Health Service Executive (Financial Matters) Bill 2013: Report and Final Stages

Bill received for final consideration.

As there are no amendments, we will proceed to Fifth Stage.

Question proposed: "That the Bill do now pass."

Looking back over my notes on the Bill, I challenged a section of it on Committee Stage and feel equally strongly at this time about the matter.

It could be argued that this Bill is a technicality in so far as it seeks to create a single budget for the Department of Health and the Health Service Executive, as against the position heretofore where we had two separate Votes. That is, in essence, a technical matter but as I have said previously, the critical point is that there is adequate funding to provide a health service that is fit for purpose and capable of responding to the needs of people when those needs arise. Quite clearly the significant cuts in the provision for health services over recent years, amounting to some €4 billion by the end of this year, have carved out a critical level of resourcing from the health structures, both in terms of the capacity of the health service to cope with all cases presenting and very especially with regard to the numbers of people employed. It has already been signalled that some 2,600 whole-time equivalent posts are to go in this current year on top of the 12,500 which have gone since 2007, almost 6,000 of which were front-line nursing posts.

It is not so much a question of whether the Minister has a single allocation or two budgets but that he has provided adequately and properly. I am afraid that the facts demonstrate that this is not the case. That is not to say that money thrown at the system is the way to do business either. We need to get value for money and there must be, at all times, a responsible evaluation of the return from public investment in our health services. We already know that many areas of the health service are under enormous strain, not least the acute hospital network. Many hospital sites are finding it very difficult, if not virtually impossible, to cope on the reduced budgets of recent years, yet section 10 of this Bill seeks to introduce what I can only describe as a piling, year on year, of any failure - in the language of the Department - of the health service to manage its affairs within the stated budget, that is, the allocated sum in any given year. What this will mean, in essence, is that if the HSE is unable to manage the health care needs of the population in any given year, it will have to carry forward any overspend as a further reduction in the following year's allocation. This would continue, year on year. That will work its way down into acute hospital sites and all of the other areas of health care delivery until we end up in an absolutely impossible situation. This is very worrying.

On Committee Stage the Minister introduced what I described as the "fantasy notion" that the executive might actually have a surplus, having underspent and he suggested we would have to get the approval of the Minister for Public Expenditure and Reform for those moneys to be carried forward and added to the subsequent year's allocation. If only that could be, but it is most unlikely indeed. This is a very worrying aspect of this legislation. While I was not overly exercised about whether we had two separate budgets or one, as the case might be, when I examined the body of the Bill and saw what is actually entailed in section 10, it was a cause of great worry to me. I did not support it on Committee Stage and wish to record again that I will not be supporting it unless the Minister indicates, in response, his willingness to revisit that particular section.

We said on Second Stage and throughout the debate on the Bill that we were very concerned about this legislation for a number of reasons. Deputy Caoimhghín Ó Caoláin has pointed to the fact that the Bill is technical in many ways in that it brings two Votes together into one under the Department of Health. However, there are also principles at stake. The difficulty we have is with a Minister and the Department setting policy with one Vote and then another agency under that Department implementing the policy. The issue we have centres on clear and distinct lines of demarcation and accountability. We want accountability in this Chamber. However, a lack of clear lines of demarcation can give rise to lines of influence. We have said previously that as the executive was structured previously, there was a certain distance between the Minister in the Department, who sets the policy and is accountable to this Chamber and the HSE which implements that policy. We can argue about whether the HSE is implementing policy in an efficient manner. Indeed, we could have that debate all day, every day. Some people argue that the direction we are now travelling, towards universal health insurance and all that will flow from that, is an effort by the Government to indicate that it wants to be different in how it funds the health service. However, it does not have any clear train of thought in terms of how that will impact on the health services. We are having discussions on an ongoing basis on universal health insurance, the establishment of the commission, the negotiations, discussions and submissions that are being received and the input of the Oireachtas Committee on Health and Children.

There are lots of reasons to be concerned about the Bill. As Deputy Caoimghín Ó Caoláin highlighted today and on previous occasions, there are also lots of things wrong with the Department of Health and the current Minister, particularly in the way they have directed policy. There is a lack of commitment to ensuring that if the entire Vote comes under the Department of Health we will have a better health service. Will this actually be more efficient and effective? Will it direct resources to where they are needed most or will it simply allow for more political interference? I do not like having to say this but the Minister has form, as do other Cabinet Ministers, in the context of deciding where resources should go. We had, for example, numerous debates in this Chamber on primary care centres, on how and why certain centres were prioritised and the lack of clarity on the criteria used for prioritisation. We had many discussions about algorithms but have yet to get a concise answer from the Minister on how particular primary care centres were prioritised. We have also dealt with issues around the funding of emergency departments, although nobody denies that funding for emergency departments in hospitals is essential. The recent HIQA report on the hospital in Dooradoyle highlights the inadequacies of the emergency department there although a new department will come on stream shortly. The point I am making relates to how decisions are made about where resources are directed.

If the Vote in question is brought within the remit of the Department of Health - of course, the Minister is the representative of the Executive in the Department - there will be potential for horse-trading to occur between Ministers in the provision of money and how and where it is to be spent. There is actually more than just potential in this regard because it has happened already. The impact of what occurred when health funding was, for horse-trading purposes, diverted to certain Ministers' constituencies has been well chronicled in recent times. That is a type of behaviour from which we are trying to move away. I am concerned that when the Vote to which I refer is transferred back to the Department of Health, there will be potential for influence to be used and interference and conflict to occur.

The Minister has not, by any stretch of the imagination, covered himself in glory in the presentation of budgets in the years since his appointment. Every year it is stated difficulties will arise. In recent times the chief executive officer of the HSE has highlighted the deficiency in this regard, namely, the fact that budgets are built on sand. We understand the need to pare back the public finances and prioritise certain areas within them. The key issue is that when a budget is set down, it must be sustainable in how services are going funded for the year ahead. Every January or February we come to the realisation that the budget the Minister presented the previous October as part of the Estimates process will not be sustainable. Representatives of the HSE have highlighted the fact in recent years, even as the Minister was negotiating the shape of the health Estimate with the Ministers for Public Expenditure and Reform and Finance. How he expects personnel in the HSE to deliver services when the budgets he is allocating are wing and a prayer efforts worthy of fantasy fiction is beyond me.

The fact that the Department of Health will have responsibility for the Vote to which I refer is a source of concern. It is with regret that I make these remarks, but at least I am being consistent. I must continue to be consistent in this matter because, as has been well documented, every September or October there has been bedlam in the negotiations on the health Estimate. Last year apparently the Minister sought an additional €1 billion in funding and ended up with €666 million less. That had an impact in the delivery of services in emergency departments, primary care centres and settings and across every other area of the health service. For all of these reasons, we are of the view that the Bill will only expand the Minister's remit even further. We have concerns about that remit in the first instance.

I point out to Deputy Caoimhghín Ó Caoláin that if the amendment to section 10 was not being introduced, there would be no legal constraint on the HSE's spending. That constraint is imposed by virtue of the executive having its own Vote.

I must inform Deputy Billy Kelleher that there will be a clear line of accountability under the new arrangements. The HSE will be given a new expenditure figure by the Minister and obliged to submit its service plan in line with the net budget. There will be a legal obligation on the executive to ensure the plan will be implemented within the limits of the resources provided. As is the case, the national service plan will have to be approved by the Minister. It will also set out the budgets to be allocated to the different sectors within the health service.

Deputy Billy Kelleher is fond of referring to shambles, disasters, catastrophes, etc. I highlight for him the fact that in 14 of the past 17 years it has been necessary to introduce Supplementary Estimates in respect of the budgets for the Department and the HSE. That was during the wealthiest period in the country's history, namely, the so-called boom years. It is not surprising that it has been necessary to introduce Supplementary Estimates at a time when the population is growing, when, thankfully, more older people are surviving and when, as those opposite pointed out, we are seeking to reduce budgets. Nonetheless, thanks to the great work of the men and women employed in the health service, 95% of those waiting for outpatient appointments have been treated or seen in under 12 months, 99% of those awaiting inpatient procedures have been treated in under eight months, while there has been a 24% reduction in the number of patients obliged to endure long waits on trolleys. That figure is still too high and we need to do more. In that context, we will continue with our reforms.

The Bill before the House is another step on the road to further reform in creating a procurer-provider split. The HSE is buying services from itself. I am sure everyone agrees that there is no particular incentive to be competitive with oneself when one is providing a service. Clearly, it is in the interests of all those involved that we create the procurer-provider split. That will be achieved in the context of a health reform Bill to be introduced later this year. In the most recent general election the people gave us a very clear mandate to, as some would say, abolish the HSE. I prefer to say we are replacing it. In order to do so, however, we must transfer the Vote back to the Department as a first step.

There are great people working within the health service and this legislation will assist them in delivering the excellent services they have been trained to deliver and which they wish to deliver but which, as a result of the system the Government of which Deputy Billy Kelleher was a member put in place, they have been prevented from delivering. It is my belief we can look forward to a brighter future. The OECD figures for health spending show that Ireland is slightly above the average and that, in actual fact, we should be below the average as a result of the profile of the population, namely, that there are so many young people living here. In order to achieve efficiencies and savings further down the road, further reforms will be required. The Deputies opposite will have to acknowledge that if money could have solved the ills of the health service, this should have happened during the 12 years in which the spend on health quadrupled. However, that did not prove to be the case.

If rhetoric could resolve the problem, we would be flying.

Instead, we ended up with 569 patients lying on trolleys in hospitals on a single day in January 2011 when the Deputy's party was still in government.

If rhetoric could solve-----

The Deputy can talk about rhetoric all he wants, but the reality is that reform of the health service is happening. As a result of such reform, we will continue to deliver better care for citizens. I commend the Bill to the House.

Question put:
The Dáil divided: Tá, 64; Níl, 38.

  • Bannon, James.
  • Breen, Pat.
  • Butler, Ray.
  • Buttimer, Jerry.
  • Byrne, Catherine.
  • Byrne, Eric.
  • Carey, Joe.
  • Coffey, Paudie.
  • Conaghan, Michael.
  • Conway, Ciara.
  • Daly, Jim.
  • Deenihan, Jimmy.
  • Doherty, Regina.
  • Dowds, Robert.
  • Doyle, Andrew.
  • Durkan, Bernard J.
  • English, Damien.
  • Farrell, Alan.
  • Feighan, Frank.
  • Ferris, Anne.
  • Fitzgerald, Frances.
  • Flanagan, Charles.
  • Griffin, Brendan.
  • Hannigan, Dominic.
  • Harrington, Noel.
  • Harris, Simon.
  • Hayes, Tom.
  • Humphreys, Heather.
  • Humphreys, Kevin.
  • Keating, Derek.
  • Kenny, Seán.
  • Kyne, Seán.
  • Lawlor, Anthony.
  • Lynch, Ciarán.
  • Lynch, Kathleen.
  • Lyons, John.
  • McCarthy, Michael.
  • McFadden, Gabrielle.
  • McGinley, Dinny.
  • McLoughlin, Tony.
  • Maloney, Eamonn.
  • Mulherin, Michelle.
  • Murphy, Dara.
  • Murphy, Eoghan.
  • Nash, Gerald.
  • Neville, Dan.
  • Nolan, Derek.
  • Noonan, Michael.
  • Ó Ríordáin, Aodhán.
  • O'Donnell, Kieran.
  • O'Donovan, Patrick.
  • O'Mahony, John.
  • O'Sullivan, Jan.
  • Perry, John.
  • Phelan, Ann.
  • Phelan, John Paul.
  • Rabbitte, Pat.
  • Reilly, James.
  • Ryan, Brendan.
  • Stagg, Emmet.
  • Stanton, David.
  • Tuffy, Joanna.
  • Twomey, Liam.
  • Wall, Jack.

Níl

  • Boyd Barrett, Richard.
  • Broughan, Thomas P.
  • Browne, John.
  • Calleary, Dara.
  • Colreavy, Michael.
  • Coppinger, Ruth.
  • Cowen, Barry.
  • Crowe, Seán.
  • Doherty, Pearse.
  • Donnelly, Stephen S.
  • Ellis, Dessie.
  • Grealish, Noel.
  • Halligan, John.
  • Healy, Seamus.
  • Healy-Rae, Michael.
  • Higgins, Joe.
  • Kelleher, Billy.
  • Kirk, Seamus.
  • Mac Lochlainn, Pádraig.
  • McDonald, Mary Lou.
  • McGrath, Finian.
  • McGrath, Michael.
  • McGuinness, John.
  • McLellan, Sandra.
  • Mathews, Peter.
  • Moynihan, Michael.
  • Murphy, Catherine.
  • Naughten, Denis.
  • Ó Caoláin, Caoimhghín.
  • Ó Cuív, Éamon.
  • Ó Fearghaíl, Seán.
  • Ó Snodaigh, Aengus.
  • Pringle, Thomas.
  • Ross, Shane.
  • Shortall, Róisín.
  • Smith, Brendan.
  • Stanley, Brian.
  • Tóibín, Peadar.
Tellers: Tá, Deputies Emmet Stagg and Joe Carey; Níl, Deputies Aengus Ó Snodaigh and Seán Ó Fearghaíl.
Question declared carried.