Dáil Éireann díospóireacht -
Thursday, 16 Nov 2017

Vol. 961 No. 6

Committee on the Future of Healthcare Report: Motion (Resumed)

Debate resumed on the following motion:

That Dáil Éireann shall consider the Report of the Committee on the Future of Healthcare, entitled ‘Sláintecare Report’, copies of which were laid before Dáil Éireann on 30 May 2017.

- (Deputy Róisín Shortall).

Deputy Joan Collins

On the adjournment of the debate on 22 June, I made a point about sections 38 and 39 bodies not being addressed in the report and that there would be future reports on the matter.

I made the point that we would have to deal with that at a later stage. We have moved on a lot since 22 June. The commitments made by the Minister for Health and the Taoiseach on the all-party Sláintecare proposals on health cannot be taken with anything other than a grain of salt. We are now 21 weeks on from that debate in the Dáil. The report was laid before the House in May. Sláintecare is a ten-year plan to implement a properly funded, universal health care system similar to the NHS. It will not be implemented if the Department of Health is in charge of the process. The Department is littered with abandoned reports and policy documents on reform. If the mandarins do not want something, they kill it by sitting on it, setting up a committee and hiring consultants until it is forgotten that there was a report. The fact that the report was laid before the House on 31 May and that we are only coming back to it in November reflects the same attitude in Government.

Sláintecare was very specific for that reason. The report recommended an implementation office in the Department of the Taoiseach, rather than the Department of Health, to be fully funded by October 2017. It recommended that a highly independent lead executive be appointed by July 2017. This post has not even been advertised yet. It recommended that the post would be equivalent to a secretary general. We now believe it will be two levels below that, much to the delight of the powers that be in the Department of Health. These are two key recommendations and they have been ignored. The implementation office is to be in the Department of Health and has not yet been set up. A consultancy group has been hired, no doubt at huge cost, and an assistant secretary general from the Department is to chair a steering group. This is all the usual stuff.

As well as an independent lead executive and an implementation body outside the Department, Sláintecare requires additional investment of at least €600 million a year on top of the normal funding. Budget 2018 provides nothing to deal with it. It does not provide one red cent to deal with the implementation of Sláintecare. Without Sláintecare and without the necessary leadership, oversight and increased investment, we will continue to have a two-tier unequal service which provides extremely poor access to poor health care at a very high cost. I listened to the debate yesterday with the Minister on the increased cost to the health system. He said that he needed to have outcomes as well. This Sláintecare report was, is, and can be the outcome. The Government will fail on this issue if it does not implement the report in the form the all-party committee recommended.

I have seven seconds left and will make one more point. This is world chronic obstructive pulmonary disease, COPD, week. It has not really been addressed in the Dáil and I think it should be. COPD groups are in Sligo today and they will be in Cork tomorrow. I encourage people to attend their events.

Deputy John Brassil

I welcome the opportunity to speak on the Sláintecare report having spent nine or ten months putting it together at weekly, and sometimes twice weekly, meetings. At the outset, I acknowledge the work of the chairperson of the committee, Deputy Róisín Shortall, who did an outstanding job and went far beyond the call of duty in respect of the time and effort she put in. I also acknowledge all the other committee members with whom I worked and the work done by the advice team from Trinity College we employed to help us in preparing the report, Dr. Steve Thomas and his team. Again, the team did wonderful work.

We acknowledged very early on in the debate that there is no such thing as a perfect health system. All we can do is try to improve what we have. Trying to model our system on those which other countries have or trying to implement those systems in Ireland does not work because every country's system is different. If one looks at world reports and indicators on health, one might find that Japan has the best system, that Singapore has a very good system and that Australia has a very good mental health system. Each individual country can provide some level of guidance on how to do things correctly. One could look at the values of universal health care in the UK. It has a very good value system but, as we know, that particular system is also currently in crisis. Israel has exceptional primary care. There are exceptional community services in Brazil. Australia tops the list in mental health and well-being. The Nordic countries are at the top of the list for health promotion. The US is strong on research and development and Singapore is strong on information and communications technology. If one was looking for choice, one would turn to France and if one was looking for funding one would go to Switzerland. If one was looking at care for the elderly, one would look to Japan. There is no one perfect system, but there are very good parts of systems. Looking elsewhere to try to find a solution for the Irish system is a waste of time. We need to adapt our system to work for the Irish population.

This report sets a blueprint whereby we can make significant progress over a ten-year period. It recognises that nothing can be solved overnight, but that ten years is a realistic timeframe. We have set out what needs to be done in each individual area and we have provided funding and costing models for those individual areas. We have asked for an implementation office, which is the key to the delivery of the Sláintecare report. The Minister will recall that at his party's conference last weekend the Taoiseach made specific reference to the Sláintecare report and its delivery. Using Sláintecare as part of a key address at an Ard-Fheis or a keynote conference speech is really not good enough anymore. We need delivery. We need the implementation office to be put in place. Some legislation is required which has not even been started.

As a newly elected Deputy, having spent a considerable amount of time and effort in the belief that the work I was doing was to be of benefit, I am very quickly becoming disillusioned. My eyes are being opened to the fact that we do a lot of hard work, a lot of talking and a lot of huffing and puffing, but when it comes down to it, there is zero delivery. If there is one key message in my contribution to the debate this morning it is that we need to deliver the recommendations. We need to set up the implementation office and start moving the report forward. Many of the contributions made indicated the disillusionment out there, particularly among staff, in trying to get people to come back and work in the system - doctors, nurses, consultants, GPs, physiotherapists, radiographers and so on. Until there is confidence in the Irish health system and people actually believe that they are coming back to work in a system which will give them job satisfaction and a good quality of life, they will not come back. This report has far more far-reaching consequences than might be seen at first.

One of the areas which we identified very early on was accountability. We keep repeating it. Who is accountable? We have set out a very clear pathway. We need legislation for a new HSE board. We need an accountability structure to be put in place so that, rather than passing the buck down the line time after time, people will be responsible for the area of expertise they are supposed to deliver. If there is not accountability in a system, it will never work correctly. We spent a considerable amount of time looking at expansion of primary care. If people only read the key recommendations of the report and nothing else, they will see that it is very succinct and shows a very clear pathway for improving our system. If we can get our primary care network working properly, we will take the pressure of the system further up the line and give our hospitals and care facilities a much better chance of functioning efficiently.

One of the key things the report focused on, and in which I was involved, was care of the elderly, home care packages and the fair deal scheme. At present, the budget line for home care is separate to that for the fair deal scheme.

A separate budget line for the fair deal scheme is needed. Unfortunately, the first thing a community welfare team asks an elderly patient who looks for a home care package is whether he or she would consider the fair deal scheme. The community welfare team wants the patients off its budget and onto another budget but the fair deal scheme costs ten times more. That makes no sense. The budgets for home care packages and the fair deal scheme should be part of the same offering because the financial incentive will then be to ensure that a person who wants to stay at home will remain there. That could happen very quickly with a minor adjustment in budgets. I am sure the Minister of State's office is inundated with people seeking home care packages, for five or ten hours a week, in order that they might care for elderly parents or relatives. There is a cost-neutral solution available and all that needs to be done is to implement it.

Another key aspect of the report is the principle of affordability. Those who can afford to pay now are treated first because they have private health insurance and those who do not go into the queue. Any fair society, no matter how it is viewed, must have a system that treats people on the basis of need as opposed to ability to pay. That key recommendation is in the report and it has been costed. Again, a very simple social objective could be achieved if we have the desire to deliver.

Rather than sing the praises of the report and point out all its good aspects, I ask that the Minister set up the implementation office, have the legislation that is needed to make the key changes in accountability drafted and get this report moving forward in order to give some semblance of hope that we can resolve the crisis in health care. We sat as one unit and worked together towards the goal of improving the health system. If a cross-party report does not get the hearing and respect it deserves, we will never get anywhere in the context of dealing with the crisis in the health service.

Deputy Brian Stanley

I welcome the opportunity to speak on the Sláintecare report. We are all agreed that our health care system is in some disarray and that we need to address the problem. I want to deal, in particular, with the emergency services in the Dublin Midlands hospital group as an example of what needs to be done. I will approach this in a constructive way.

Ministers often shout at us about not having solutions. We produced a plan for universal health care two years ago, when Deputy Ó Caoláin was Sinn Féin spokesperson on health. Much of what was in that document is now in the Sláintecare report. The Social Democrats and people from other parties also had a major input to the report. There is broad agreement on that. I raise this issue in a constructive way because we put a great deal of effort into our plan at the time. Deputy Ó Caoláin consulted widely and met people in the sector.

An issue raised by the public, and one that I have come across when interfacing with the health service, is that consultants and specialists are two-timing. The Minister of State knows what two-timing means when people are having love affairs - they are deceiving both parties. In this case, consultants and specialists are running private practices within the public system and are taking patients out of the public system. For example, a person employed by local government told me yesterday that he brought his child to hospital to have a procedure and was put on a waiting list for a year or more. However, the child could not wait. He and his wife pay a lot of income tax but he happened to mention that he had private health insurance with an excess of €500. They were in Slane clinic within a day. They paid the €500, the insurance company paid the rest and the procedure was carried out in a couple of days. Senior staff whisper in patients' ears - sometimes they do not even bother to whisper - that if they pay privately, the procedure can be carried out. I have had that experience. It has to stop. If people want to take out private health insurance, that is grand but the private system has to operate separately from the public system.

When Fianna Fáil was in government in the noughties, and Deputy Micheál Martin was Minister for Health, it wanted to have co-location. I am glad that we have moved away from that insanity. We have to build a new system around the proposal in the Sláintecare report. Deputy O'Reilly has said that we agree with 95% of it, including the need for a single-tier system, recognition of the role socioeconomic background plays in the quality of people's health, the "carta sláinte", a universal card for access, etc., employing extra staff and single waiting lists to avoid queue skipping.

On page 78 of the Sláintecare report, it is set out clearly that "concrete measures to improve access to Emergency Departments and manage waiting lists [properly]" must be put in place. On page 110, there is a recommendation to "Introduce a maximum wait time in EDs, working towards a four hour target". We all agree with that and we understand this cannot be done in an hour or a week but that it will take time. Deputy O'Reilly has articulated much better than I the detail of what needs to be done there.

Side by side with this report, the Dublin Midlands Hospital Group produced a report that was leaked to me three weeks ago. Since then, the top tier of the HSE - which is feeding information to a Sunday newspaper - has put in place a news management strategy. It is a case of shock horror one week and the following week it leaks a report similar to this one, specifically dealing with areas of care in Portlaoise. The Minister of State knows, as do I, that the 24-hour emergency department in Portlaoise is in danger of being closed. The report I received sets out what is to replace it, namely, a minor injury unit and medical assessment unit operating between the hours of 12 noon and 7 p.m. There will be nothing after 8 p.m. I have spoken many times about the effect that this will have and the crisis it will create. In the first six months of this year, 20,000 people presented at the emergency department in Portlaoise. There is nowhere else in the system to put the emergency department. According to the leaks to The Sunday Business Post from those in the top echelons of the HSE last weekend, it will cost €100 million to provide the extra capacity in other hospitals such as Tallaght. If the emergency department at Portlaoise hospital is removed, according to the plan leaked to The Sunday Business Post, serious paediatric services, maternity services and the intensive care unit will go. It is widely acknowledged on the Government benches, and on this side of the House, that since the improvements were made in staffing levels in the maternity unit in Portlaoise, services have improved dramatically. They are now linked to the Coombe, which provides an excellent service. Investment has been made in that service and I welcomed that publicly at the time.

While the services have been brought up to a high standard, the proposal is that emergency services will now be removed and shifted to the Coombe.

Has the Minister of State, Deputy Jim Daly, ever tried to get from Portlaoise to Dublin during the three hours of rush hour in the morning or the three hours of rush hour in the evening? How will the patients be transported? They cannot be transported by road because apart from the gridlocked traffic, outside of those six hours the ambulances are not available to do that.

I listened carefully to the views of local consultants and GPs about what needs to be done in terms of critical care provision in the midlands, in particular with regard to Portlaoise. They produced a strategy for the future of services at the Midland Regional Hospital, Portlaoise and a copy was sent to the Department for information. They set out clearly what needs to be done. They say the same thing needs to happen with emergency care as has happened with maternity services in terms of being linked in with units in Dublin hospitals with the sharing of consultants and expertise. That is what we need to do. That will not cost €100 million, which is what the HSE intends to spend if it gets its way to beef up Dublin hospitals to take the supply from the midlands when it closes down the emergency services in Portlaoise.

We heard much talk in the past about the golden hour but the health experts who are pushing the agenda have stopped talking about it. We all know that the first hour after a serious accident or health incident where a person has a heart attack, for example, is key. If Dr. Susan O'Reilly, who is leading the drive to close the emergency services at Portlaoise, is allowed to have her way, based on the fantasy of the Dublin Midlands hospital group, we will not be able to get people to hospital through the gridlock and because the ambulances are not available. The critical golden hour will be lost. If the proposed change is allowed to happen, people will hold Fine Gael to account. Dr. O'Reilly sent a letter to staff this week to inform them that a decision to that effect has been made. I have a copy of the memo with me. She said the issue is now in the hands of the Minister. If that happens it will come down on Fine Gael's head, and the party that is propping it up in government, namely, Fianna Fáil. If anybody dies in the back of an ambulance either travelling to Tullamore across very bad roads or to Dublin it will come down on the Minister's head. The issue is on the desk of the senior Minister. If he signs off on it he is signing the death warrant of people in Laois and the surrounding counties. He is also signing the death warrant of Fine Gael and there will be political consequences for the party that is propping it up in government if it goes ahead with the proposal.

The Minister should push ahead with the Sláintecare report. The report from Dr. Susan O'Reilly and her team should be put in the shredder. The Minister should talk to the GPs and hospital consultants and make the necessary investment in Portlaoise hospital. It will not amount to €100 million or even €20 million. The Minister should shred the fantasy plan of Dr. Susan O'Reilly and push on with Sláintecare.

Deputy Ruth Coppinger

This is a report on the future of health care. We all know that Ireland has been in the dark ages for a long time in respect of reproductive health care. It is extremely disappointing that this report has practically no reference to reproductive health care at all, that is, to contraception and abortion. A total of 51% of the population are women who potentially may become pregnant and who would like to have control of their fertility. One would think that a report on the future of health care would take sufficient account of that. The only reference I can see that is made to it at all is on page 58, which states that the committee has agreed the following services should come under the remit of universal health care: public health preventative care, including health promotion activity, screening and family planning supports for self-management of health. The only reason family planning was added in there was because the Solidarity representative on the committee, Deputy Barry, put it forward. We put forward a much more extensive amendment and proposal on the issue but the committee saw fit to reject it. I will return to that point later.

What is the future of health care for women in this country and for those who can become pregnant? The report totally ignores reproductive health. The HSE reported to the Joint Committee on the Eighth Amendment of the Constitution yesterday that women on low incomes are having difficulty affording permanent contraception. Even with the so-called State subsidy, one still has to pay €148 for the Mirena coil. For many women finding that amount of money becomes a barrier to getting it and as a result, the HSE reported yesterday that many of those women will end up with crisis pregnancies because other forms of contraception are not reliable for them. The VHI and private health insurers do not provide any coverage at all for contraception. It seems that is allowed by the State. Are women to continue to be ignored in the future of health care in this country?

We are meant to be emerging - but have not emerged - from a situation whereby the church controls a huge number of hospitals that have direct control over women. Some of the major hospitals in the capital city do not supply contraception. The Government was going to hand over control of the national maternity hospital to a church-run charity and the Government had to backtrack on it following a huge protest. Those are major issues and this really shows how the Dáil is far behind the needs of society and public opinion.

It was also reported at the Joint Committee on the Eighth Amendment of the Constitution yesterday that 536 packets of abortion pills were seized by the Customs and Excise under the direction of the Health Products Regulatory Authority, HPRA. That means the State directly obstructed at least 536 women from accessing a safe, early abortion and probably forced women to go abroad to have a later one. We do not know. What we do know is that whatever comes out of the Joint Committee on the Eighth Amendment of the Constitution will come back to the Dáil. Are we going to leave this entire issue in the shadows? There is a half-hearted effort by the HSE and the State to find out the extent of abortion in this country but it will have to be addressed in the health system. The alternative is for us to continue to have an Irish solution to an Irish problem.

Research has been done, which of course is always done outside the country. One could not expect the Government to do it. Two studies have been done on how widespread is the extent of the use of the abortion pill in Ireland. One was done in Texas by Dr. Abigail Aiken, who testified at the committee, and another more up-to-date study has been done in the University of Kent on access by Irish women to safe but illegal abortion. The results of the study are pertinent to the future of health care in Ireland. It showed that in one year, 3,000 requests for abortion pills were made from the North and South of Ireland to the websites of two organisations, namely, Women on Web and Women Help Women. Those pills are legal and used in every other health system in Europe bar Ireland and Malta. A total of 99% of people in Europe have access to that safe, essential medicine declared by the World Health Organization as being much safer than surgical abortion, for example. What will happen in that regard? Are we going to continue to let thousands of women from this State access illegal abortions or will it be catered for in the health service? If one breaks down the figure of 3,000 women seeking abortion pills between the North and South, more than 2,000 are from the South. I accept that not every woman will proceed to carry out a termination even if she gets the pills but it works out that five people a day are having home abortions in their bedroom in this country today. How will that be catered for in the health service whenever we do repeal the eighth amendment and legislate for abortion in this country?

The fact that the future of health care report does not even refer to it speaks volumes. Will another chapter be inserted? What does the Minister of State have to say about that? We should be planning to repeal the eighth amendment, which we all know is inevitable, but we should also be planning to legislate to allow women to access this in our own country rather than another one. This could be easily done. GPs could prescribe the pills, as they do in other countries. A woman could go to her own doctor and be prescribed a safe, early medical abortion, and she could ring up if she has any difficulty. That would be the end of the matter. We do not need huge clinics to the same extent as in the past given the availability of this pill.

It is extremely disappointing that the all-party committee rejected an amendment proposed by Solidarity-People Before Profit that there would be a new section on sexual reproductive health, which historically has been neglected by the Irish health system. The number of consultant obstetricians and gynaecologists is one of the lowest in the OECD and Ireland is one of the few developed countries without universal foetal anomaly screening. We keep hearing this mantra about it being the safest place in the world to have a child, but it clearly is not. More than one third of women attending antenatal services last year did not get a foetal anomaly ultrasound and we all know that women outside Dublin, in particular, would have real difficulty getting one. Ireland is almost alone in Europe in terms of the complete lack of access to abortion and free in vitro fertilisation, IVF, services. There is some assistance available, but it is not free.

We proposed that the committee would recommend free universal access to sexual and reproductive health services. These would include LGBT+ sex and health education; gender confirmation surgery and hormone therapy; contraception; screening, prevention and treatment for sexually transmitted diseases, including pre-exposure prophylaxis, PrEP; substantially expanded and properly resourced public gynaecology services; fertility treatments, including IVF; access to abortion services, along the lines of the Citizens' Assembly recommendations; and antenatal screening, including non-invasive prenatal testing and foetal anomaly scans. Consultants recently reported that these scans could now be done at eight and ten weeks, but they cost €150 to €300, so they are not carried out. We could be preventing so much difficulty for families who are expecting.

In addition, we also proposed pregnancy-related sick leave and an examination of extended paid maternity leave. It is extremely discriminatory that someone who has become pregnant uses up health benefits dealing with inevitable health issues. That is not equality. To achieve those goals, we also put forward that it would be necessary to separate church and State. The church should not have control of hospitals because these services will not be provided. It is extremely disappointing that none of this is catered for in the future of health care report, which raises the question whether women will have to come back, fight and demand that these things are provided in our own country.

Deputy Brendan Smith

I welcome the opportunity to make a brief contribution on this report as I have to go back to a committee meeting. I compliment Deputy Róisín Shortall. My party colleague, Deputy John Brassil, and Deputy Michael Harty were members of the committee. The committee put in a huge amount of work over a considerable length of time, which showed their commitment and knowledge of the whole area of health. It is an ambitious programme and a challenging one to fund, but it has to be realisable for the good of the people of this country.

Far too often, we hear about the need for structural change, etc., but part of the structural change is implemented and then the other commitments that were made in advance of those changes are not implemented. In too many instances in this country, we have had the removal of services from the smaller general hospitals but we were told that the ambulance service in those regions would be upgraded to ensure that no delays occurred in transferring patients to the new centre, if one wants to call it that. The Minister of State will be aware of the concerns we have in the Cavan-Monaghan area in regard to the ambulance services. Many years ago, when some services were removed from Monaghan General Hospital and transferred to Cavan General Hospital and Our Lady of Lourdes' Hospital in Drogheda, we were promised the ambulance service would be upgraded. Not alone would the fleet be upgraded but the paramedics working there were to be upskilled and would take on new responsibilities. In some instances, that has happened. When it has the most modern facilities and vehicles and highly qualified paramedics, the ambulance service can make a significant difference to the patient in need of treatment. However, far too often, we are coming across instances of undue delays in ambulance response times and the issue needs to be addressed.

The Department of Health will not be able to convince people of the need for structural change and the transfer of services from one location to another if the public is not confident that the structural change promised will be implemented. Those resources have not been given to the ambulance service to ensure the services that personnel working in the ambulance service want to provide are effective on an ongoing basis. I have had correspondence with the Minister for Health with regard to some instances in County Monaghan. The delays that occurred were deplorable and, sadly, some people who may have been saved if there had been intervention at the right time have passed away. That is an obvious source of terrible grief, anguish and concern for those families. However, those families who lost loved ones as they did not get the response from the ambulance service in time have said to me repeatedly that unfortunately they cannot bring back their family member but that their concern is about saving someone else in the future. I will speak to the Minister of State another time about some of those instances. However, it is essential that the ambulance service is upgraded if we are to have meaningful reform and structural change.

I have not had an opportunity to refresh myself on the contents of the Sláintecare report this morning because I have been at committee since early morning. The report is both good and ambitious, and it should be realisable. That should be the concern of all of us who are privileged to be Members of this House. However, my recollection of the report is that there is very little mention of the potential for co-operation with Northern Ireland. All of us in this House are influenced by where we come from. In the worst of days of North-South relations and British-Irish relations, particular initiatives were put in place. What is called the Ballyconnell agreement goes back to July 1992, when the co-operation and working together, CAWT, partnership was introduced between the trusts in Northern Ireland and the North Eastern Health Board and the North Western Health Board, as they were structured at the time, to provide services for those regions on a cross-Border basis. That particular initiative has been very successful. I recall over the years from my early days making representations that some services were delivered from the then Omagh General Hospital to Cavan General Hospital and Monaghan General Hospital. At the minute, some ENT services are provided by the hospital in Coleraine.

In providing services on this island, we have to assess the capacity for elective surgery on all of the island. For instance, in the area of ENT, with which I am familiar, that level of co-operation exists but needs to be upgraded. However, surely there are other areas where we have to identify potential for greater co-operation. I welcome the fact that paediatric cardiac services are provided at Crumlin hospital for children from Northern Ireland. We are too small an island to be living in isolation and in silos. We must have increased co-operation. We know the Brexit challenges that are coming down the road. We have to plan on the basis that health care on this island should be delivered, where possible, on a cross-Border basis. I am talking about elective surgery and access to emergency departments on both sides of the Border. Some of my constituents in Cavan-Monaghan live nearer to the South West Acute Hospital in Enniskillen than Cavan General Hospital. We have to ensure that there is increased co-operation at all levels. It would be farcical if there was spare capacity in the South West Acute Hospital in Enniskillen while we were not able to treat in time the patients needing such services on our side of the Border.

I believe I am accurate in saying that not enough emphasis has been placed on North-South cross-Border co-operation in this Sláintecare report and if there is any review or further analysis of the report then this is an area I would like to see revisited if at all possible.

Like some of the rest of us here in the Chamber, the Minister of State represents a very rural constituency. There is increasing concern among rural GPs over their inability to attract support staff or indeed other GPs. I know that the age profile of GPs in my counties of Cavan and Monaghan is quite high. Some of the GPs with what might be considered good practices say to me that there is no hope of those practices continuing when they retire themselves. This is a very worrying prospect. Speaking in his professional capacity as a GP, Deputy Harty has spoken here about the need for proper supports for the primary care sector so as to ensure that people have access to a proper service at the appropriate time. GP and primary care have to be resourced properly. We need to give urgent consideration to how we can attract more GPs, particularly to rural communities.

With regard to care for the elderly, I welcome some of the developments and indeed some of the facilities that the Minister of State and I have visited together. These are very good and provide a very good service but in too many instances delays and pressures arise over getting people in. One particular initiative was taken many years ago in my home county of Cavan and it may even have crossed into Deputy O'Rourke's native Leitrim. It was called "boarding out" and was targeted at elderly people who lived alone but were still somewhat independent. These were people who did not need to be in a nursing home but were nonetheless unable to manage living at home on their own, particularly those in remote areas. Provision was made under this scheme that four or five people could go to live in a "boarding-out house", as it was called, with adequate care and attention provided by the people running the facility. The older people could then lead independent lives: they could go down the town or down the village and they became part of the family. That scheme was very successful for many years in County Cavan but is currently being run down. The cost to the Exchequer of such a scheme was substantially less than the costs that would have been incurred had those people been placed in nursing home care. I know people who lived in these kinds of boarding-out houses for many years. They were semi-independent and were able to go down the town or go out to football matches with a family member, or whatever else; they were also cared for and all of their needs were met in a family home setting. We should be pursuing initiatives like this which would ease the pressure on both public and private beds. Perhaps the Minister of State could have a chat with me about this. The bottom line is that, as well as providing proper care - I am not talking here about care delivered below the standards that we all want to see - the cost to the Exchequer was considerably lower than that of a person going into a nursing home.

To conclude, I would also like to stress that the whole area of home support, an excellent service, needs additional funding and we cannot wait for the reorganisation of the health service to provide this. We need additional supports as soon as possible.

Acting Chairman (Deputy Frank O'Rourke)

As no other Deputies have indicated to speak, I call on the Minister of State to respond.

Minister of State at the Department of Health (Deputy Jim Daly)

I welcome the opportunity to do so. I thank all Deputies who have contributed and assure them that these contributions are noted and will be brought back to Deputy Harris, the Minister responsible for the implementation of this report. I also thank the Deputies who contributed to the Sláintecare report committee. I was an early member of that committee myself but had to come off it due to being involved with too many other committees at the time. I thank all of those committee members for their time, their contributions and for the dedication and commitment they gave to the committee. On behalf of the Minister for Health and like many others in the House today, I also acknowledge Deputy Shortall's leadership of that committee. This was, to my mind, an example of politics at its best. We can talk about politics and about politicians in various guises but this showed politics working very well, with a group of ideologically differing individuals able to sit down together and put in a lot of hard work, engagement, reading, consultation and resources. The members were able to reach a consensus and plan a future for health care for the next ten years. The Vision for Change mental health strategy, an example from my area of responsibility, shows what has been achieved over the last ten years and what dynamic changes have taken place in that time. We can never be completely satisfied, of course, but if we compare the days when mental health care meant institutionalised care with what we have today with CAMHS and the work of various organisations, it is clear that there has been a radical transformation of mental health care. We can be equally ambitious for the radical transformation of our broader health care system over the coming ten-year period.

The Minister has supported the work of the committee since it was established and he has strongly welcomed the consensus achieved and the vision and principles that underpin the report. The Government is committed to making tangible and sustainable improvements in our health services and the Sláintecare report now provides a framework and a direction of travel within which to do this. We have an unprecedented level of consensus and support for the vision and strategic direction outlined in the report. The Minister has indicated his intention to harness this and to work with colleagues across the political spectrum and all stakeholders to move forward on a programme of health reform. The Government has already given its approval to move ahead with the establishment of a Sláintecare programme office in the Department of Health. This office will be tasked with implementing a programme of reform as agreed by Government and arising from the Sláintecare report. Recruitment will commence shortly. In parallel to this, work is underway in the Department of Health to develop a detailed response to the report for consideration by Government in December of this year. The process will seek to translate the Sláintecare report into a programme of action for the next ten years and will consider issues that arise in designing such a programme including key actions, deliverables, costings, timelines and key performance indicators. It was acknowledged in the Sláintecare report that more detailed consideration of these issues would be required and this work is ongoing.

Many of the recommendations in the Sláintecare report are already policy priorities, including the roll-out of our eHealth and health and well-being strategies, the development of a new GP contract, proposals for enhancing community nursing services, further roll-out of integrated care programmes, the undertaking of a capacity review and the development of an integrated workforce planning framework. The Minister is also anxious to advance a number of the Sláintecare report proposals which he regards as early priorities. In October he announced the following steps that he is taking in this regard: an impact study of the removal of private practice from public hospitals, to be chaired by Dr. Dónal de Buitléir and with terms of reference and further members of the group to be published shortly; a public consultation process on the future alignment of hospital groups and community health organisations, to commence next month; and plans to establish a governing board to oversee the HSE's performance. As well as this, most of the additional funding for new health initiatives in budget 2018 has been targeted at areas identified in the Sláintecare report: the new primary care fund of €25 million; the additional home care and transition beds at €37 million; a reduction in medicine and prescription charges at €17.5 million; targeted funding for waiting list reduction at €75 million; and a new Sláintecare implementation office at €1 million.

To conclude, I assure the Deputies that I will relay the comments they raised here today back to the Minister for Health. I am sure that this debate will continue for some time.

Acting Chairman (Deputy Frank O'Rourke)

I call on Deputy Shortall to wrap up the debate.

Deputy Róisín Shortall

I thank everyone who contributed to this debate, though I think it very disappointing that it was very quietly slipped in this morning. I think many Members were not even aware that this debate was taking place this morning as this was not signalled last week. The debate also clashes with a number of other events this morning, with committee meetings for example. This is unfortunate and I am not sure what the reason for this was.

I too wish to thank sincerely all 14 committee members who put huge time, effort and real commitment into this process. This was a once-off process, the like of which we had not seen before, of developing an agreed cross-party position on a very significant area of public concern.

Sláintecare was and is a once-in-a-lifetime opportunity to do something of real importance in this country and should be grasped with both hands by Government. We have a cross-party consensus on health policy for the first time which is key to making progress. For the first time we can take the politics out of health and end the situation that has existed for so long where health was used as a political football, to score points against each other. Sláintecare gives us the opportunity to do this as it is a fully costed, phased plan. It deals with the issues that go to the heart of the problems within our health service, namely the dysfunction that arises as a consequence of Ireland's two-tier system. That system is inequitable, very inefficient and is a huge barrier to people being able to live a life free from illness and worry over what will happen in the event of their developing an illness.

Sláintecare is radical in Irish but not international terms. The committee was keen to learn from the experience of other countries, especially the successful health systems elsewhere, and how they might be replicated in Ireland. The question of how we might learn from best practice and ensure that Irish people have the same kind of entitlement to good quality universal health care that all our European neighbours have was always at the forefront of the committee's thinking. Ireland is alone in having a two-tier unfair health system which speaks volumes of the mistakes that have been made in this country. Sláintecare charts a clear path for how we can develop a really good public health system.

Cross-party agreement exists on the direction in which we need to go towards the final destination, which is a universal single-tier health service where people are treated on the basis of health needs rather than their ability to pay. This political agreement represents a huge step forward. It is the bedrock of Sláintecare which we are now challenged to deliver.

There are some critics of the report but no one has come forward to suggest a plan B. Sláintecare is now the only game in town. It is evidence-based and has full political support. Anyone who criticises elements of the report should be challenged. For instance, the Irish Hospital Consultants Association has been critical of the report and has suggested that we should have more consultants and hospital beds. Those things are important but the hospital consultants have failed to address the fundamental point about equity. How do we achieve equity in the system if the two-tier system continues? My question of the Irish Hospital Consultants Association is this: do they believe in equity? Do they believe in universal access to services? If they do, how do they propose that we will deliver on these two important principles?

I am increasingly concerned about the Government's commitment to Sláintecare. I do not like to say that and had not said so in the first part of this debate but the Government seems to be dragging its heels. The Minister, Deputy Harris, speaks very positively on the plan and expresses his full commitment, but his actions do not follow through. Undoubtedly, for the last 70 or 80 years, health reform in Ireland has been held back because it is so dominated by vested interests. These interests are wide-ranging, and include health insurance companies, the pharmaceutical industry, the private hospital sector and some hospital consultants. Various interests are doing okay from our health system, it is good for their business, but the Government has a duty to serve the concerns of patients, not those of vested interests. That requires political leadership which has not been evident here in the past but it is required now. We must put patients' interests first and be clear and categorical in so doing.

The Government needs to make up its mind. Does it enthusiastically support Sláintecare or not? If it supports the principles that underpin Sláintecare, we need to see delivery. Today the Minister of State, Deputy Jim Daly, outlined a number of steps the Government has indicated it is taking. It is strange that the Government would make its first announcement on an impact assessment on the separation of public and private. That is a core recommendation from Sláintecare and is fundamental to achieving the universal system. Considerable political pressure was put on members of the committee towards the end of the process, as well as commercial pressure, to block the recommendation to separate public and private. That lobbying was not successful but it did succeed in having a line written into the report that an impact assessment would be required. The impact assessment mentioned in the report refers specifically to public patients. It does not relate to vested interests, but to assessing the impact on public patients because that is where the key responsibility lies. It is strange that this would be the first thing on which the Government moved. I sincerely hope the Government will not use this process as an excuse to abandon this key recommendation because it is central to a universal health service.

I am also concerned by the lack of progress in establishing the implementation office. When I met the Taoiseach in August, he told me the Government was in the process of starting recruitment and it would commence shortly. In September, we were told exactly the same thing, and again in October. Now, in November, the Minister of State told us today that recruitment will commence shortly. I have to question the Government's sincerity and commitment to this if we have now wasted what is almost six months since the publication of the Sláintecare report. There seems to be no urgency in setting up the implementation office. The key thing which every member of the committee said from the outset was that we would not produce yet another report on health reform. We would not engage in this unless there was a very clear commitment on implementation which is why the report includes a strong recommendation to establish a fully funded independent implementation office. What is the delay in recruiting the person to head the implementation office?

I am further concerned that yet again an attempt has been made by the Department of Health to capture any kind of change proposed in health. The committee recommended that the implementation office would be located in the Office of An Taoiseach because we wanted to avoid that departmental capture. I hear on the grapevine that attempts are being made in the Department of Health to slow down this whole process and put obstacles in its way.

The Government must not squander this opportunity to do something of real significance for the Irish people by at last introducing a universal single-tier health service. It must not allow the vested interests to get in the way. It must not let departmental interests slow this down and block progress. The responsibility of all Members is to the people who elect us, to the public.

It is not before time that this country finally started to introduce a universal single-tier health service because Irish people should have exactly the same entitlement to good quality public health care as have all other European citizens.

The Minister of State should bring back to the Minister the message that there is growing concern among former members of the Committee on the Future of Healthcare that the Government is not serious on this and that progress is so slow. Even though the committee has stood down, several of its members have requested that I ask the Minister to meet a representative group from the committee. We are keen to meet him to address what would seem to be a slowing down of the process. A slowing down would represent a very serious mistake by the Government. The Minister of State should ask the Minister to come back to us with an early date on which to engage on this.

Question put and agreed to.

Sitting suspended at 11.10 a.m. and resumed at 12 noon.