Dáil Éireann díospóireacht -
Wednesday, 3 Dec 2014

Vol. 860 No. 2

Health Services: Motion (Resumed) [Private Members]

The following motion was moved by Deputy Deputy Billy Kelleher on Tuesday, 2 December 2014:

That Dáil Éireann:

agrees that:

— the health services are underfunded;

— the 2015 Health Service Executive National Service Plan is not sufficient to fully address the increasing demands and demographic pressures being placed on our hospital system; and

— key targets in the Plan are regarded as unrealistic by its authors; and

calls on the Government to fund the health services appropriately and sufficiently in 2015.

Debate resumed on amendment No. 1:

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

"welcomes the Health Service Executive’s national service plan for 2015;

recognises that the Government, in next year’s budget, has made provision for a welcome increase in the total financial resources available to the Health Service Executive, HSE, in 2015, and that this is reflected in the plan;

notes that this increase in funding, which is comprised of additional Exchequer funding of €305 million, increased projected once-off revenues of €330 million, and minimum savings of €130 million in areas such as procurement and drug and agency costs, is part of a two year programme to stabilise and improve health funding after seven years of significant retrenchment as a direct consequence of the emergency financial situation the Irish State has had to address;

further notes the fact that the Health Service Executive's 2015 national service plan provides generally for the delivery of existing levels of service while additionally targeting service enhancement in a number of priority areas through increased funding provision and further progress in the health service reform programme;

further recognises that:

— these enhancements include programme for Government commitments to extend the BreastCheck programme, the introduction of free general practitioner, GP, care without fees for those over 70 years of age and under six years of age, an expansion of mental health services, and further investment in suicide prevention; and there is also provision for 20,000 additional day surgery cases, additional funding of €2 million to improve maternity services, improved pilot ultrasound access for GPs in priority care sites and additional spending on community orthodontic and ophthalmic services; and

— an additional €25 million is being provided to help address delayed discharges from acute settings which will fund a range of community and non-acute supports, including an additional 300 places under the nursing homes support scheme, the provision of 115 short-stay beds, including the opening of Mount Carmel as a community hospital for Dublin, 600 additional home care packages and the extension of community intervention teams; and

supports the fact that the plan includes a considerably enhanced governance and accountability framework for 2015 which describes in detail the means by which the HSE and, within this, hospital groups, community health care organisations and other units will be held to account in 2015 for their efficiency and control in relation to service provision, patient safety, finance and human resources."

- (Minister of State at the Department of Health, Deputy Kathleen Lynch).

Deputy Mick Wallace

The motion says our health service is underfunded. Michael Keary of Rochestown in Wexford was admitted to Beaumont Hospital on Monday night and his son Patrick wrote to me last night. This is his letter:

My father recently started chemo in Beaumont Hospital. He was home for a few days when he got an infection and was requested to return to hospital on the night of 1 December by his own doctor. On arrival, Michael was very weak and unwell. His health continued to deteriorate throughout the night. He was informed that there would neither be a bed or a trolley available for him to spend the night. He was assigned a very uncomfortable chair using his coat as a pillow. Michael had previously been told to stay away from anyone with infections. The chair which he was allocated was among people with a vomiting bug and other contagious infections. Michael asked for a drink of water and nobody could assist as cups were unavailable. Throughout the night, Michael became so uncomfortable his only option was to lay on the floor. Following him laying on the floor, his blood pressure dropped and his heart started to race. They put him on a heart monitor because of concern for his health and only then did they manage to provide him with a trolley.

Michael is 59 years of age and has been in good health up to this point. He has never depended on the public health service before and has paid health insurance throughout his life. He was very disappointed with the assistance he received when it was most needed. It is not a good country to be unwell.

We know the staff cannot magic up trolleys and beds and can only work with what they have. We also know our health service needs help. In our last budget, we cut some taxes and there is talk of cutting more in the next one. The Government would be better advised to spend its money by investing more in the health service rather than to cut taxes.

Deputy Tom Fleming

I welcome the increase, albeit modest, in the 2015 budget. At least it is on the positive side. I also welcome the fact that for the first time since the HSE was established, the Department of Health and not the former will be responsible for the health budget. A very significant development is that for 2015 the HSE will be able to hire additional staff instead of having to pay the high cost of agency staff. It is an opportunity to provide meaningful permanent employment to our highly skilled medical personnel and enables them to stay at home rather than to seek work abroad. This measure will also relieve the pressure on our understaffed hospital and community services and will facilitate increased hospital activity in the coming year. This is good for patient care and overall budget management.

On the downside, the 2013 plan estimates that there will be 60,000 fewer people on medical cards by the end of 2015. This is based on declining numbers of unemployed persons and a projected increase in income. However, I cannot envisage in my own county, Kerry, any reduction of this type in medical cards due to the fact that we are totally neglected regarding job creation by the IDA. Many small and medium firms are experiencing difficulties in keeping their businesses viable.

I plead with the Minister of State here tonight not to act in a heavy-handed manner on the renewal of medical cards. I also ask for a favourable appraisal in the adjudication of new applicants. I ask that the initiative regarding new medical card guidelines will assist people with medical conditions, disabilities and hardship cases to access full medical cards in a customer-friendly manner. I request that services mentioned in the plan for County Kerry are expedited and commence at an early date in the coming year. They will be very welcome.

Deputy Richard Boyd Barrett

The most telling thing in the service plan is the comment of Tony O'Brien, Director General of the HSE, in the executive summary to the effect that it will not be possible to put in place any additional or new service developments. That says it all. Despite fanfare about increased funding, all we have done is allow the €500 million overrun and thereafter is it €80 million or €110 million we have got? I would like to know if the €110 million figure includes the €35 million which has been earmarked for several years for mental health services. Perhaps the Minister of State could clarify that. Either way, the funding will just about deal with demographic pressures. As Tony O'Brien says, it will have no significant impact in terms of the delivery of services.

There are so many questions. All of this is against a background of a budget cut from €16 billion to €13 billion over the last number of years, 10,000 staff gone and thousands of beds closed. It is not possible to see how this budget can have an impact on the crisis that has 40,000 people on waiting lists for over a year and 300,000 people on waiting lists altogether. There are also questions around medical card discretion. In the 2014 budget, €1,875,000 was allowed for but in 2015 there is only €1,722,000, which is a cut of €150,000 on what was allowed for last year. The target last year for elective procedures for children was 100%. While the service plan shows we only managed 50%, the target is back to 100% this year. It does not add up. The target for compliance with the working time directive last year was 100% but the actual outturn was only 67%. The target is nevertheless back up to 100% this year. Again, it does not add up.

Deputy Thomas Pringle

I am glad to have the opportunity to contribute to the debate tonight. The statement in the motion to the effect that health services are underfunded is probably the greatest understatement that has been made in the House in a long time. We could spend hours going through where the funding difficulties and problems in the health services are, but my focus in the time allotted to me is on the crisis in care for older people, particularly with regard to the fair deal scheme. The budget for next year provides for an increase of €10 million in the fair deal scheme, which will be nowhere near adequate. Community nursing homes are in crisis because they cannot access enough funding under fair deal to meet their running costs. I think in particular of Áras Ghaoth Dobhair in County Donegal which depends on the fair deal scheme. On foot of the pricing arrangement worked out under the scheme, that community run and led facility cannot even meet its running costs.

As the number of over-65s will double in the next ten years, there is a massive crisis on our doorstep. We need to see the roll out of a building programme to provide public beds. We must double the number of beds in the system. I wonder if the Department really wants to include the €25 million to come from stopping bed blocking within the HSE. If one moves an elderly person out of an acute hospital into a nursing home under the fair deal scheme, it does not save the HSE any money, it increases the costs of the fair deal bed. Right away, the bed in the acute hospital will be filled with another patient. Being efficient and moving people out of blocked beds will actually increase the cost pressures within the service. I wonder what the motivation is and whether it is to deal with people who are holding up beds in acute hospitals and getting them out into nursing homes and community care. That is really where the issue is.

Deputy Clare Daly

It is demoralising to note the number of times the House has discussed the critical and dysfunctional nature of the Health Service Executive. The HSE impacts on citizens from before the cradle to the grave, starting with the crisis in maternity services. It would be much more cost-effective and better for everybody if we shifted the focus to community and midwifery services.

I will briefly highlight a scenario that calls to mind the Mad Hatter. A small charity, the Jack and Jill Children's Foundation, is propping up the HSE by providing care to vulnerable children with severe disabilities. The foundation does incredibly good work, provides an excellent service, has a track record spanning 17 years, does not have waiting lists and provides services for children on a 24-7 basis. Due to insufficient funding, it is unable to provide services for children before they reach six years, which would correspond with the early years strategy.

There is a crisis in the north Dublin area where three children with severe disabilities are waiting to transition into HSE services. Despite the Jack and Jill Children's Foundation giving ample warning that this scenario was imminent, the three children have been left in limbo and at the mercy and kindness of the foundation, which cannot sustain the additional funding burden into the new year. This is only one example of the dysfunctional nature of the health service and the lack of joined up thinking in it.

It is not true that the Jack and Jill Children's Foundation receives annual funding of €630,000, as is often claimed. It receives slightly more than €500,000 because some of the funding ostensibly provided to the foundation is accounted for by HSE hours that are filtered through the organisation. If we want to improve the health service, we must place a much greater emphasis on community provision and palliative care.

Deputy Bernard J. Durkan

I am pleased to have an opportunity to speak on this particularly important subject matter. In the economic climate the Government inherited only a few weeks ago it quickly emerged that the Government faced the prospect of having to throw up its hands and abandon all attempts to provide large areas of service. We inherited a health structure that clearly did not work. It is all very well to criticise the holes and pockets in the health service and its patchiness.

Over the years, experts have visited this House to opine on the best structure to run the health services. I never agreed with the view that a single health body was the appropriate model for running the health service. This approach could never work as events such as recent developments in the area of medical cards and many other areas of the health service have demonstrated without a shadow of doubt. One simply cannot run a health service based on an amorphous mass of administration for the entire country. Local knowledge is lacking, circumstances differ and an emphasis on the need to be more personal in the delivery of services is absent.

I congratulate the previous and current Ministers for Health on tackling the health service. While the problems have not yet been resolved to their satisfaction or ours, changes are taking place and a new structure will emerge. I hope the types of things that occurred in the past will not be repeated. We were going around in circles as we tried to deliver a health service to citizens who were crying out for services. Individual cases were not dealt with in a personalised fashion and people felt as if they were numbers on a board. The classic example was the medical card issue that arose in the past year. This problem should never have arisen and I am pleased to note the changes taking place in this regard.

I am also mindful that the health service had to do more work with less money in recent years. This is a difficult task and I do not know how it was intended that it should be done. It is fine to criticise the inability of the Government to deliver serious and demanding services on which expenditure is required when there is no money available. The same people will declare that we must tax the rich. I would like to find out who the rich are and I assume they must be Members of this House. If that is the income that is to be chased after, we need to know where we are going. It is all very easy to produce answers when sitting around having a cosy chat. It is a different kettle of fish, however, when one must deliver the goods and raise money by imposing the taxation required to deliver the quality of service we need.

Health services have always been demand driven and demand is ever increasing. This must be recognised when we speak of remedies because the solutions will cost a great deal. Like many other Deputies, I was a long time member of one of the health boards in a previous incarnation. We learned the basics on the health boards and one of the basic facts was that one got down to the nitty-gritty and knew exactly what everything cost. Government and Opposition representatives had this information, which meant the matter was in their own hands and they could do what they liked. However, they also knew that they had ultimate responsibility.

I welcome the current budget. It is an improvement and I hope it is successful in delivering an improved quality of service. I also hope we have found the formula to replace the HSE because the current structure has never worked. My colleague, Deputy Billy Kelleher, would no doubt argue that it was never given a chance to work. I was a Deputy when the previous health board structure was abolished because it was not working. The HSE could not work and will never work. I am glad the Government, in difficult circumstances, has taken upon itself the task of restructuring the health service and has provided the money to achieve it.

Deputy Michelle Mulherin

The motion addresses a serious issue. The truth is that if a person is sick, dying or in serious pain, he or she does not have many options and will want to avail of a health system that can provide help. I welcome the honest attitude taken by the Minister because a lack of honesty adds insult to injury. Having read the motion and noted the signatories to it, I can only describe it as a scam. The scam here is having people lured in by a show of empathy, the wringing of hands, crying and pointing out all the hardship in the health service - for instance, waiting lists - before a general statement is made about how the service should be. As Deputy Durkan stated, one can cherry-pick while never providing answers to questions on where the money will be found. Somebody must make these difficult decisions and sometimes one would need the wisdom of Solomon to make them.

Deputy Billy Kelleher

It seemed to be very easy when Fine Gael was in Opposition.

Deputy Michelle Mulherin

It is disgusting to note the tenor of the motion. It states the budget is insufficient. The Minister recently left Deputy Kelleher a little stuck on national radio when he corrected him by pointing out that the budget proposed by the Government is much the same as what the Fianna Fáil Party proposed before the budget.

Deputy Billy Kelleher

The Deputy is making up the figures.

Deputy Michelle Mulherin

Sinn Féin provided for even less funding than is provided in the budget. Let us not make a joke at the expense of the people of Ireland. Savage cuts have been made in health in recent years. The embargo on recruitment meant hard-pressed staff had to make do without new recruits.

People are no longer able to pay for private health insurance because of the downturn in the economy. More pressure has been put on a system which is not in a position to take any more. More people are turning up at accident and emergency departments because GPs are not in a position to service them. There is more pressure in regard to medical cards and never before have so many received them. People are being put in a position where they cannot afford to pay for health care and it all stems from what happened when the previous Government was in power.

Not long after I was elected to the Dáil, I had the experience of seeing a large march in my town because the local district hospital in Ballina was to be shut down. A crowd of Fianna Fáil hacks organised the march, something I can say without reservation. The hospital was to be closed because there was a question mark over bed numbers as a result of the recruitment embargo. The truth of the matter was that funding had been found, but it was for agency staff and the unions, rather than the staff in the hospital, objected. Was any of this said to those who were afraid they would lose what was a valued hospital and which provided respite and step-down beds? No, it was not. I am glad to say that not only was the 50 bed unit retained, but there has also been an extension to and refurbishment of the hospital. There are hospice suites, while there has been a €1 million capital investment, in conjunction with Mayo-Roscommon hospice, and the unit was officially opened by the Taoiseach. I did not hear any Fianna Fáil hack welcome this or say they got it wrong. Apparently, that is not how politics works.

As I said, these issues are too serious to mess around with them. If we are serious about any problem facing any person in distress, we should treat it as if a house was on fire. One does not throw oil on a fire; rather, one quenches it, tries to save people and sort out the problem, but the Opposition does not know how to do this.

Since the Government came into power, there has been additional provision for psychiatric services. Ballina will shortly have a psychiatry in older age team for older people with mental health problems. There is a second child and adolescent mental health service team in Ballina, in my county. There are many other good news stories, where things have been salvaged from nothing. There have been no budgets. We have had to decide on priorities and when money is put into one area, it has to be taken from another, but that is not to say there is no need for reform in some areas. However, it is very hard to do everything when budgets are constrained.

Minister of State at the Department of Communications, Energy and Natural Resources (Deputy Joe McHugh)

I welcome the opportunity to say a few words about this issue. I acknowledge the work of my colleague, the Minister for Health, Deputy Leo Varadkar, during the short time he has been in his position. There are obvious constraints, but the work he is trying to do is important. It is important to say it is the first time since 2008 that there has been a modest increase in funding. During a time when money was supposed to grow on trees, that is, from 2003 to 2006, and problems accelerated within the health service, more money was thrown at it, but things did not get better. There were still bed blockages and fundamental problems within the system, but there is now an opportunity to examine the ethos of accountability and responsibility within the health service. Many good people are doing sterling work and have been working within a number of constraints in the past few years. Fundamentally, there has to be a point where there is accountability.

I refer to a sensitive case in Carndonagh, where Mrs. Maura Porter lay dying on a street because there was a problem in getting an ambulance to the scene. The family provided a very stark description of the last few minutes of their mother's life. Rather than spending them with her, holding her hand, they spent them trying to get the emergency services to the scene. That is wrong. Everybody knows that should not happen in a modern society - ambulances were available, but they were not at the scene when they should have been. It was not the case that somebody decided not to go; rather, there were problems with the system. Beds were available and there were ambulances in the county. There is a relationship with Altnagelvin hospital, but there seemed to be a complete and bizarre simple communication malfunction.

A large number of young entrepreneurs are working on computer programmes in both a very sophisticated and simplistic way to try to develop communications and responsible programmes to deliver services to customers in the private sector. One such person in Buncrana has developed a new programme, Click Clinic, which tries to provide communications, using computer technology, for persons who are relying on simple physiotherapy procedures. We need to reach out to a new generation of young people who provide these models to ensure the tragedies and travesties that happened in the past do not happen again. Gartan Technologies which is based in Letterkenny is doing wonderful work throughout the United Kingdom and recently won an Australian contract. It provides communication alert systems for fire brigade and fire services in the greater London area to ensure people are in the position they need to be in at a given time. I cannot begin to get a grip on the magnitude of the Minister's portfolio, but we have to reach out to a new generation who are working on new ways of doing things to counter the negative consequences of a number of tragedies. We now have an opportunity to do this and the Minister is the person to do it.

Deputy Derek Keating

I am pleased to be able to make a contribution to the debate in the presence of the Minister. The HSE will benefit from an additional €305 million in Exchequer funding over the amount allocated last year, which is a very good beginning. It has identified a minimum savings target of €130 million in procurement, drugs and agency costs. I am anxious that these savings, in particular in the provision of drugs, will filter down to the pharmacy counter in order that those who benefit from the drug payments scheme and have private prescriptions see realistic savings in their monthly prescription costs.

In its manifesto prior to the 2011 general election Fine Gael set out a number of key areas of reform within the health care setting. The provision of increased access to GP care without payment for those over 70 and under six years of age is a key measurable element on the pathway towards universal health care. In addition, the manifesto provided for the extension of and additional investment in mental health and suicide prevention teams.

Those who know me well will know that I spent six years as a very proud director of Pieta House. It continues to do wonderful work, which I commend. I also commend the commitment and expertise of those who seek to increase awareness and provide an insight into the supports necessary to save lives.

We in this House were left without a valuable friend, former Minister of State, Shane McEntee, at his death in the prime of his life. He is never forgotten. Suicide is the scourge of Ireland and every life saved has far-reaching benefits for individuals, families and communities.

The extension of the BreastCheck programme to women up to the age of 69 will allow for earlier diagnosis and screening among the target group and is a critical expansion recently committed to by the Government. CervicalCheck is a new indicator which targets the provision of 271,000 tests in 2015 and BowelScreen targets over 200,000 people in the age range of 60 to 69. Diabetic retinal screening will provide 78,300 tests for the target group of diabetics, those over the age of 12.

The manifesto also provided for increased access to primary care settings. Many of the tests mentioned will be provided in such centres through the increased allocation of €14 million to increase the range of services that can be provided in order to keep people out of hospitals and provide treatment in their communities. I have already seen the benefit to my constituency in Palmerstown and I am glad to note the advances made towards progressing a primary care centre in Lucan. I have had discussions with the HSE and interested parties in an effort to bring a primary care centre to Lucan and I am delighted this process is at an advanced stage, as Lucan is the fastest growing satellite town in the country.

We must not forget the changing age of our population or the need to provide for our citizens as they age. The provision in the plan for older persons, as part of one of the five integrated care programmes, is welcome. This will improve integration of services, access and outcomes for patients generally.

I have a particular interest in the provision of palliative care services and to this end, I have also been engaged with Peamount hospital in my constituency. I acknowledge the willingness and openness of the CEO, the chairperson and director of nursing at Peamount with whom I have engaged over the past number of years to examine what measures they can provide through existing facilities to provide end of life care. Peamount is an independent hospital and it has already developed expertise in end of life care, particularly in regard to people with COPD. Palliative care is something we can bring to that. Our Lady's Hospice in Harold's Cross provides outreach services, but there is a shortage of palliative care beds in the Lucan catchment area. West Dublin is identified particularly in the HSE plan as needing measures to address this deficiency in 2015. I welcome the positive engagement with the relevant stakeholders who can meet this deficit.

I commend the counter motion and urge the HSE to continue its mission to provide targeted appropriate actions that are measurable, accountable and sustainable for the people.

Deputy Liam Twomey

I listened to Deputy Kelleher's contribution last night and thought he almost acknowledged that previous administrations, in which his party was to the fore, made many mistakes in regard to how our health services were arranged. Looking back, we can see that when the economy went into a severe downturn, our health services were poorly positioned to deal with it. No meaningful reform had been carried out. Money was being poured into health services, but there was no great sense of where the money was going.

As far back as 2001, the then Minister for Finance, Charlie McCreevy, felt putting money into the health sector was like putting money into a black hole. In 2004 when Deputy Martin was Minister for Health - I was a Member of the Dáil at the time - his Secretary General appeared before the Oireachtas Committee on Health in regard to the Minister's failure to deal with the illegal nursing home charges. The Secretary General stated at the time that the important constantly conspires to push out the urgent in health. I believe this is one of the reasons former Ministers, Micheál Martin and Mary Harney, lost their way in regard to what they were doing with health. They were not quite able to separate what was important from what was urgent in regard to health services. To some degree there was a sense they just gave up on it, despite the fact €1 billion extra was being put into the health service at the time.

The collapse in the economy was a disaster for the health service, because there was no great sense of a policy being followed or no sense that people had the courage to make the right decisions. There has been a turning point in this regard since we came into power. The first turn around came in the ethos of the health services and now we have reached a new turning point where we are in a position to put additional funding into health. It is important we start reinvesting in the health services and that we begin to deal with the core issues where additional funding is required.

It is even more important that we have clear communication in the health area, not just with patients but with all individuals working in the area. In my 20 years in health and as a Member of the Oireachtas, I have seen much frustration and exasperation, not alone among patients but among everybody who works in the health services. Often this has nothing to do with failures in the health services, but with perceived failures and the failure to communicate policy or what is going on. We are getting better in this regard, slowly but surely.

The talks on GP contracts for dealing with children under six are progressing. The majority of GPs have also acknowledged the need for new contracts for medical card patients. We must move away from the acute illness type system to a more chronic care type system in primary care. There is much to be done in the area of primary care, but significant change has taken place already. For example, my practice nurse takes bloods, does vaccinations and smear tests etc, jobs that were done by GPs just seven or eight years ago. The system is changing. IT is changing also. One of the biggest problems in regard to IT is that the hospital sector is not moving at the same rate as the primary care sector, which would help maximise IT efficiencies.

We are going to see more changes for the greater benefit of patients. I offer my full support to the Minister, Deputy Varadkar, because he has got the concept, and separates what is important and deals with what is urgent in a clear and precise manner. Although there are problems with our current medical card system, these are not insurmountable. All of the issues that have arisen can be dealt with. It is an issue of communicating what we are doing to the people most affected - the patients - and of providing a clear system that works well for those who provide the service to patients - the GPs. I note from my communication with GPs across the country that their main concern is about how the Government communicates with them rather than how the system operates. We need to progress further in this regard in the coming weeks.

Deputy John Paul Phelan

I am glad to have the opportunity to raise some issues regarding the recently published HSE service plan. I thank Fianna Fáil for putting forward this motion, despite the fact the first sentence states the health services are under funded. It seems Fianna Fáil has no sense of shame or humility regarding the reason for the series of cuts over the past seven or eight years in funding for health services. This HSE service plan is particularly welcome because it sees the first increase in funding in that time and a substantial increase in funding is projected for the HSE in the year ahead.

I welcome the provision in the capital budget for the finishing of the new emergency department and medical assessment and endoscopy units in St. Luke's General Hospital in Kilkenny. It has always been a fantastic hospital, but many of its facilities are outdated.

Deputy Billy Kelleher

Fair play to the former Minister, Mr. Hogan.

Deputy John Paul Phelan

Fair play to Commissioner Hogan, indeed, and to others - well pointed out, Deputy Kelleher. I myself had some slight hand in it being built, if I could be so presumptuous as to suggest it.

For the past number of years and to this day, the emergency department in St. Luke's in Kilkenny was in what was originally designed as the washing-up area of the original hospital that was built in the 1950s. Thankfully, the new emergency department is well on its way to completion and I am glad the service plan includes that.

I too welcome the fact the BreastCheck service is to be extended to women up to the age of 69 following a national campaign in that regard. I am glad the Minister has been able to accede to that request.

Another important measure in this plan relates to the funding the HSE has included for drugs for those who suffer from hepatitis C, a particularly debilitating illness for which there is now a cure. Some €30 million is being set aside under this service plan to provide people who heretofore would have been in a very difficult situation with some hope that their medical condition can be improved dramatically.

I also want to welcome the fact €25 million has been included in the service plan for the additional provision of up to 300 places under the fair deal scheme and 115 short-stay beds. It has been apparent in recent months in particular that a bottleneck has emerged in this area and many people are waiting too long for assessment and admission to the fair deal scheme. I welcome the fact additional funding has been provided for that in the service plan.

I join with Deputy Twomey in regard to the Minister's announcements on medical cards. There is no doubt that, in the past 12 months, this has probably been the most contentious issue in the health area. The committee was charged by the previous Minister to come up with recommendations and it came back and suggested it would find it impossible to draw up a list of illnesses which would automatically qualify people for medical cards, and that the means-tested system would have to be included and adapted. The Minister has chosen to act quickly on that, which I welcome. In fact, the Minister has been a breath of fresh air in many respects in his few months in the Department of Health. It is a difficult Department but, in particular with regard to medical cards, which has been a protracted and difficult political issue but which is obviously and more importantly a difficult issue for families and individuals across the country, he has been willing to look at a practical solution for people in difficulties.

An Ceann Comhairle

I call Deputy Kitt, who I understand is sharing time with Deputies Keaveney, Troy and McConalogue.

Deputy Michael P. Kitt

I am glad to have the opportunity to speak on the motion, which I compliment Deputy Kelleher on tabling. Down through the years in my part of the west, we have been hearing about consultants and specialists being appointed and that they would be shared between hospitals. In my own area, this is usually between the hospitals at Ballinasloe, Galway and Roscommon. I am disappointed that the sharing of these posts does not seem to be of great benefit to the smaller hospitals, by which I mean the grade 3 and grade 2 hospitals, which seem to be forgotten about. The proposal was that, as well as sharing the work between the hospitals, many more procedures would be carried out in the smaller hospitals. I would like to see that happen and I am disappointed it has not happened to a fuller extent. This leads to uncertainty in the health service and leads to many meetings being called and demonstrations taking place.

One of the reasons for this is obviously that budgets in these hospitals have reduced, in particular in 2013 and 2014, and the indications for next year are not yet available. While there is a great effort by the HSE and the hospitals to keep down costs, I believe we are still not treating these hospitals fairly. Portiuncula Hospital in Ballinasloe is a grade 3 hospital but a significant hospital nonetheless which serves the east midlands and the mid-west, and Mayo Hospital is in a similar position. These hospitals need extra staff and new equipment but there has been no response in recent times. Five years ago I attended the opening of a special care baby unit and an emergency department at Portiuncula Hospital but I do not believe I have seen the opening of any new services since then. This is particularly disappointing given there are applications to improve that grade 3 hospital.

There is an excellent hospital in Galway city, University College Hospital. While it has a fine budget, I wonder about its capacity to develop services when I see what is happening with the psychiatric services there. There was a 22-bed acute psychiatric unit at St. Brigid's Hospital in Ballinasloe but the beds were transferred to Galway, where there was already overcrowding. Ballinasloe was to get crisis beds but that has not happened. There is funding under the mental health budget but recruitment is an issue, although it should be happening.

There are also issues with the fair deal scheme, which I dealt with in a recent debate in the House. I was approached by the Roscommon home care co-operative society, a not-for-profit organisation that is involved in caring in three counties, Galway, Roscommon and Mayo. It was very concerned when it received correspondence from the HSE stating that, in providing services to private clients, it may be in breach of EU state aid regulations due to the potential for cross-subsidisation. I certainly do not understand what that is about or how cross-subsidisation could arise.

Deputy Keaveney and I both know the ambulance base in Tuam has been idle for some time. I welcome the fact the HSE service plan includes Tuam with Mulranny and Loughglynn but, again, there is a staffing issue. I hope staff will be recruited quickly because we need a 24-7 ambulance base in Tuam. HIQA has recognised this as a blackspot in the west region. We saw in media reports today that the HSE has admitted that urgently needed improvements in the ambulance services will now have to be delayed because of a lack of resources. That is a worrying situation because it refers to rural areas more than to those operating in the larger towns and cities.

The situation at Tuam would be dealt with by having 11 staff, as that number would be needed for a 24-7 hour service, but there is no staffing at present - that is the bottom line. The fact HIQA criticised the lack of co-operation between the national ambulance service and the Dublin fire brigade shows there are problems and challenges. In fact, it was noted that 14,000 calls a year to the brigade were left in a queue while it tried to source an ambulance from the national service.

I hope we can have work on that announcement about the ambulance service and that the Minister will take on board what Deputy Kelleher has said in proposing the motion.

Deputy Colm Keaveney

I am glad the Ceann Comhairle is in the Chair tonight because I want to publicly acknowledge his kind written words to my family with respect to the passing of my brother, Kieran. The Ceann Comhairle has had a difficult day, or at least attempts in that regard were made by some, but I want to acknowledge his commitment to being the father of this House and the good work he does behind the scenes.

The Minister for Health recently engaged in a PR stunt by going out with an ambulance crew on a shift. In fairness, it generated some positive focus on the ambulance crew and the Minister probably got some kudos out of it for himself. However, the people who are dependent on the ambulance service require him to be less focused on PR stunts, to get behind the desk of his new Ministry and to start dealing with the problems that are coming up every day within the health service.

One of those problems is the state of the national ambulance service.

HIQA recently published a report which explicitly says: "[I]t is of significant concern to the Authority that the well known ambulance 'black spot' areas of Tuam Co Galway, Mulranny Co Mayo and Loughglynn Co Roscommon remain without a dedicated ambulance resource." The report also says that at the time of review there were no staff at Mulranny and Tuam and there was occasional movement of an ambulance between Tuam and Roscommon, serving both locations. It is a damning review that states that if we do not properly resource these areas and address any deficits, we are astray with regard to the national ambulance strategy. It should be a concern to everybody where I live, because the HSE has failed to act with regard to emergency response times.

I am asking the Minister to pay particular attention to the black spot in Tuam. I appreciate that I am here to represent my constituency, but I ask the Minister to remember that the absence of investment in the 11 EMTs identified by Deputy Kitt is essentially playing Russian roulette with my community, because the closest response time is 62 minutes from Galway city. This is completely out of sync with regard to adequate or acceptable response times. The Minister was canvassing in the by-election in Roscommon, as was I. The people there are as angry as the people of Tuam with regard to commitments for the delivery of health services. I ask the Minister to pay attention to the commitment to open that ambulance base in Tuam and to be more honourable than the Taoiseach was when he stood in front of the people of Roscommon with regard to the commitments he made. I ask the Minister to pull back from the preliminary rounds of Fine Gael's leadership battle and to focus strictly on his job, because I think he could do a good job in health if he was less obsessed with taking out the Taoiseach and focused more on the role of Minister.

I will now move on to mental health. As the Minister is aware, an additional commitment of €35 million is ring-fenced this year as part of the programme for Government to provide for the roll-out of specialist staff for community-led psychiatric teams. The Government has consistently failed to honour that commitment since 2011. In fact, we should have expected €50 million in ring-fenced and focused investment in light of the fact that the Minister of State, Deputy Kathleen Lynch, capitulated and let the former Minister for Health pickpocket her in the 2014 service plan. This has consistently undermined the roll-out of A Vision of Change. The Minister of State has abjectly failed. The only consistency she has managed to maintain since 2011 is her failure to protect her budget. The fact that she has failed to protect her budget means that she has failed to deliver on the service plan. This year, only a small quantum of the €20 million in additional funding provided for mental health staffing is being invested. This is a consequence of the deliberate situation designed last year whereby staff provided for in the service plan in 2014 were time-delayed. The service plan provided for 200 staff last year but not one of them is currently in situ and we are now in December. This is the tactic that people out there are seeing through. I accept that there is a cynical approach with regard to the hiring of staff. I now know that it has been designed to ensure that it came at the end of the year, but mental health and mental illness do not wait for budgets, time delays and deliberate manipulation of the budget to ensure its effect is maximised. I ask the Minister of State to speak to stakeholders and look at the impact of these decisions, because I have a sense that she is surrounding herself with and hand-picking managers who offer advice she wants to hear. The Minister of State is opposed to any sort of critical analysis with regard to the roll-out of A Vision for Change. She does not listen to the front-line staff. I ask the Minister to listen to the words of Dr. Shari McDaid, director of mental health reform. She has said that the HSE's ability to provide people in mental and emotional distress with the support they need depends on the presence of skilled staff, and that services will not run 24-7 because crisis intervention support is simply not there. She went on to say that while more than 700 staff have been recruited into mental health services since 2011, there are still only 90 additional posts in light of the fact that natural wastage, redundancy and retirement have been the opportunities the Minister of State has used with regard to further recruitment. She has spoken about how the HSE service plan commits to building capacity for mental health services to respond 24 hours a day to people in a crisis. This is pushing it out there until the latter part of 2015, which is a concern for the stakeholders. In particular, I ask the Minister of State to sit down and talk to the service users and front-line staff in respect of the roll-out of the subsequent aspects of A Vision for Change.

The Disability Federation of Ireland, DPI, welcomed the additional €20 million provided for in the service plan. However, as we sit here today, the Minister is taking money from the Brothers of Charity and Ability West. John Dolan, CEO of DPI, stated that it is a demand-led service and that it continues to draw out money in light of the fact that one person a week sustains a spinal cord injury. He also said that we are seeing increasing numbers entering the service and that with only €20 million the service is running to stand still. He stated: "The HSE Service Plan talks about disability services moving towards new models of service delivery that enable people with disabilities to participate in a meaningful way in their own communities." Talking in general about the service plan, Mr Dolan stated:

The health system is deteriorating at a worrying rate. Ireland’s population is increasing, people are living longer, waiting lists are drastically increasing and there are worrying levels of unmet need. Those providing health services simply don't have the resources required to deliver to an acceptable standard.

I am entirely in agreement with Mr Dolan. I think we should all work together to focus on his concerns. Health desperately needs adequate funding. It is demand-led. I know the Minister is honest and can identify the issues, but he needs to stay with them. We need to work together to find solutions for these issues because we have a mutual interest in the health of this country. We cannot approach the health service in the same way we approached the last budget, whereby we set out essentially to buy votes with tax cuts. We need to learn lessons of the decisions of the past, as I was elected to do. We need to be honest about budgeting and to have a proper framework on how we budget for the health service. The Minister will have support from this side of the House if he is prepared to be transparent, honest and realistic with regard to those budgets. People within the health service are alarmed at the deteriorating conditions in which they are working. It is becoming patently clear to the public that the public health service is in crisis. It is no wonder we hear that everything is dandy in the mental health service, as the Minister of State said last week. There were no problems. She went out and allegedly listened to front-line staff. Like Catherine the Great, she allows herself to be presented with Potemkin villages. I ask the Minister to speak to the Minister of State so that she gets out of that bubble of senior managers, advisers and experts around her and listens to the experiences of service users and front-line staff and, for once, gets an honest opinion about what is happening rather than listening to people who tell her what she wants to hear.

Deputy Robert Troy

I welcome the opportunity to contribute to this debate this evening. It is an extremely important and timely debate, given that the Minister published the HSE service plan in the past number of days. The Department of Health is an extremely important Department. It is a Department that touches the lives of practically everybody in the country. Usually, it touches people's lives at a time when they are particularly vulnerable. Unfortunately, over the past number of years, many decisions that were taken - some by the Minister's predecessor, but many collectively by the Cabinet - have had a detrimental effect on the sick and the vulnerable. In many instances, this has compounded the problems and illnesses that people have experienced.

It has contributed unnecessarily to anxiety and fear among many people. We do not have to look very far back to be reminded of the anxiety and fear inflicted on the people of County Longford due to the deficit in St. Christopher's hospital. In a previous debate I thanked the Minister for his intervention in this matter but I have since been informed that the Taoiseach had to instruct him to make the necessary funding available. This information came from Deputy Bannon. Whoever was involved, it should not require 3,000 people protesting in the spilling rain, including families, sick people and people with intellectual disabilities, to force the Government into a U-turn. Despite the increase in the HSE budget, the deficit that emerged in 2012 means there will not be sufficient funding even to stand still in 2015, let alone meet the increasing demands placed on our hospital systems. I fear that we will have more of what we experienced in the last several years.

The HSE service plan indicates that free GP care for children under the age of six years will be delivered next year. Funding of €37 million had previously been promised to implement the free GP scheme in 2014, for which there would be no fees at point of use. Twelve months later, the funding has been reduced by €12 million and we are still being promised that it will be delivered. What confidence can the parents who are waiting for free GP care for their children have that it will be introduced in 2015? Free GP care means no charges but I note that the Minister in some of his media outings mentioned a nominal fee. Perhaps he can confirm whether there will be a nominal fee or if the service will be free. I worry about this Government's record on nominal fees. It came to office promising to abolish the nominal fee for prescription charges but it was instead increased fivefold.

I acknowledge that an additional €20 million is being invested in disability services but this has to be viewed in the context of the reduction of €159 million since 2008. As Mr. John Dolan, the CEO of the Disability Federation of Ireland, said, this does not even start to plug the gap. I recently spoke to the parent of a young man who lives with three other men in a community house in my constituency. In the past 12 months, the number of staff working in that house decreased from four to three, which has resulted in a savage deterioration in the quality of life for the men who live in the house. They are no longer able to go bowling and are effectively prisoners in their home because there are insufficient staff to ensure they can enjoy extra-curricular activities. It does not say much for us as a society if that is how we are treating young men with intellectual disabilities. These men, who have Down's syndrome or other intellectual disabilities, are being forced into reviews of their medical cards on a yearly and, in some instances, a half-yearly basis. Talk about an administrative burden given that the medical conditions of these young gentlemen will, unfortunately, never get better.

The Minister is living up to his commitment on mental health by investing €35 million in the sector this year. However, only €20 million was provided last year. The Minister of State at the Department of Health, Deputy Kathleen Lynch, promised that the shortfall would be made up in this year's allocation. That has not happened. A colleague recently outlined the case of young person known to Túsla who was in residential care due to her psychiatric condition. Even though this person was under the age of 18 years and was experiencing suicidal ideation, she only received one visit from the child and adolescent mental health service in a 13 month period. That is not good enough. Dr. Shari McDaid has pointed out that the HSE has fewer than three quarters of the staff it needs to deliver the Government's mental health policy. How do we propose to deal with the critical issue of mental health and the number of young men, in particular, who are taking their own lives if the experts say we have fewer than three quarters of the staff required? This is something that the Minister needs to address urgently.

In regard to the fair deal scheme, I commend staff in Longford-Westmeath on their efficiency and punctuality in dealing with application forms. However, a concerted effort is needed to provide funding for people who are no longer able to live in their own homes. The population of those over 80 years of age is increasing by 4% annually but this increase is not being matched by the necessary funding. It is a sad reflection on this society if we cannot acknowledge the contribution these people have made to society by providing adequate nursing home care to them when they are in their old age.

At the HSE forum of 21 October, a councillor raised the issue of the downgrading of our local office of the Registrar for Births, Marriages and Deaths. When I raised a similar issue by way of parliamentary question, I was told the office would be open three days per week, namely, Mondays from 9.15 a.m. to 4.30 p.m., Wednesdays from 9.15 a.m. to 12.30 p.m. and from 2 p.m. to 5 p.m., and Fridays from 9.15 a.m. to 12.30 p.m., and that the introduction of lunchtime opening and later opening hours was well received by the public. Last week notice was posted on the door of the office that it would open one day per week for five hours. When the HSE was asked to comment it stated the late opening hours were well received by the public. Why is a birth registration office located on the campus of one of the busiest maternity hospitals outside of Dublin only open for five hours per week? I ask the Minister to investigate the problem. I am informed that two staff members in the office are on long-term leave because of bullying. This should be investigated urgently to ensure we provide a proper service for the people of Mullingar.

Deputy Charlie McConalogue

I thank Deputy Kelleher for tabling this motion on the inadequacy of the HSE service plan for 2015, which was published in the past week.

I will comment, first, on the HIQA review of the ambulance service and emphasise the importance of investing to increase the number of ambulances in different parts of the country. The report indicates difficulties in co-ordination between hospitals and the ambulance service which must be addressed. There is a definite need for investment in the service, particularly outside Dublin where there are large areas to be covered. In the absence of ambulances and staff working in these areas, waiting and response times are impacted on. In that regard, I refer to the death last year of Maura Porter on New Year's Eve and the experience of her family who are but one of many other families who have been impacted on by the lack of co-ordination, on the one hand, and the need for additional investment, on the other.

With regard to the service plan, I will focus on its impact on County Donegal and Letterkenny General Hospital, in particular. The experience in Letterkenny is replicated across the country. There are over 2,400 people on the waiting list who are waiting for more than one year for an outpatient appointment with a consultant at Letterkenny General Hospital. That number has increased by 1,500 in the past six months. There are also 3,000 people on the surgery waiting list. These are the official hospital figures which I received in response to parliamentary questions to the Minister. It is unacceptable and not the type of service which people in County Donegal or elsewhere in the country should expect from the health service.

I focus, in particular, on people who have been affected by the outpatient waiting list initiative which the HSE and the Department of Health brought forward this time last year. In the case of Letterkenny, 2,700 patients were outsourced from Letterkenny General Hospital to private hospitals to be seen by a consultant. These are separate from the numbers I quoted for hospital waiting lists. Of this number, approximately half were either treated or discharged back to their general practitioner. However, 1,300 have been left in limbo since last year, with no follow-up treatment. Over one year after being outsourced by the HSE to a private consultant or private hospital, 1,300 people across the county have not had either follow-up tests with these consultants or the surgery it has been indicated or reported to the hospital that they require. There is no funding set aside in the HSE service plan to address this issue.

I hope the Minister will deal specifically with the patients who were covered by the waiting list initiative last year and what will happen to them. It has been indicated to me that there is a likelihood these patients will have to return to the hospital waiting list and will not receive the follow-up treatment they require from the consultant to whom they were initially referred. That means the outsourcing and visits to these consultants will have been a waste of money in many cases because the patients will have to be seen by the internal hospital consultants again before appropriate follow-up treatment can be arranged. It is totally unacceptable that the Government is prioritising funding towards what it regards as election winning measures through decreases in the higher rate of tax, while not addressing this very serious issue or allocating funding to ensure patients can be treated. I ask the Minister to address this issue or that he revert to me with specific proposals for how the needs of these patients will be addressed. In just one county over 1,300 patients are in limbo for over one year with no indication of how they will have the tests or operations they require. It is unacceptable and the issue must be addressed immediately. They cannot be left to continue without any follow-up treatment, which is the current position.

Minister for Health (Deputy Leo Varadkar)

I will certainly follow up on the matter raised by Deputy Charlie McConalogue.

One of the most frustrating things about reports, into which those involved put a great deal of hard work, is that people do not understand them fully. The HIQA report on the ambulance service is silent on whether there should be additional ambulances. That issue will be addressed in the HSE's capacity report. HIQA talks about the age of the fleet, but it does not call for additional ambulances. However, it points out that we use ambulances very inefficiently. We do not conduct a dynamic dispatch system. There are too many ambulances sitting in fire stations, ambulance centres and hospitals when they should be available for dynamic dispatch. HIQA criticises the communications and speed of dispatch. It also points out that if we were to apply what is done in other countries, 40% of those covered by ambulance calls would not require to go to an emergency department at all. It is a good report and people should read it, rather than just default to the obvious stuff about providing more resources, the fleet and journey times.

Deputy Robert Troy mentioned the Government's decision, intervention and U-turn in the case of St. Christopher's. To be clear, there was no decision, intervention or U-turn in the case of St. Christopher's. Deputy James Bannon expressed his concerns to me many times, as did the Taoiseach. It was a matter of great interest and concern to the Deputy, but it was one for the HSE. They were not decisions made at ministerial or government level, which I hope is clear.

I am pleased to have the opportunity to contribute to this debate on the funding of the health service and, in particular, the HSE's national service plan for 2015. I will deal with a number of specific matters that have been raised by Deputies during the debate.

Several Deputies raised the issue of discretionary medical cards. The HSE is taking the necessary steps to improve the operation of the medical card scheme and especially the arrangements for the issuing of medical cards on a discretionary basis, generally on medical grounds, even though the means test has not been satisfied. I do not claim that the new system will be perfect, but I will continue to oversee implementation of these steps and, if further improvements are deemed necessary, I will consider them. It will, however, be six to eight months before the ten actions announced last week are implemented and I ask for patience until then and also that issues or shortcomings be flagged to my office.

Waiting times under the fair deal scheme are now approximately 14 weeks. This is not satisfactory and I am anxious to address the issue. It is recognised that the matter of delayed discharges is not one that can wait until the new year. Last night the Minister of State, Deputy Kathleen Lynch, outlined a number of measures that were already under way to start to deal with this issue of concern. It requires an integrated response across primary, community and residential services and my Department is working closely with the HSE to ensure the available resources are deployed in the most effective way.

A number of Deputies mentioned health reform in general. Next year will see the establishment and development of hospital groups, community health care organisations and the development of the national clinical programmes which will be delivered through these new structures. These core health reforms are essential if we are to deliver better quality care.

I share the concerns of Deputies about waiting times; too many are waiting too long for surgical procedures and outpatient appointments. We know from past experience that throwing money at the problem of waiting lists does not make it go away. This was particularly demonstrated during the Celtic tiger economy years, when waiting lists remained a significant and ongoing cause of concern, despite the increasing level of funding provided. Providing more resources without reform simply does not work. If we learned anything from the years of boom and bust, the years of splurge, followed by years of austerity, we should have learned that. That is the reason the Government wishes to address the underlying structural issues which are contributing to increasing demands on the hospital sector and the resultant rise in waiting times. The establishment and development of hospital groups and community health care organisations and the development of patient-centred integrated models of care are central to this structural shift and will, over time, ensure quality patient care is delivered in the setting most appropriate to the needs of the patient which, in most cases, will be a primary care setting or a setting close to home. The service plan provides for an additional €14 million to further develop primary care services, including an extension of the pilot GP ultrasound access project and the provision of additional minor surgery services in agreed primary care sites.

The HSE is also putting in place a number of measures next year to tackle waiting lists more efficiently, including prioritising day-of-surgery admissions, pre-admission clinics to ensure patients are fit for surgery and flexible use of theatre capacity within and among specialties.

I am also pleased to inform the House that I have, this week, approved an initiative to provide additional GI scopes for endoscopies and colonoscopies up to the end of 2014. This decision was taken to address very long waiting lists for these procedures in certain hospitals which, between them, are responsible for over 80% of the waiting list.

During last night's debate, Deputy Kelleher referred to a level of pretence that exists around the health budget for 2015. The opposite is the case. The HSE management, the Minister of State, Deputy Kathleen Lynch, and I have been honest and up front about what can be delivered in 2015 with the increased resources available. We have not over promised, but have been realistic, and have explained that the modest increase in resources being provided in 2015 is but the first step of a two year process to stabilise the health service budget. I have already secured an increased ceiling of €174 million for health expenditure in 2016.

Deputy Sean Fleming

I thank my colleague, Deputy Kelleher, for tabling the motion on the underfunding of the national service plan for 2015. When he launched the plan on Thursday, 27 November, the HSE Director General, Tony O'Brien, said the additional funding "will not...be sufficient to fully address the increasing demands being placed on our hospital system, in particular the growing waiting lists for elective admissions.” This is an indictment of the national service plan 2015. Mr. O'Brien said the plan does not meet the needs for 2015. Enough said. It is no wonder we will be back with a Supplementary Estimate in the coming days for 2014, as we will be for 2015. While the Minister might say otherwise, evidence from the HSE Director General will contradict him, and I accept what Mr. O'Brien says because he is a straight talker.

On budget day in October, when the Estimates were published here, we pointed out the black hole of €460 million in the Estimate for the Department of Health, comprising the magical, increased revenue of €330 million and drug procurement savings of €130 million. The HSE has proved itself incapable of delivering the savings required in the drugs procurement budget and it should be removed from the HSE and given to the Government's Office of Government Procurement. One national office is getting increasing strength and ability in national procurement. It is so good that it is causing flack at a local level because small, local suppliers can lose out. It is getting the best price for the taxpayer and that is what is needed in this situation. The expertise needed is available in the Office of Government Procurement, not in the HSE. The job of the people in the HSE is to deliver health services, and they should not be doing a job that can be better done by another State agency, such as the Office of Government Procurement.

At last week's meeting of the Committee of Public Accounts, I was shocked to hear the HSE intended to spend a lot of money next year on a patient identifier number system. It is a disgrace and I ask the Minister to reconsider it. Given that everybody in Ireland has a PPS number, why does the HSE want to invent another system? It should attach the PPS number to existing files. The Revenue Commissioners have everybody's house listed in the local property tax system. Practically 40% of the population have medical cards with a number from the HSE. Yet the HSE proposes to spend millions of euro on a new IT system for a new numbering system for everybody in the country. Will the Minister tell the people in his Department and the HSE, who should be working to deliver health services, to leave the job of identifying people by number to those who do it best, namely, the Department of Social Protection, which already supplies the PPS numbers? People will have a PPS number, a patient identification number and a medical number. It is nonsense. Each person should have one number. The Minister should ask his staff to hand over that operation. I was shocked to hear that the HSE does not have a patient identifier number. The Department should not need to spend money on it.

There are 2,200 people on the waiting list for the fair deal scheme and although the Minister said there was an average waiting time of 14 weeks, I find cases of people waiting up to 20 weeks. What people do not understand is that this is not 20 weeks after a person applies but after he or she has gone through the full assessment process. After a person's application for payment has been approved, he or she is told he or she must wait 14, 16 or up to 20 weeks. It does not take 14 to 20 weeks to get a payment. Imagine if a person applied for a social welfare payment and when it was eventually approved he or she was told it would be paid in 14 weeks. It is unacceptable. One of the reasons for the delay is the 850 delayed discharges in hospitals.

I welcome the recent announcement that the HSE will convert the former Mount Carmel Hospital into a community hospital to help alleviate the problem. I can give the Minister two more suggestions to further alleviate it, of which the Minister will be aware. Abbeyleix District Hospital in County Laois is a community hospital which the Minister is running down. With a tiny investment, it could take 50 people. However, it is not taking new patients except for respite cases. The same applies to St. Brigid’s Hospital in Shaen, Portlaoise. With a small investment, it could take 30 or 40 people. I ask the Minister to consider those to help solve the problem.

I have come to the conclusion that the delayed discharge is not just a financial decision but a HSE policy. Although some people will say there is nowhere to discharge these 850 people, I believe there is a policy in the HSE and the acute hospitals to keep them in the beds because when they are full, they can stop new people from coming in through accident and emergency. In the past month, I have visited two accident and emergency departments in respect of a person aged well over 90, in very poor health and suffering from an illness. When the person's family suggested that the hospital should keep the person overnight, there was pandemonium. The hospital staff said there were enough people sleeping in the accident and emergency unit that night and that with 12 people in the wards they could not take in any more people. They wanted to send him home.

A few weeks later, the same patient ended up in Naas General Hospital, and when I visited, one could not get in the door of the accident and emergency unit. There were beds in both sides of the corridor backed up to the front door of the accident and emergency unit, head to toe. One could not get through the place. There was no room to wheel a bed or a chair in an emergency situation. Old and young sick people were lined up, head to toe, on trollies on both sides of the corridor, never mind getting into the unit. The nurses were right to take to the streets two or three weeks ago to protest what was happening in the hospital. It was unsafe and unfair on the staff, never mind the loss of dignity and medical care that should have been provided to the patients. It was not the fault of the nursing staff, but the physical infrastructure was far too small.

In some parts of the country, orthodontic treatment does not exist at school level. In County Laois in the midlands, a child is lucky to be assessed by sixth class and might wait until the age of 16, almost finished secondary school, before receiving any treatment. Killeshin is in south County Laois on the border with County Carlow. While the children in County Carlow will be assessed in fourth class and receive treatment before they leave primary school, down the road in Killeshin national school, the children are in a different county and region. Did nobody tell anybody we have a national HSE? It still operates on the basis of county boundaries. Even more bizarrely, children in Carlow who happen, for family reasons, to attend the school in Killeshin in County Laois, will not receive orthodontic treatment because they are going to school in Laois even though they are from Carlow, where everybody else can get the service.

The situation regarding the income limit of €900 per couple for medical cards is farcical.

The Health Service Executive uses that figure of €900 when it suits it and disregards it when it suits it. In the cases to which I refer the people were applying for discretionary medical cards. I had a case in the past week where an elderly couple were told their household income was over €900 and therefore they do not get a medical card. They applied for a discretionary card. They looked at their legitimate outgoings as part of their medical expenses and they came in below €900, at €850. They were told that because they were above the basic figure they will now disregard the €900 when it comes to an application for a discretionary medical card, but they implement the €900 ceiling when it comes to a medical card application. I hope the Minister will fix that.

Deputy Leo Varadkar

There will be a single application-----

Deputy Sean Fleming

I am pleased because my e-mail to the HSE was so intemperate a lady phoned me the other day on it.

Deputy Leo Varadkar

It is the legislation.

Deputy Sean Fleming

Yes. I told the lady that I understood what she was saying but it is not possible for this 75 year old elderly couple to understand it.

I am holding out hope for those people to whom I have spoken in my constituency this week that early next year the system will be reviewed and we will be able to get them the medical cards to which they are entitled.

Deputy Billy Kelleher

I welcome the contributions from all Deputies to the debate. I find it extraordinary that the Deputies opposite and the Minister criticised me for tabling this motion because what I am doing is stating the obvious. I am stating clearly that in December 2014 we will have a problem going into January 2015 in terms of the delivery of this country's health services simply because we do not have adequate funding in place to ensure we can underpin the basic services in the year ahead. As has been outlined by Deputy Fleming and others, it is not just Fianna Fáil that is saying that. The director general of the HSE, Mr. Tony O'Brien, stated it at the launch of the HSE service plan for 2015 when he was categorical in stating that the funding being provided would not be sufficient to cater for certain areas, particularly day case procedures and outpatient appointments.

While listening to the debate today I wandered onto a Fine Gael website and looked at the fair care proposals outlined by the Minister's party in advance of the general election and it is extraordinary that some of the targets it was criticising have now been well passed in terms of waiting lists, waiting times and issues with regard to the fair deal scheme, as pointed out by Deputy Fleming. It has gone backwards in many cases and what is more disturbing is that it has gone backwards in terms of the priorities it set.

A woman rang my office this week. She is in her late 70s. Her husband is in his 80s. He was in a nursing home. He has Parkinson's disease. She had to take him out of the nursing home because she simply cannot afford the nursing home costs while she is waiting for a fair deal bed to be made available. That is what is happening. These are not isolated cases. We are not making them up. These are happening day in, day out in the context of elderly people in our communities throughout the country.

As to the idea of a 20 week waiting list, that is an elderly person waiting 20 weeks for a bed, often at end of life time. We hear that the nursing homes support scheme will be improved next year and that extra funding has been made available, and we talk about a target of ten to 12 weeks. In key areas the Minister has to prioritise and I suggest looking at that particular area of the HSE service plan in terms of funding for the fair deal scheme, and also in the other key area with regard to waiting lists for day case procedures. It is simply unacceptable that we are now talking about 50,000 people waiting, and 380,000 people waiting for an outpatient appointment.

Many plaudits have been laid at the Minister's door because of his honesty and his upfront approach to the issue and the challenges facing him but to say the least, this budget is dishonest because it will not be able to sustain what it outlines. Deputy Fleming referred to some of the areas where the Minister spoke about savings being accrued and extra income streams, but some of those will not happen.

When we consider the overall context of what the Government has done in the past three years in terms of budgets, it gives us no hope or confidence that it will be able to deliver this plan with the funding underpinning it. That is the reason we highlight it on a continual basis.

It has been said that the Minister has a better bedside manner than the previous Minister. There is no doubt about that but the diagnosis and the prognosis will be the same for the patient and in this context, the patient being the HSE itself, it will not be able to deliver on what it is trying to achieve because the Government is being disingenuous in terms of the public relations spin being put forward that somehow extra money has been delivered to the HSE service plan this year. When demographic changes and the aspirations in terms of savings and income are taken into account, the Minister is starting with a deficit next year again before we even start. I can assure the Minister that if we are all here this time next year, we will be in this House again talking about a supplementary Estimate because the service plan will not have been able to achieve what it set out to achieve.

I thank the Deputies who spoke on this motion. I reject the criticisms from the other side of the House that it was put down for no other reason than to have a debate on health. It is critical that the Opposition Members highlight the failings of this Government in terms of basic funding. We are not asking for anything over and above that. I commend the motion and I ask Deputies to consider when they are sitting down that this particular budget will not sustain delivery of health services in 2015 as stated by the Deputies opposite.

Amendment put:

The Dáil divided: Tá, 68; Níl, 45.

Tá

• Bannon, James.
• Barry, Tom.
• Breen, Pat.
• Burton, Joan.
• Butler, Ray.
• Byrne, Catherine.
• Byrne, Eric.
• Cannon, Ciarán.
• Carey, Joe.
• Coffey, Paudie.
• Conaghan, Michael.
• Conlan, Seán.
• Connaughton, Paul J.
• Conway, Ciara.
• Coonan, Noel.
• Corcoran Kennedy, Marcella.
• Costello, Joe.
• Deasy, John.
• Deering, Pat.
• Dowds, Robert.
• Doyle, Andrew.
• Durkan, Bernard J.
• Farrell, Alan.
• Fitzpatrick, Peter.
• Griffin, Brendan.
• Hannigan, Dominic.
• Harrington, Noel.
• Harris, Simon.
• Heydon, Martin.
• Humphreys, Heather.
• Humphreys, Kevin.
• Keating, Derek.
• Kelly, Alan.
• Kenny, Seán.
• Kyne, Seán.
• Lawlor, Anthony.
• Lynch, Ciarán.
• Lyons, John.
• McCarthy, Michael.
• McFadden, Gabrielle.
• McGinley, Dinny.
• McHugh, Joe.
• McNamara, Michael.
• Maloney, Eamonn.
• Mitchell, Olivia.
• Mitchell O'Connor, Mary.
• Mulherin, Michelle.
• Murphy, Eoghan.
• Neville, Dan.
• O'Donnell, Kieran.
• O'Donovan, Patrick.
• O'Dowd, Fergus.
• O'Mahony, John.
• O'Reilly, Joe.
• O'Sullivan, Jan.
• Phelan, Ann.
• Phelan, John Paul.
• Rabbitte, Pat.
• Ring, Michael.
• Ryan, Brendan.
• Stagg, Emmet.
• Stanton, David.
• Tuffy, Joanna.
• Twomey, Liam.
• Varadkar, Leo.
• Wall, Jack.
• Walsh, Brian.
• White, Alex.

Níl

• Boyd Barrett, Richard.
• Broughan, Thomas P.
• Calleary, Dara.
• Collins, Joan.
• Collins, Niall.
• Colreavy, Michael.
• Coppinger, Ruth.
• Daly, Clare.
• Doherty, Pearse.
• Dooley, Timmy.
• Ellis, Dessie.
• Fitzmaurice, Michael.
• Fleming, Sean.
• Fleming, Tom.
• Halligan, John.
• Healy, Seamus.
• Healy-Rae, Michael.
• Higgins, Joe.
• Kelleher, Billy.
• Kirk, Seamus.
• Kitt, Michael P.
• Lowry, Michael.
• McConalogue, Charlie.
• McGrath, Finian.
• McGrath, Mattie.
• McGrath, Michael.
• McGuinness, John.
• McLellan, Sandra.
• Martin, Micheál.
• Mathews, Peter.
• Murphy, Catherine.
• Ó Caoláin, Caoimhghín.
• Ó Cuív, Éamon.
• Ó Fearghaíl, Seán.
• Ó Snodaigh, Aengus.
• O'Brien, Jonathan.
• O'Sullivan, Maureen.
• Pringle, Thomas.
• Ross, Shane.
• Shortall, Róisín.
• Smith, Brendan.
• Stanley, Brian.
• Tóibín, Peadar.
• Troy, Robert.
• Wallace, Mick.

Tellers: Tá, Deputies Simon Harris and Emmet Stagg; Níl, Deputies Billy Kelleher and Sean Fleming.

Amendment declared carried.

Question put: "That the motion, as amended, be agreed to."

The Dáil divided: Tá, 67; Níl, 44.

Tá

• Bannon, James.
• Barry, Tom.
• Breen, Pat.
• Burton, Joan.
• Butler, Ray.
• Byrne, Catherine.
• Byrne, Eric.
• Cannon, Ciarán.
• Carey, Joe.
• Coffey, Paudie.
• Conaghan, Michael.
• Conlan, Seán.
• Connaughton, Paul J.
• Conway, Ciara.
• Coonan, Noel.
• Corcoran Kennedy, Marcella.
• Costello, Joe.
• Deasy, John.
• Deering, Pat.
• Dowds, Robert.
• Doyle, Andrew.
• Durkan, Bernard J..
• Farrell, Alan.
• Fitzpatrick, Peter.
• Griffin, Brendan.
• Hannigan, Dominic.
• Harrington, Noel.
• Harris, Simon.
• Heydon, Martin.
• Humphreys, Heather.
• Humphreys, Kevin.
• Keating, Derek.
• Kelly, Alan.
• Kenny, Seán.
• Kyne, Seán.
• Lawlor, Anthony.
• Lynch, Ciarán.
• Lyons, John.
• McCarthy, Michael.
• McFadden, Gabrielle.
• McGinley, Dinny.
• McHugh, Joe.
• Maloney, Eamonn.
• Mitchell, Olivia.
• Mitchell O'Connor, Mary.
• Mulherin, Michelle.
• Murphy, Eoghan.
• Neville, Dan.
• O'Donnell, Kieran.
• O'Donovan, Patrick.
• O'Dowd, Fergus.
• O'Mahony, John.
• O'Reilly, Joe.
• O'Sullivan, Jan.
• Phelan, Ann.
• Phelan, John Paul.
• Rabbitte, Pat.
• Ring, Michael.
• Ryan, Brendan.
• Stagg, Emmet.
• Stanton, David.
• Tuffy, Joanna.
• Twomey, Liam.
• Varadkar, Leo.
• Wall, Jack.
• Walsh, Brian.
• White, Alex.

Níl

• Boyd Barrett, Richard.
• Broughan, Thomas P.
• Calleary, Dara.
• Collins, Joan.
• Collins, Niall.
• Colreavy, Michael.
• Coppinger, Ruth.
• Daly, Clare.
• Doherty, Pearse.
• Dooley, Timmy.
• Ellis, Dessie.
• Fitzmaurice, Michael.
• Fleming, Sean.
• Fleming, Tom.
• Halligan, John.
• Healy, Seamus.
• Healy-Rae, Michael.
• Higgins, Joe.
• Kelleher, Billy.
• Kirk, Seamus.
• Kitt, Michael P.
• Lowry, Michael.
• McConalogue, Charlie.
• McGrath, Finian.
• McGrath, Mattie.
• McGrath, Michael.
• McGuinness, John.
• McLellan, Sandra.
• Martin, Micheál.
• Mathews, Peter.
• Murphy, Catherine.
• Ó Caoláin, Caoimhghín.
• Ó Cuív, Éamon.
• Ó Snodaigh, Aengus.
• O'Brien, Jonathan.
• O'Sullivan, Maureen.
• Pringle, Thomas.
• Ross, Shane.
• Shortall, Róisín.
• Smith, Brendan.
• Stanley, Brian.
• Tóibín, Peadar.
• Troy, Robert.
• Wallace, Mick.

Tellers: Tá, Deputies Simon Harris and Emmet Stagg; Níl, Deputies Billy Kelleher and Sean Fleming.

Question declared carried.

The Dáil adjourned at 9.20 p.m. until 9.30 a.m. on Thursday, 4 December 2014.