year, it must discharge liabilities arising as a first charge in the following year.

The Bill imposes certain legal obligations on the director general to ensure the HSE operates within the financial limits imposed by the Minister. It provides for a new procedure for the approval of capital plans which are very important. In the context of disability services, it is important that we keep up the work that was started when I raised the issues some years ago of people with cystic fibrosis. The unit is now open in St. Vincent’s University Hospital, but we must keep our eyes focused. There are other needs in Beaumont hospital, as well as in Cork and Limerick. We must ensure the families of those with cystic fibrosis are given the maximum support. They must be part of the service plans and sensible solutions. I urge that such an approach be taken.

Recent scandals emerged in various services in terms of governance and the problems caused. It is important to note that the Bill does not directly address the top-up payments scandal recently reported, for example, in the Central Remedial Clinic, CRC. I was one of those who was very critical of the carry-on at board level in the CRC. It is equally important to state parents and staff on the front line should not be included in the criticism. I received an invitation during the week from the parents of those who use the CRC to attend an event next Friday night. One of the points made in the invitation concerns how shocked and upset they were by the revelations on the governance of the CRC. They were very concerned about the effect it might have on the wonderful professional care the children had always received from the CRC. They were also very concerned about the impact it had on fund-raising. The clean-up has begun. Management levels are being reformed and new people are being appointed to boards. I urge people not to turn their backs on the CRC and other organisations that have stepped up the mark and are doing their best. Bad practice should not be tolerated in the health and disability sector. Equally, we cannot blame everyone for the problem.

To return to the broader thrust of the legislation and the reform agenda, we have all listened in recent years to the criticism of the HSE. Issues raised include the fact that personnel numbers did not reduce on the creation of the HSE, the continuation of separate financial and other structures from the health boards within the HSE, insufficient openness and transparency, a general lack of integration and coherence across the organisation and also criticism about the specifics of the relationship between the HSE and the Department of Health. That is an important issue. Deputy Bernard Durkan likes to remind me of a time when I supported a previous Government.

The Deputy was a signatory.

I raised the issue of the need for a cystic fibrosis unit. I remember the shenanigans and blazing rows we used to have behind the scenes between the HSE and the Department of Health and all we wanted was to have the unit built. I remember the many long meetings and fighting in pushing the agenda. I learned a lesson that such a situation could not be allowed to carry on. I hope this legislation deals with such issues. It is welcome that the unit was eventually built and I commend all those involved, but by God, it was a case of sitting on a plan for four to five years before we got it up and running. Issues arose between the Department of Health and the HSE and I was in the middle trying to keep the project on target.

Free GP cards are due to come on-stream for young children and I welcome the broad thrust of the initiative. When one is involved in reform, one must try to bring others along. People must be involved in the negotiations and one should not start a row over nothing or contribute to something that is negative. It is also important to consider the pitfalls. If people have concerns, it is important to take a sensible approach. In this context, I hope the Minister will listen in the coming weeks to the views of GPs.

If they state they may have issues with queues in their GP services let us see what we can do about it rather than getting into the blame game syndrome. The IMO has expressed concerns recently. One issue it raised is that efforts by the Department of Health to rush through the fundamental changes to the GP GMS contract without negotiation will lead to a service which cannot deliver what has been promised to patients. The IMO has warned the change proposed would fundamentally alter the way GP services operate in Ireland and lead to long delays for GP appointments, a massive increase in administration, costs for GPs and ultimately a shortage of GPs. The Department of Health is refusing to negotiate these matters for the first time in the history of the GMS. I ask the Minister of State to bring the message back to the Government there should not be a row and these issues should be dealt with through negotiations at which a deal is hammered out. I know this well from my own past.

Every year an estimated 24 million clinical consultations are done by GPs in the country. General practice is the most accessible, effective and trusted part of the health service. It can do much more to help patients in the community and alleviate pressures and costs in other parts of the health service. The IMO states it is committed to a GP service free at the point of access to all patients in Ireland, but the proposals announced by the Government are not capable of delivering this. We should examine the issues. We need planning, resources and negotiations so all patients have a quality health service. I have outlined some ideas which have come onstream. The Opposition is often criticised for not putting forward new ideas. The Minister of State and the Government should examine these issues, get on with it and stop the fudge.

It is important that we state the Health Services Executive (Financial Matters) Bill is a huge opportunity. We have had problems in the past and we are now having a big clean out following the disastrous banking crisis. Now is a good time for reform. There is much in the legislation which is good and I welcome these aspects. It is not only about legislation; it is also about the quality and efficiency of staff and we must examine this in the health service, education and throughout the public service. If somebody is paid to do a particular job and does this job well it leads to efficiency and productivity. Where people opt out of doing their jobs well it begins to break down. It is not all about legislation, the Dáil, Deputies, the HSE or the Minister. If everybody went to work and did their best at their job many of these issues would not arise. In the health sector one must give 100% and it is not acceptable to fall below certain standards because we are speaking about people's lives, quality of life and public safety. It is important to emphasise this.

I welcome the broad debate on the legislation. I strongly support the reform agenda because we need reform in our health services. As part of the reform agenda patients should be put first. People with an intellectual or physical disability should be prioritised. The money must go to the right places. This was a criticism in the past and we have seen the recent scandals. We must ensure the money and limited resources in a time of economic crisis go to the most needy. I welcome the legislation and look forward to hearing the views of other Deputies.

I am delighted to have this opportunity to speak, particularly after the speech by the renowned Member opposite. I am glad he mentioned the much discussed piece of paper to which he signed up years ago-----

I have the evidence.

-----which was selective in the sense that those whom it accommodated were a particular group which excluded the rest of us. I am so sorry to have to advert to it now but I remember being here during the course of it. Those were the halcyon times, which I am sure the Deputy will recall.

The House lacks the ability to address in legislation the issues which arise from time to time which need to be dealt with. We seem to react to them in off the cuff debates, emergency measures or short statements. The legislation required to deal with a structure as important as the health service is something we must all welcome.

It is not so long ago when the health boards were in operation. People who would normally be resident on the other side of the House are momentarily absent. When they were in control the cost of the health services increased fivefold in a very short space of time. One of the causes for this was they began to tinker with the system. When one begins to play around with a system adding balances, swings, roundabouts, weights and measures one ends up with something which does not work, and this is what happened. To resolve the problem what did they do at the time? I saw the same debate taking place then as is taking place now. They decided to abolish the health boards because they tried everything else and they all failed. The structure did not fail, but the boards failed because of the failure of the Government at the time to interact with the structures which existed, recognise what needed to be done and make changes. The health boards had one distinct advantage over anything else which superseded them; they had representation on the boards which consisted of GPs, nurses, the disability sector, consultants, management and every facet of the health service. Over a number of years people got lazy and did not really address the issues they were intended to address in the first place. They became distant and flitted over the issues in a way which did not really engage with the developing demand, to which I will refer later.

I am amazed at commentators who do not seem to realise what happens in these situations. The criticism at the time was one group was superimposed on another. The HSE was superimposed on the health boards and many of the same people were kept in place. How else would it have happened? How else could it have happened? Those with expertise who were involved in the delivery of services at the particular time were familiar with the services. Of course it cost more. All changes of this nature cost more. The question was whether they delivered the service. I remember posing the question of the first chief executive of the HSE as to whether he thought the structure of the HSE was the appropriate mechanism to deliver the health services throughout the length and breadth of the country. He stated he did not know. He learned subsequently.

In the debate which took place prior to the establishment of the HSE comparisons were made by well-placed economists between the population of this country and that of the greater Manchester area, with approximately 4.5 million people, and they argued it should be possible to deliver health services in the same way with the same cost effectiveness as was done there. This is rubbish because they were not comparing like with like. There is a hell of a difference between them, because one can walk across the greater Manchester area in half a day but there is a much greater distance between Kenmare, Carlingford, the tiptop of Donegal and Wexford. Like was not compared with like. It was then suggested the HSE would do the job cheaper. It did not because it could not be done.

As I stated, the groups of people involved in the old health board structures included GPs, the nursing profession, specialists and psychiatric representatives.

In addition, one had the politicians of all groups represented in the local authorities and the Oireachtas. The amazing thing about it was there was local representation and regardless of whether one likes it, that representation, elected by the people and selected by the professions, was there. Consequently, they were all together at meetings and were not obliged to consult anyone else or to consult consultants or to read reports. They were all present together in the course of the meeting and regardless of whether that meeting took place in the Western Health Board, the Eastern Health Board, the Southern Health Board, the Midland Health Board or wherever, all that was required to make a decision was to hand and they had the requisite information. In any event, this was dispensed with in favour of the structure that hopefully now is being disassembled once again. I believe eventually the point will come whereby there is direct local input in respect of the delivery of health services, which one must remember are demand-driven. One cannot predict them one or two years in advance or whatever the case may be. There will be glitches and blips from time to time when there will be demand surges to which there must be a response. It will be interesting to learn whether it will be a cost-effective move, whether the delivery of the services Members envisage will revert to being done in a way that it used to be done, whether the requirements of the people will be met and whether there will be a democratic structure that is accountable to the people.

I have heard many lectures from Members from the opposite side of the Chamber, which I reiterate is empty, in recent years as to accountability, the need for it and how there was accountability in the old days. I can assure the Acting Chairman there was none. When sitting on the other side of the House, I raised issues relevant to the health services numerous times and the only reply I received was the subject raised was a matter for the Health Service Executive. The reply would state it was a matter more relevant to the HSE and the Minister had no responsibility to the House. Yet, I hear Members sitting on the opposite side of the House mention repeatedly that the quality of service they get now is not up to what it used to be, is not what they expected or what they had. Such people are talking rubbish as the service given with regard to answers and accountability in this House is as good as anything that prevailed during the time after the abolition of the health boards and the establishment of the HSE. That is a fact and I will engage in chapter and verse with anyone who wishes to debate the subject at any time.

I had an interesting analogy to draw in the past couple of weeks based on another subject, namely, Irish Water. There were howls of derision and indignation from that absent side of the Chamber, because there were costs associated. It was cried there were costs associated with the setting up of Irish Water but what did they expect? From where in heaven's name were they coming? Did they really think there would be no costs associated with it? Did they think the people who already were involved in the provision of those services nationwide would be made redundant? That of course is what they were suggesting but they were putting a nice turn on it. That is what they wished for, to enable them to state it could be done for less. Nothing could be further from the truth. I will finish with this deviation by noting that amazingly, when Eircom was sold - there was no sharing of responsibility at all - it cost £55 million to handle the sale alone at the time. Consequently, I ask those who now give lectures to Government Members about value for money, the need to conserve and the need for openness, accountability and responsibility, to please give them a rest and not to go there any more. We have heard it all before and it does not get any better with repetition and the passage of time. We have seen it all before.

The invisible Opposition may not accept what I am about to say about waiting lists. Incidentally, that is an amazing feat. There once used to be a programme on television in which a guy became invisible when he switched a button or something like that. They must have done that all together. I presume they are there but one simply cannot see them. The entire question of waiting lists has been addressed in extremely difficult circumstances in which there has been a massive reduction in the funds and staff available. When Members on the opposite side of the House are pretending that there should be none of that, they should think back over the past couple of years. They should reflect on where this country went when there was a genuine lack of accountability and transparency and when the country went down the drain. Moreover, no one said a thing about it as they were too concerned about the frivolities of playing around with the luxuries that existed at the time of the peak of the boom. Nothing was said about it and the waiting lists were massive at a time when there were more resources available and less demand.

As the Acting Chairman is aware, I am a regular critic of services of all shades and natures and continue to be such. However, I must compliment the Minister for Health and his colleagues on doing the job they have done under appallingly difficult circumstances at an extremely challenging time. Moreover, they have done it with fewer staff and less money than it has ever been done with before. In the same breath, I compliment those health service operatives involved in the delivery of health services on the front line, at management level and in the hospitals, including nurses, doctors and consultants. I compliment them on doing the job they have been obliged to do in these challenging times. Moreover, one should be in no doubt but that it was a challenge. If one asked anyone in any branch of the public service in this country four years ago as to the direction in which the State was heading, they would have shrugged their shoulders. Consequently, I compliment those involved and recognise the job they have done in those circumstances. Members do this on a regular basis by interacting with the relevant people in local hospitals and the health services in general.

The issue of trolleys is an emotive subject. Good management and good operational procedures will eliminate the trolleys and this is being done to a much greater extent than was the case. Again, I accept that more must be done and that these are challenges. However, by making that additional effort, I believe a service will be delivered to which the public will respond. Moreover, Members must recognise the front-line staff are in the position of being inundated and challenged on a regular basis. When I hear admonitions coming from the opposite side of the House - where the invisible people are - I note they state "the Government promised". While such Members anticipated that someone made a promise, three years ago, the only thing that could be promised on this side of the House by either party in government is simply what the Government did, namely, to try to maintain as best it could the front-line services, notwithstanding the serious economic difficulties with which the country was faced. When I hear people asserting the Government has not done this or has not spent money on that, my response is we are lucky to be here at all. We are lucky to have survived what has been endured over the past three to five years. This country had gone down the tubes and as Ministers have acknowledged, the country was bankrupt and no one wished to recognise that. Moreover, from time to time one hears clever people coming forward to state there is some money out there the Government still can get. If there is, get it. That is the simple answer. Where is it? Ireland was on its knees but I am glad to state that under good, careful management, it is crawling back. That is due in large part to good leadership and largely is due to the willingness of people to take responsibility, recognise what had to be done and stick with it. They have done so and they also are to be complimented on their efforts over the past three to four years.

As for projections, over the years I have tabled numerous parliamentary questions to determine where overruns took place. Needless to say, when a member of a health board, I used to do the same thing. It is a simple matter to work it out because all that is required is to divide it by 365. One adds in the blips and glitches that will take place, one recognises the increased demand, which obviously is the situation in which we find ourselves, and one then comes up with what should be sufficient to run the service. Thereafter, one must include for contingency purposes a sum to cover those unforeseen circumstances that will arise from time to time. It is difficult to do that and to come out at the end of the year with a clean slate. It has been particularly challenging in the health services but, amazingly, what comes from that side of the House is criticism of the Minister and the Government for their alleged failure to deliver services with a decreased budget and a reduced number of staff, while they failed to do it with all the staff and all the resources.

If anybody wants to make the comparison they can do so, but it is there for all to see. We must recognise these matters in the debates in this House. When I see this posturing from the invisible multitudes over there about the idea that there is something wrong here, that the Opposition has not got to the bottom of it yet but that if they keep going they will, I know we are on a doubtful path.

Like the Minister for Justice and Equality, Deputy Shatter.

I see Deputy Mattie McGrath has entered the House and I welcome him because he, also, was part of that during the halcyon days. It might grate on his teeth and his nerves might get slightly raw at the prospect of this but he was concerned about only one thing: he wanted to spend more money on everything. His exit even from Fianna Fáil was on the basis of his failure to accept that there had to be curtailments and, my God in heaven, he did not want to hear about that.

If I remember right it was the poor stag Deputy Durkan was after.

Responsibility was not at the races.

Vincent Browne is looking for Deputy Durkan.

The unfortunate horse, Responsibility, was left standing in the stalls while the whips were out and everybody said, "Go for the line". Unfortunately, poor old Deputy Mattie McGrath was not able to measure up to it at the time and they threw him overboard.

Vincent Browne is waiting for Deputy Durkan to go back.

Since then he has found his voice again, licking and sucking up to his former leaders, looking lovingly with doe-like eyes at them, hoping for that day when he might be brought within the fold once again, buried in the bosom of his former party.

Vincent Browne is waiting for Deputy Durkan.

I would hate to be around when that happens because then this country will surely be going back to where it came out of in the last few years, back down the tubes once again. The sooner the people of this country recognise that, the better.

They are waiting for Deputy Durkan in the long grass.

People like that are still around shooting the breeze in the same old way as they did before, behaving as if there was nothing wrong, looking around and saying what they would do. It is called sticking-plaster politics. You add a little bit here, a little water here, a bit of steam, a little bit of hot air over here now and again and all of a sudden everything is rosy in the garden again. This is about a serious issue, the delivery of health services, the most fundamental issue the people of the country expect. They expect to be able to rely on a reliable health service in every aspect and area throughout the country where delivery is required on a 24-7 basis. They will do it provided the structure is right. It can be done. While we prevaricate, hang around and make political capital out of every opportunity, as in the past, it will not happen.

I hope this legislation will do the job for the people of this country and recognise, in so doing, the importance of a reliable, cost-effective, efficient and readily available health service, which is a basic thing. When I was a young lad, which was neither today nor yesterday, in the 1950s, the late Dr. Noel Brown was pursuing his health campaign on tuberculosis. I remember how the people looked with hope to what was going to happen, and it did happen. It took a long time to change people's thinking and habits and to address the issue, but the issue was addressed and the services were put in place to deal with it, thankfully. All that was needed at the time was a concentration on the requirement, not the rhetoric, and it was done.

Like previous speakers across the House I very much welcome this Bill. Any move by the Minister to reform the health system is welcome, particularly the inclusion in this Bill of the establishment of a new financial governance system for the HSE. The HSE has had some bad press since it was established but particularly over the last number of years. Politicians and the public have been crying out for more accountability and transparency to be included in its remit. I am glad this Bill will ensure that and that the Minister will ultimately be responsible and accountable for its actions.

Under the terms of this Bill spending will be determined by the Minister with, I hope, more input from elected representatives regarding areas where the money is needed. I trust that the Minister will take on board problems that constituents have highlighted with their elected representatives when finalising the health budget in future. The HSE is a separate entity and it is sometimes difficult to communicate with it and put one's points across, including so many negative experiences people have had with it. I welcome that the Minister will have more responsibility for finalising the health budget and a more hands-on approach to health service matters in general.

The Bill is an interim measure towards the dissolution of the HSE, the transfer of its functions to other bodies and the provision of universal health insurance for all citizens. It is hoped the HSE will cease to exist over time. Perhaps the Minister might comment as to whether a date is set for the HSE to cease to exist and for the functions to transfer to the Minister for Health or to the universal health insurance system. The most important point to note with this Bill is that it ultimately seeks to ensure that there is more value for money for the taxpayer from our health service. Like others I was shocked to see that the estimate for pension lump sum payments for HSE administration staff this year is €72 million. That is a lot of money. Could the Minister comment on the situation underpinning that amount of money?

The HSE was established in 2005 under the Health Act 2004. It was hoped that the new service would clearly differentiate between the responsibilities of the Department of Health and the HSE, with the Department of Health responsible for the management of services. The goal at the time was that the new HSE service would put patients first and get clear value and results for the money spent. There has been much overlap between both areas and duplication as well as issues falling between the HSE and the Department of Health not accepting full responsibility for various issues I and other Members have raised over that period. Parliamentary questions are answered when they are put to the Minister for Health but if they are put to the HSE it is a much longer process, sometimes taking up to 15 working days, over three weeks, to get answers, if one is lucky enough to get answers. No doubt that will change with this Bill.

There have been problems and it is important that the goal of putting patients first is fully realised. It is a mantra the Minister has used in the past and the idea is that, ultimately, the money will follow the patient and the patient will get the best service possible. We know that, sadly, that has not always been the case. One of the main aims of the HSE was to ensure that patients were put first in the design and management of health services. The patient is often not put first in the HSE and it is vitally important that we move towards more patient-centred care. The taxpayer pays a substantial level of tax, much of which is allocated to the HSE to fund the health service, but they often do not receive a satisfactory level of service.

I welcome the Minister to the House and thank him for his presence. Various constituents of mine have raised a number of issues regarding the health service, particularly the accident and emergency department in Beaumont Hospital and the inefficiencies in the primary care reimbursement service, PCRS, medical card application system.

We all seek to help our constituents in obtaining medical cards when they fit the criteria. Recently, a case was brought to my attention by a constituent who was dealing with the PCRS in Finglas who was told on three occasions that the application was not received. It was only when the application was sent by registered post that it acknowledged that the information had been received and the constituent was issued with a full medical card within a week. That was a turnaround in the end. This case shows there are substantial problems with the system in place to deal with medical card applications. There appears to be a lack of communication between departments to notify the system when an application is received. In this case the application had been received and signed for but, for some reason, had not been added to the computer system. Obviously, a better-quality integrated system is necessary in this case. That an inadequate infrastructure was in place undermines the whole process and the public's confidence in the health system, particularly the processing of medical card applications. Once received in the various departments, documents should be scanned and the information added to constituent's files within the system in order that it can be easy retrieved at a future date.

The accident and emergency unit at Beaumont Hospital is under extreme pressure, as Deputy Seán Kenny is aware. One in three patients has been admitted since the start of 2014, in comparison with one in five prior to that time. I am glad to hear that six additional nurses have been appointed to Beaumont Hospital to improve processing and help patients, but I want to hear what further plans the Minister has to improve the accident and emergency unit. I appreciate that the special delivery unit is doing good work. However, there appears to be some ongoing niggling issues in regard to the accident and emergency unit and the length of time people have to wait to get an adequate service. One of the criticisms is that the level of service is not the same as it used to be and, obviously, there is greater pressure on the Minister, given the reduced budget, to deal with some of these problems.

Following an operation and discharge from hospital, less support is available to patients. An element of extra help could be provided to patients to help them rehabilitate. One of the recent scandals was that of top-up payments at the Central Remedial Clinic. Why was that issue not considered in the Bill to ensure that individual agencies were not allowed pay salaries above and beyond the health sector pay policy? When the HSE is dissolved and changes have been made, we hope this type of scandal will never recur. Hospitals must become more transparent in respect of the salaries paid to their staff. I would welcome a comment from the Minister on that issue. The heartbreaking aspect of the top-up payments at the Central Remedial Clinic is that it is the patients and those at the receiving end of its services who are suffering. The CRC's image and reputation have been damaged and people are no longer donating as much as they did previously. That was obvious in the CRC Santa Bear appeal. Fund-raisers and donators feel cheated by the scandal and it is important that confidence is restored to the sector. I call on any directors who received moneys to examine their conscience and return that money so as to improve the image of the CRC and restore confidence to the organisation.

I am pleased to speak on the Bill. I thank Deputy Terence Flanagan and others for sharing time.

At the beginning of his contribution on the Bill last Thursday, the Minister took time to give a list of all the great things that he and his Department are doing, such as publishing reports on the establishment of hospital groups and on the future of smaller hospitals. He has appointed chairpersons for each of the seven groups and is currently in the process of appointing the chief executive officers. In March 2013, he published Healthy Ireland, a strategy for empowering people in Ireland to get healthier. However, if I took the time to list all the deficits in the HSE and in the Department I would need more than the ten minutes available to me. In the limited time at my disposal, I note the Minister is now speaking about 2019 for the full implementation of universal health insurance, as envisaged and espoused by him on many occasions. The problem is that it is not clear what the Minister has in mind given that we are still waiting for the publication of the White Paper on universal health insurance. We heard the rumblings from the Minister for Public Expenditure and Reform, Deputy Brendan Howlin, at the weekend, while on Monday morning I heard the Minister of State at the Department of Health, Deputy Alex White, on "Morning Ireland" speaking about a little charge. I do not have a fundamental issue with a small charge on medical cards as applied to prescriptions, for reasons the Minister will be aware of, being a doctor himself. However, let us be honest with the people if nothing else.

The Irish Medical Organisation, IMO, and other groups representing general practitioners are deeply unhappy with both the content of the draft contract drawn up by the Government and the proposed new service, and the insistence of the Department of Health that it will enter only into consultations and not negotiations on the issues. The Minister appears to have forgotten his past. He was on the other side negotiating on behalf of a certain group and he expected, demanded and got negotiating rights and, I might add, negotiated a very good deal for his own group at the time. It was a group that negotiated well and got plenty from people who were willing to give plenty at the time. We all thought we had plenty but we had not. Faraway cows have long horns.

Last week, the IMO warned that it would consider seeking an injunction to prevent the Government from introducing changes to the contracts of its members without agreement. That is what the Minister would have espoused when he was on that side, but he should not forget everything. I hope the Minister and the Department will be open to more constructive forms of dialogue on this matter and listen to the experience of general practitioners on the ground. My experience is that the vast majority, 99.9%, give a tremendous service. Their clinics are overrun because the hospitals cannot cope and people go to them when, on many occasions, they should be in hospital. Some people who visit the GP discover they do not have medical cards. At this stage the GP has to be a counsellor and deal with traumatic situations and has to engage and listen to people. Medical cards have been systematically removed from old and vulnerable people who have not been notified. They only learn this when they visit their GP.

I wish to challenge the Minister on one issue. I have seen in print that a person's medical card cannot be removed for a period of three months from the date of a letter from his or her doctor. Perhaps the Minister would respond to that issue and put the lie to that if it is untrue. Many old people are traumatised because of the situation. I have a regular flow of e-mails on the issue, including two yesterday from GPs in my constituency who said that GP visit cards had been removed without notice even though they were not due to expire until 2017. Such action is faceless, cold, bureaucratic and shows no sensitivity. The way the system deals with it is outrageous.

I have been in regular contact with local GPs who are deeply concerned about the proposed changes to the system, especially the proposal for free GP care under-fives. This will be a banana-skin issue because the Minister will slip on it and will fall and will need medical treatment. I do not wish the Minister any ill, but that could happen. This is a real sickener for hundreds of people. At least 20 people per day contact my office about the removal of medical cards and the Minister is talking about giving them to under-fives who, thankfully, normally are quite healthy.

He will flood GP clinics with people who thought they were healthy until last weekend when the Minister for Public Expenditure and Reform, Deputy Howlin, put his oar in. Thankfully someone can talk sense to the Minister for Health who is not a good listener and say they will not provide the money for the Minister. That is the only way to deal with him, turn off the tap. Then he will not be able to go ahead with his crazy plan to give it to the under-fives and take it away from cancer patients and patients in all kinds of situation. This has to be visible to the Minister unless he lives in a bunker. This is happening up and down the country. Sick people are traumatised and devastated. A man rang me today who has been waiting months for his medical card. He is a cancer patient who is unemployed and receiving social welfare. The hospital demanded €75 from him. He rang me from the hospital to know what is the situation regarding his card. That is a sad, desperate situation. The Minister talks poppycock about introducing free GP care for under-fives or under-sixes as a first step on a ladder that is going nowhere. It is a ladder that will fall as soon as it is erected because it is standing on ice and will fall through the cracks when the Ministers for Public Expenditure and Reform and Finance pull away the funding.

We were disappointed when we heard that our hospital was being disenfranchised from the South East region which we had been part of for years but vested interests in Kilkenny and elsewhere wanted to link up with Dublin and left us high and dry. Thankfully, our hospital is now aligned with Cork University Hospital. That is all that has happened. The Minister has appointed chief executive officers for those regions but nothing else. We are in Limbo.

There are many good outcomes in my local hospital. Front-line staff, from those at the front door all the way up to the consultants do an enormous job in terrible circumstances. The Minister has only once visited that hospital, to launch a learning programme with Limerick University. He did a quick tour of the hospital. He ran out of it quicker than Cromwell fled from Clonmel. He was to meet us Oireachtas Members-----

The Deputy has a great imagination. I will say that for him.

I was there. I saw him.

The Deputy was there for a very short time.

Deputy Tom Hayes, Deputy Healy and I waited for hours to meet the Minister but he left us standing in the yard and never met us. He has not met the Oireachtas Members from south Tipperary once since he took office. That is a shame on him. Under the last Government, which I supported, we had regular meetings with the then Minister for Health, Deputy Harney, at least every six months, sometimes quarterly. The present Minister has not met us once. When he has met us in the corridor he has said he will meet us or do this or that but he has never brought us into his office, or sat down to meet us in any office. The same happens with senior management in south Tipperary. It does not engage with me as it used to do quarterly under the last Government, with the local Members and the then Minister of State, Deputy Mansergh.

We are in a vacuum. I have received calls telling me that yesterday there were 19 people on trolleys and 15 today. On other days there have been 28. That is the second highest number in the country compared with Beaumont Hospital or Cork University Hospital, which have four times as many beds. It is not because the front-line staff are not doing their job. They work very hard. It is a crisis in Clonmel, South Tipperary. Front-line staff cannot cope. The Minister just rubs his hands and makes glib remarks and does not even have the interest to meet the Members or engage with senior management. I do not know whether the Minister has instructed the senior management not to engage with us. People call me with harrowing stories about people on trolleys for two or three days. A few nights ago there was a woman there whose oxygen container was empty. That is third world standard. There is no room. I will be forced to call in the Health Information Quality Authority, HIQA, and the Health and Safety Authority, HSA. Worst of all I was asked last Sunday night to call in the fire officer because it is dangerous, unsafe and unwise for patients, families, staff and everybody else to be there.

The Minister can sit and smile all he likes but this is a Third World, primitive situation. The Minister should hang his head in shame at leaving it as it is. Then he talks about free GP care for under-fives. He is in a world of delusion and illusion. I challenge him to give me a date, as soon as possible, when he will visit the hospital, and an earlier date when he will meet the Members elected from south Tipperary, or indeed all of Tipperary and part of west Waterford as well. I challenge the Minister to do that, across the floor of the House because it is no good writing to him or asking him because he will only laugh and talk about it. What is happening is an outrage. I heard a Deputy from Roscommon ask this morning what happened about the Bills last night. The Government is robbing Peter to pay Paul. I salute the front-line staff for the work they do under appalling pressure. I acknowledge that the Minister allowed the recruitment of some nurses recently. The pressure is on sick people – and most people do not go into hospital unless they are very sick. Some go in at weekends as a result of drinking but they should be segregated and put somewhere else because they are annoying and frightening and the security staff have to keep them away from everybody else, from the ordinary sick people, especially those who are old. It is an indictment of the Minister, who is a qualified medical person and has taken the hippocratic oath, that he would allow such conditions to continue in any hospital but above all in our hospital in south Tipperary. I challenge the Minister to meet the Tipperary Members to discuss it at first hand. I further challenge him to come back and not run away as fast as Cromwell ran out of Clonmel. We hunted him. The Minister was welcome to stay but he will not be welcome again if he does not have some respect for the elected representatives and the people of south Tipperary.

Under the Health Act 2004, the Health Service Executive had its own Vote. In other words it was funded through a separate process from the Department of Health. The programme for Government contains wide-ranging commitments regarding the reform of the health services and the dissolution of the HSE is a necessary step in the process of implementing these reforms. The Health Act 2004 provided that the Minister for Health had no legal role in setting the HSE budget. The intention then was to give the HSE greater operational autonomy from what was characterised as a very politicised decision-making system. It is clear, however, that in the years since this was done the health service has been weakened because the accountability of the HSE to the Minister and the Department of Health was lacking. 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 another step on the way to necessary reforms, including the dissolution of the HSE, the establishment of a health commissioning agency, new community care structures, and hospital trusts.

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 Minister for Health by way of grants paid to the executive. The executive will 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. The Bill sets out an alternative statutory framework to govern the funding of the HSE and to ensure that the director general exercises proper controls on expenditure. The Bill also makes consequential changes to the service plan process to align it with the new budgetary arrangements. I look forward to speaking on the service plan when it comes before the House soon.

The central aim of the health reform programme is to improve equity and access to services. This Bill is an essential part of that goal. Transparency and accountability around service delivery are fundamental to the health service reform programme. This Bill, together with the other changes being made, will help ensure more accountability during the time the HSE continues in existence. I welcome this Bill which will, I hope, bring stronger control to the overly-bureaucratic HSE that has removed accountability from the provision of health services and has taken accountability away from the political authority and through that from the people.

Before I was elected to this House I was a local authority member of the Dublin North East Regional Health Forum, which replaced the health board. It was purely consultative in nature and had no real decision-making powers or functions. I seriously question its effectiveness.

I pay tribute to the individual staff members of the HSE who work very hard. The HSE model has not worked, as the last decade has shown clearly. It is too large and unwieldy to function in a cohesive and consistent manner. It is time to move on and take a new approach. I support the Bill.

When the Health Service Executive was established in January 2005 it replaced the existing ten health boards. At the time the health boards were regarded as problematic from a governance perspective. To a certain extent this view was correct. Ten different systems without any co-ordination were obviously going to be ineffective.

Also, as technology developed, systems had to develop. The exchange of information and shared services would become central to the management and running of any organisation, particularly a complex and evolving organisation such as the health service.

I believe there were political motivations at the time in putting the health service at arm's length from the then Minister. The establishment of the Health Service Executive gave the impression that there would be a division of responsibility for policy and management. Responsibility for policy remained with the Minister and the Department, while responsibility for its implementation and management transferred to the HSE. The changes meant that the then Minister was no longer directly responsible to the House for the day to day running of the health service. There is no doubt that despite the apparent affluence of the economy in 2005, the health service was in crisis. Unfortunately, the establishment of the HSE was ill-conceived and it was badly set up. That led to a deepening of the heath crisis which became more acute as the financial crisis worsened.

As part of the programme for Government, the Minister committed to a health reform programme. The goal is to have a universal, single-tier health service based on universal health insurance. As part of this process, the HSE is to be abolished and its functions will return to the Minister for Health where they rightly belong. The Minister and the Government should be accountable to the House for the functioning of the health service. This legislation is part of that reform. It provides for the funding of the HSE and its successor through the Vote for the office of the Minister for Health from the start of next year. The HSE will be abolished and a new and robust financial governance structure introduced. The main features of the Bill are to provide for the dissolution of the Vote for the HSE; the funding of the HSE through the Vote for the office of the Minister from January 2015; the establishment of a new financial governance structure for the HSE; giving the Minister powers to set a net budget for the HSE and approve gross income and expenditure plans; and imposing certain legal obligations on the director general to ensure the HSE executive operates within the financial limits imposed by the Minister.

As the Minister pointed out, this legislation will enable new funding arrangements to be put in place as part of a wider restructuring of the health service and the ultimate implementation of a universal health insurance system. In that regard, I will make a point that arose at a recent meeting of the Committee of Public Accounts. Representatives of the health service were before the committee and stated they had 15 certified chartered accountants engaged in the HSE. One example of a reform not having been introduced is that one cannot get details of any hospital budget at the touch of a button, which is unimaginable today, without the necessity of having people involved in reforming them, reanalysing them and so on. Deputy James Reilly is a reforming Minister, but the pace of reform is not as fast as he or the general public would wish. Reform and change are difficult at any time but particularly difficult in poor economic times. Despite this, however, fundamental reforms, changes and better results are being achieved every day with fewer resources. I commend the Bill to the House.

Debate adjourned.