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Dáil Éireann díospóireacht -
Thursday, 8 Feb 2018

Vol. 965 No. 3

Priority Questions

The first question is in the name of Deputy Billy Kelleher. The Deputy has 30 seconds to introduce it.

Is the question grouped?

Questions Nos. 1 and 2 are grouped.

Do we have 30 seconds each?

No, you do the introduction, but there is double the length of time for the answer.

HSE Funding

Billy Kelleher

Ceist:

1. Deputy Billy Kelleher asked the Minister for Health to outline his views on whether the HSE will be within budget in 2018; and if he will make a statement on the matter. [6586/18]

Louise O'Reilly

Ceist:

2. Deputy Louise O'Reilly asked the Minister for Health to outline the position regarding a potential financial shortfall for the HSE of up to €881 million before the end of 2018; his plans to rectify this; if more funding will be forthcoming; if hospitals will have to increase stretch income targets to meet the shortfall; and if he will make a statement on the matter. [6473/18]

Will the Minister for Health outline his views on whether the HSE will be within its budget in 2018? I am asking in view of the commentary by the director general of the HSE and the concerns consistently expressed from this side of the House on the aspirational elements of the budget that incorporate savings identified. Clearly, these elements will not be delivered. Indeed, it is already being said that the targets will be singularly challenging to deliver and that some are in fact more strategic and long-term in nature. Already, sizable amounts of savings must be realised to deliver the services outlined in the service plan.

I propose to take Questions Nos. 1 and 2 together.

I thank Deputy Kelleher and Deputy O'Reilly for their questions. We had an opportunity to engage extensively on this matter yesterday. The meeting involved myself and the director general of the HSE. Anyway, I welcome an opportunity to engage again this morning.

As I said yesterday, the need for effective financial management remains crucial as the health service deals with a larger and older population, more acute health and social care requirements, increased demand for new and existing drugs and the rising costs of health technology. The costs associated with these service pressures will increasingly need to be managed not solely through increased Exchequer allocations but through improved efficiencies, productivity and value from within the funding base in 2018 and beyond as well. This is the norm in other health services. It is probably the norm in most businesses and public services. People are asked to ensure they get value for money. If anything, it is more important at a time when we are increasing budgets that we do not get back into the Celtic tiger spiral of taxpayers' money being spent without ensuring that it delivers decent outcomes for our patients.

The 2018 national service plan set out a budget of over €14.5 billion for the HSE, the highest budget ever allocated. The health budget was increased by over €600 million on 2017, a substantial additional level of funding by any objective standard. The amount allocated follows an extensive process of engagement between my Department and the HSE that considers the funding requirements as submitted by the HSE and the fiscal position available to the Government. These engagements are a normal part of the budgetary process and occur with agencies throughout Government.

As I remarked yesterday, it is simply that the process for health is more transparent since the director general and myself write to each other. I imagine someone may wish to find out whether IDA Ireland asked for money or this or that agency asked for money. Obviously, oftentimes agencies ask for more funding than the amount available. All public bodies put forward spending proposals but all such bodies, including the HSE, are required to operate within the amounts proposed by Government and determined by the Dáil.

While increased resources contribute to health service improvement, there are always ways in which improvements can be achieved within current resources. The HSE has my full support in achieving these improvements as part of our shared reform agenda.

Since I have come to office, the allocation to the Health Service Executive has increased by €1.4 billion or 10.6%. More resources are always welcome in contributing to the development of services but there is a responsibility on the HSE to seek greater value from the substantial existing resources at its disposal as well. Deputies heard yesterday from the director general and the deputy director general that they are up for the challenge as well. They accept that there is a need to ensure every euro counts in the delivery of health care.

The HSE 2018 service plan notes that provision of the level of services and activities will require the delivery of value improvements totalling €346 million. The HSE will lead on that aim, including a corporate value programme. It is focused on cost reductions and savings, including procurement savings and agency conversion, something we have talked about for some time but which needs to be delivered. It also identifies savings and cost reductions across all corporate operations. This might include better control of central administrative costs, such as travel costs, and better management of supplies. I imagine our citizens think these aims are appropriate, normal and good practice.

The Department of Health will work with the HSE within a shared governance and oversight framework. As Deputy Kelleher correctly stated, this will be a multi-year strategic initiative, because we need to get it right. The funding of our health service, and every health service, is a challenge and therefore we need to drive value. The objective is to identify and implement savings from improved productivity and changes in models of care or policies.

Health services to the public will not be reduced in 2018. The services to be provided in 2018 are as set out clearly in the national service plan. All levels within the plan are either equal to the level delivered in 2017 or, in many cases, higher than the level delivered in 2017. For example, as set out in the national service plan, the budget for acute hospital income will be set at €44 million less than the planned levels for 2017 and, as such, it contains no stretch targets. That addresses Deputy O'Reilly's question about the stretch targets. The additional funding provided in budget 2018 for new developments will support new or expanded levels of services throughout priority service areas. I expect the HSE to operate within the funding provided to it in 2018. The HSE has signed up to do precisely that.

The Minister used the expression "typically equal to or higher than planned or delivered" services in 2017. That does not give us much confidence in view of the fact that there is considerable pent-up demand. We have vast waiting lists. Large numbers of people are consistently on trolleys in our emergency departments day in, day out. There has been an extraordinary increase in the number of outpatients on waiting lists. Throughout the general health services there is an inability to deliver what is required of the services in terms of the changes in demographics, the changing nature of health and the provision of health care.

The Minister refers to funding being typically equal to or higher than what was planned or delivered in 2017. Last year, 2017, was not exactly a great year in terms of delivery. We are keen to see major improvements. In the budget we have provided for €346 million in savings to be identified to fund the delivery services. Many people, including me, maintain that is simply not possible.

Deputy Kelleher can add my name to that list. Of course it is not possible and the Minister knows that well. The Minister published a plan knowing he did not have the money to fulfil it.

Several questions leap out following the Minister's statement. The Minister referred to transparency. In truth, that this information is in the public domain is down to freedom of information requests from Martin Wall. The Minister need not pat himself on the back for having information dragged out of him - it was not volunteered. It is in the public domain because of freedom of information requests.

The Minister referred to value for money savings and targets. He has a target for the money. How much does the Minister believe he will save on travel costs for administrative staff? Certainly, he will not save on travel costs for staff who are providing front-line services in the community. Those people have to travel; it is a necessity for the job. Is the Minister suggesting some people are over-claiming on travel? Is there a view in the Department of Health that over-claiming is taking place for travel?

The Minister referred to agency conversion and how it feeds directly into the recruitment strategy. The recruitment strategy is not working. The Irish Nurses and Midwives Organisation has said it – the Minister need not take my word for it. How does the Minister intend to convert? What is the plan? What are the targets? What amount of money is set beside each of these targets? How will we know? Will we be relying on freedom of information requests this time next year?

When I write a letter, I am aware of the law of the land with regard to freedom of information. If I did not want processes to be transparent, I would not write letters. Presumably, the same is the case for anyone in my Department or anyone in the health service. I know some people, rightly, will use what this House has passed. I know how the law works.

It is an entirely transparent process that I set out clearly in writing, subject to freedom of information, for everybody to see what I expect. What was yesterday described as an extraordinary letter was actually a terribly unextraordinary letter. It basically told an agency that we had given a lot of money to it this year, it needs to live within its budget, that is the norm for every other agency and that is what it has signed up to do. A service plan is meant to be a list of what one is going to do in 2018, not a list of what one cannot do.

I take Deputy Kelleher's points, particularly about access. There is a need to do it much better. However, in the case of, say, home care packages, 750,000 more hours of home care will be provided by the Minister of State, Deputy Jim Daly, and the HSE in 2018. The budget for the National Treatment Purchase Fund, NTPF, has been doubled. We have already seen inpatient day-case waiting lists fall for five of the past six months. I expect that to continue right throughout 2018.

I am glad the Deputy agrees with me on the need for more capacity in the health service. That was not Government policy between 2007 and 2010, when beds were taken out of the health service. We now plan to put them back in.

It was also Government policy in 2011 and 2012.

The Deputy is correct. It was the same in 2011 and 2012. The Taoiseach, when he was Minister for Health, reversed that policy.

I am delighted the Minister and Deputy Kelleher agree with me. I have been saying it since 2005.

I know Deputy O'Reilly gets upset when I agree with her. I would not want to destroy her street credibility by doing so.

I have no problem with that when I am right.

However, we need more beds in the health service. We will fund that through the capital plan which will be seen in the coming weeks.

Deputy O'Reilly is correct on the issue of recruitment and retention. That is why we have asked the public sector pay commission to look at strategies for recruitment and retention. This process was welcomed by the nurses' organisations and one to which they will contribute. My Department will also contribute to it. I hope the public sector pay commission will accept there is a challenge, particularly with the retention of medical staff.

On the issue of travel costs, there is no impact on front-line staff. I was referring to reducing corporate costs. Every agency should be able to try to find savings of 1% or 2%. Every household can do that.

I do not accept the Minister's points about the delivery of service. The fact of the matter is that there is a significant demographic change occurring and huge demands will continue to be placed on the health service. This year, the health service will find it has not got the capacity, both financially and within itself, to deliver on these demands. We have seen this already at the start of the year with trolley numbers. January 2018 was the worst month ever for numbers of people waiting on trolleys. Beyond that, in the whole area of elective surgery, as well as for outpatient and inpatient appointments, I do not believe there is sufficient funding in place, even with the NTPF, to deal with and get to a situation where people can be seen in a timely manner. These are my observations with which many of those who put together the HSE service plan also concur. The savings identified will not be achieved.

I am delighted people are finally agreeing with what I have been saying for the past 13 years. I think I can go home now as my job is done.

The Minister is not going to hit value for money targets by reducing travel costs. To suggest he will is insulting to people.

It is not just in that area.

I do not know of people in senior management, or at any level, in the HSE who actually drive around to claim expenses. I do not believe that happens.

I did not say that.

I am happy the Minister has confirmed it will not affect people on the front line delivering services.

Saying something is transparent because it can be obtained under freedom of information is an issue on which we will eternally disagree. If it was a freedom of information request, it would not be there.

The correspondence shows there is a tension of sorts between the Department and the HSE. It arises from the fact the HSE has stated clearly it cannot fulfil the delivery of services. We also see the Department having a hand in trying to change the language the HSE uses. I found that quite disturbing. If the HSE brings a problem to the attention of the Department, the Department should be trying to work with it to address it, not trying to get the HSE to reframe the problem to ensure it does not look like such a significant issue.

Deputy Kelleher rightly identified the fact we had a significant number of people on hospital trolleys in January. I pointed out that one of the contributing factors was the decision to reduce hospital beds. That is why we are going to put in more hospital beds. We already have opened 170 and we will open 300 this year. I expect the capacity review will be funded through the capital plan process.

I do not believe the debate about health care can always be just about money. If it were, then the problems in the health service would have been fixed many years ago. The idea that the answer to every challenge in the health service is to write another cheque misses the point. It has to be about value for money also. I know Deputy Kelleher accepts there are ways of getting better value for money for the taxpayer through savings in procurement, the use of supplies and corporate costs. These are used in other health services, such as the National Health Service, NHS. Members say they want to create a NHS-type system. This is the norm in many of the health services Members would like to create here.

Just to disagree with Deputy O'Reilly in case she gets too carried away, nobody suggested everything is going to be achieved in the value for money programme through saving money on travel. It is one of several elements through which one can make savings at corporate level. She knows this from her long time around the health sector. One can save money through procurement and supplies. One can save money in the same way any business or public service does without impacting on services.

I asked the Minister for the targets but there are none.

The HSE made it clear yesterday that it will put in place a value improvement programme. We are asking people to find value for money in the context of not cutting but dramatically increasing their budgets. The health budget has increased by €1.4 billion since I became Minister. The health budget will continue to increase year-on-year. That has to be matched-----

Yet trolley numbers are increasing too.

That has to be matched by reform.

Why does Deputy O'Reilly never comment on 479,000 people missing outpatient appointments? Why does she never comment on the fact that inpatient day-case lists have gone down for five of the past six months? There are good things happening in our health service too.

I do comment on those positive developments.

Eating Disorders

James Browne

Ceist:

3. Deputy James Browne asked the Minister for Health if he is satisfied with the level of mental health supports in place for persons with eating disorders; and if he will make a statement on the matter. [6587/18]

An individual who has concerns about eating disorders should attend his or her general practitioner, GP, in the first instance for primary care screening assessment and examination. The GP may then make recommendations, which may include referral to the secondary care mental health services for full eating disorder assessment.

Nationally, outpatient mental health services for adults presenting with eating disorders are provided by the general adult mental health teams. Similarly, children and adolescents with eating disorders are treated by the child and adolescent mental health service, CAMHS, teams. Specialist training in the treatment of eating disorders has been provided to clinicians within those teams as part of the national clinical programme in eating disorders.

Although most people with eating disorders do not require inpatient care, where an individual's needs are more acute, inpatient admission may be required following the recommendation of the consultant psychiatrist or physician. When the risk is primarily physical and the person is in need of physical safety monitoring while re-feeding, admission will be to a HSE acute hospital under the care of a physician or paediatrician. Currently, there are specialist eating disorder services for adults, including inpatient bed provision, at St. Vincent's University Hospital in Dublin, and for children and young people at Linn Dara services also in Dublin.

The HSE is currently developing a clinical programme in eating disorders. The HSE recognises that, although eating disorders are managed and treated by existing mental health services, these services may need support, particularly with high risk, severe and complex presentations. The clinical programme will help to develop greater capacity to manage people with eating disorders in the community to reduce the likelihood of acute hospital treatment.

As part of this programme, a collaborative model of care was formally launched in January 2018. This includes a stepped model of care delivery, a specialist training programme for existing outpatient mental health services, a new dedicated national eating disorder network, specialised inpatient eating disorder programmes within key existing psychiatric units nationally, and additional levels of care provided by the dedicated eating disorder network teams.

When this new collaborative model of care is implemented, there will be a national network of specialist eating disorder community team-based services and access to an enhanced level of special treatment beds. New clinical posts are being developed as part of this clinical programme. Recruitment for these posts will be advanced in 2018.

The Minister of State set out a wonderful theory of what is meant to happen in mental health services where one can go to a GP and be referred on to CAMHS. However, the waiting lists to see a psychiatrist, psychologist or dietician in CAMHS in some areas are so bad, the service may as well not exist. The Minister of State referred to Linn Dara. It was shut down for several months last year because of staffing problems. I read the new recommendations for the stepped model of care delivery. While it reads fantastically, where will the Government get the staff for it? The Minister of State spoke about providing more mental health teams when the majority are underpopulated, some significantly so.

Under the current model, there are 500 mental health nursing vacancies. From where will we fill those? Right now, 867 staff are eligible to retire and a further 885 will be eligible to retire within the next five years.

Plans and theories are great but, in practice, people are not getting the help they need with eating disorders. The rate of eating disorders is exploding. Practical solutions are needed.

I accept what the Deputy is saying. Of our population, 5% will suffer from eating disorders. That is a large cohort. Anorexia nervosa has the highest mortality rate of any mental health issue, with a figure of 10% attributed to it.

The Deputy referred to staffing challenges. I am acutely aware of them. More than 2,000 posts in mental health services have been approved since 2012, but we have only been able to fill 1,300 of those. It is not a question of resources or money. The Government can only control so many factors. We must examine a new way of working. For that reason, I have asked the HSE to explore the avenue of teletechnology and telepsych, through which we can deliver mental health services online and in new ways. A consultant psychiatrist does not need to go to every crossroads and spend half the day travelling. Mental health is one of those areas in which we can be imaginative and more creative. We can examine ways of doing that. Among others, this is one of the initiatives that I am pursuing with the HSE to try to deal with the recruitment issue. I am confident that we will make progress.

I understand that there is pressure regarding the child and adolescent mental health services, CAMHS, waiting teams, but 114 assistant psychologists have been recruited. We must introduce a lower level of intervention. Not everyone who attends a GP with a mental health issue needs to be referred to a consultant psychiatrist. That has been the practice for years, but it is not necessary. We are in the process of building a lower level of intervention that will deal with many of these issues.

Some 34% of mental health nurses are either eligible to retire now or within five years. By last August, 93 additional mental health nursing posts were filled. The issue is not being tackled. There are consistent criticisms from judges, in particular High Court judges. Anyone with a serious eating disorder is being made to travel to the UK, which has a further impact on people's mental health issues. Families must travel over just to see them. The President of the High Court, Mr. Justice Peter Kelly, has highlighted an oncoming issue arising from Brexit. All of the enforcement of children getting treatment in the UK - there must be two enforcement orders, one from the Irish High Court and a complementary one in the UK - is implemented under EU regulations and legislation, which could fall away. It will be a major crisis. As Mr. Justice Kelly pointed out, this issue is growing so quickly that it must now be financially, if not morally, viable - it was always moral - to provide these services in this country. We cannot keep exporting the treatment of vulnerable people to the UK. They need their treatments to be available in this country.

If we enhance community supports and services as well as increase and make more widely available lower level supports, we can prevent many of these cases escalating to the acute level. For too long, too much of the debate and focus has been on the extreme end of mental health. We need to build a community base, give assistant psychologists and therapists an increased role and deal with these issues as they emerge rather than after they have moved to being acute. Putting all of the focus on the acute end and building with that in mind is not the solution. We must reorient our direction and planning towards community supports and community teams, which is the policy that we are pursuing.

Before we move to Question No. 4, there are six and a half minutes for each question - 30 seconds for a Deputy to introduce, two minutes for a Minister to reply and then four minutes overall for a supplementary discussion between the Minister and the Deputy. While I was in the Chair yesterday, I allowed a run-over on a number of questions, which meant that, although we should have been taking at least 13 or 14 questions, we took two fewer. In fairness to Deputies' colleagues, who often sit in the Chamber for quite a while only to not be able to have their questions answered, I appeal to everyone to obey these rules as best as possible. I never like to inhibit debate because doing that would not be a good thing, but if Members remember the time slots, I will be fair to everyone.

Hospital Services

Michael Lowry

Ceist:

4. Deputy Michael Lowry asked the Minister for Health the specific services that will be provided under the new schedule with particular reference to the day hospital, diagnostics, community care and minor injuries units further to his commitment to fully reopen Our Lady's hospital, Cashel; and the timeframe involved in bringing the accommodation and facilities at the hospital back into full use. [6472/18]

I appreciated the Minister's commitment on a visit to Cashel to reopen Our Lady's County and Surgical Hospital.

I thank the Deputy for asking this important question and for consistently raising the issue of how we can better use Our Lady's hospital in Cashel to support the care needs of people in Tipperary while also working hand in glove with what is being done in Clonmel. I am pleased that we are making progress on the modular build in Clonmel. The next phase must determine what more can be done in Cashel. If we can get the investment in Clonmel with its extra 40-bed modular unit right, consider how to build a permanent extension to that hospital and then complement that by providing more services in Cashel that would alleviate pressure on Clonmel, we can make a meaningful difference to health services for the people of Tipperary. This is something for which Deputy Lowry has been advocating for some time.

With the Deputy and other Oireachtas colleagues, I visited Our Lady's hospital in Cashel on 13 September last year. It was clear that there was considerable potential to provide additional services that could benefit not only that community, but also Clonmel by alleviating pressure in its hospital. The campus in Cashel provides a wide range of services, from those operating on a 24-7 basis to those that use the campus as a base to provide care in peoples' homes. Community services play a significant role in supporting older adults living at home and those who have been discharged from hospital with ongoing non-acute care needs, and also in preventing admissions to hospital in the first place.

HSE social care works closely with its colleagues in South Tipperary General Hospital to facilitate hospital discharges as appropriate. In terms of getting people home, many of these services are based in Cashel.

As a result of my visit with Deputy Lowry to Cashel, I allocated €450,000 for this year to develop community services for older people in south Tipperary further. That money is in addition to funding that I have provided for a 40-bed modular extension to South Tipperary General Hospital. With this additional funding, the HSE at local level is working on a plan to deliver a further range of services in Cashel to support older people in the south Tipperary area. I will provide the Deputy with more details in a moment.

I thank the Minister. He will have that opportunity.

A task force is working within the HSE against the background of three empty wards in the hospital. That unit is capable of holding 35 beds. It has been refurbished at a cost to the HSE of approximately €13 million, but it is unoccupied. This is happening in Cashel when, down the road in Clonmel, there are trolleys in a corridor. It does not make sense that we are not maximising the potential of this vacant unit.

I appreciate that the Minister had been helpful and has taken practical steps with funding to alleviate the problems with our health services in Clonmel and Cashel, but what types and levels of service will be provided by the community hospital at Our Lady's hospital? Will the Minister be specific as regards what he intends to do with the hospital?

Absolutely. A number of services are being provided there in the form of the minor injuries unit, community intervention teams, primary care teams, community mental health services, disability services, outreach services provided by the Irish Wheelchair Association, a substance misuse team, home care services, acquired brain injury services, catering for the St. Patrick's Hospital campus, which is across the road, and a 24-7 ambulance station.

Now that I have supplied the funding, I have asked the HSE to identify what further services can be provided locally utilising the empty space in Cashel to alleviate pressure in Clonmel and provide greater services in Tipperary. The HSE is specifically considering services for older people as well as rehabilitative services. It tells me that it is drawing up a plan to develop a further range of services to support older people and that the overall model will be discussed in collaboration with relevant stakeholders locally, in which respect I will ask the HSE to liaise with the Deputy. In particular, it is considering the expansion of rehabilitation programmes. If more such programmes can be run in Cashel, people can be discharged from Clonmel earlier. With the 40 beds that we are putting into Clonmel plus those services in Cashel, we can make a real difference.

I agree with the Minister's approach. I understand that whatever services we provide in Cashel will help to alleviate the pressure on Clonmel hospital. It is important there would be a high level of liaison and co-operation between South Tipperary General Hospital and Our Lady's Hospital in Cashel. We are all anxious to know in what way and to what extent will the newly established services at Our Lady's Hospital relieve pressure on South Tipperary General Hospital.

What is the current position regarding the modular unit? I know it is in the tendering process and significant progress has been made. What is the up to date position on the provision of that unit?

The Deputy is right. When I went to Cashel I was annoyed to see the potential that there is in that facility is not being fully utilised when there is clear pressure on South Tipperary General Hospital. Therefore, we need joined-up thinking. As a result of working with the Deputy and others, I have asked the HSE to look at Cashel and Clonmel hospitals together to see what services can most appropriately be provided there. The key area it is examining is rehabilitation and services for our older people. We do not want older people in particular to be in a busy acute hospital if we can provide services for them in a more comfortable and appropriate environment.

I will get the Deputy a specific update as to exactly where the modular unit is at. I am very clear on this. We have provided significant funding for the delivery of this unit. I know people, including the consultants and management in the hospital, have been working very hard. I want and need this unit delivered for the people of south Tipperary to ensure those 40 beds are in place well in advance of next winter, which would alleviate the pressure on the hospital. I will keep in touch with the Deputy on that.

National Maternity Hospital

Róisín Shortall

Ceist:

5. Deputy Róisín Shortall asked the Minister for Health the details of the draft framework agreement on the future ownership of the new national maternity hospital; if the new hospital will remain in public ownership; if he will bring before Dáil Éireann details of the proposal prior to the final legal agreement being signed; and if he will make a statement on the matter. [6588/18]

At the end of August the Minister stated that his Department was finalising an agreement with St. Vincent's Hospital and Holles Street hospital under which the new national maternity hospital would remain in full public ownership. However, as of last month discussions on the legal framework were still ongoing. Will the Minister recommit today to ensuring that the hospital will remain in full public ownership? Will he update the House on the progress of the talks?

I thank the Deputy for raising this issue, which I know she has consistently raised. I will recommit to those two issues. I want to assure the Deputy that we are making progress on the draft legal framework. We have involved the Chief State Solicitor's office on that to make sure it is as robust as we would all want it to be from the State's point of view. That will ensure the State's significant investment in a new maternity hospital, which is so badly needed, will be protected. While completion of the detailed legal agreement will require some further engagement between both hospitals, the HSE and my Department, I can confirm there is a broad understanding and agreement on the way forward. That will protect the State's resources in investing in this important project and it will also further underpin the operational independence of the maternity hospital; it is envisaged that the new hospital building will remain in State ownership. I know that is something people have been seeking.

My Department undertook to develop the initial draft legal framework and this work, which has proved highly complex, is nearing completion. The Deputy will, I hope, appreciate that pending its finalisation it is premature for me to give too much further information. However, I intend to brief Government once the agreement has been finalised and I will happily share the agreement with the Deputy, the House and the appropriate Oireachtas committee having regard to whatever the Oireachtas considers is appropriate in due course.

In terms of the project, I would like to reiterate my commitment and the Government's commitment to the development of a new maternity hospital on the St. Vincent's campus. This is vital for women and babies in Ireland in terms of the co-location of a maternity hospital with an acute adult hospital. It will represent the flagship project of the national maternity strategy and constitute the largest single investment ever made in maternity services, which makes the case for the Deputy's point in terms of how important it is that we get the legal framework right. The new development will cater for up to 10,000 births per annum and include state-of-the-art obstetrics, neonatal and gynaecology care facilities. Following the granting of planning permission, which thankfully has now happened, the design team is continuing to work on the detailed design of the hospital and the preparation of tender documents. As I have made clear, the agreement needs to be finalised and brought to Government before any of that progresses.

We are all conscious of the fact that when it emerged last year that the new hospital building would be in effect gifted to a private interest, there was an understandable public outcry. The Minister's commitment last August to State ownership went some way to alleviating public concerns about that. However, the language he used in his statement was and still is to some extent concerning. He referred to the building on a number of occasions but never to the site. He replied to a parliamentary question in recent times and he has been quite vague about this. We need to know what legal arrangements will be put in place in regard to the site. Does the Minister expect it to be a lien, a licence a lease or some other arrangement? Will financial commitments be made to secure the use of this site and what will they be? Will the Minister commit to return to the Dáil with details of the proposal prior to any legal agreement being signed?

The Deputy is correct in that there was significant public concern regarding this situation, which I heard loudly and clearly. That told us that while we have invested significant resources in the past in facilities that we have not necessarily owned, the public want that to change now. That is why I have set up a group chaired by Dr. Catherine Day and including Professor Jane Grimson and Professor Deirdre Madden to examine the relationship between the voluntary and the public health service. I am very pleased they are doing that good body of work.

I am not endeavouring to be vague, I am just endeavouring to be careful because of the fact that the legal agreement is pending finalisation. The Deputy will be well aware that often we could see a lease or a licence of a site granted at a nominal or peppercorn rent. We could see a lien put in place, which is the normal course of action, to protect the State's investment. The issue that was very clear, which I believe the Deputy raised, among many others, was on whose balance sheet would the asset sit. I am being very clear in saying the asset will sit on the State's balance sheet. That is what I want the agreement to be.

In terms of sequencing, I am more than happy to have this issue debated in the Dáil. The approval process is one for myself and specifically for the HSE, but I will brief Government also before there is any further progress.

I thank the Minister for that information. He mentioned a lien and certainly Nicholas Kearns said last year that a ministerial lien would be the approach that would be taken and an undertaking was given on that. If it is to be a lien, will the Minister require the approval of the Bank of Ireland to agree such a lien, given that the land and much of the property is mortgaged to Bank of Ireland? Is that an issue currently and is it holding up matters? Will the Minister assure us that no final decision on this agreement will be taken without bringing the proposal back to the Dáil, as substantial public money is involved? While other means have been talked about in terms of a licence or a lease, these would not give the type of protection that the public would demand. It is a lien that is expected. Can the Minister clarify exactly what the position is about the role of the bank in all of this?

I have no knowledge, nor has any issue been brought to my attention, that an issue relating to any bank is causing any delay. I have been told that there has been very constructive and intensive engagement, which has moved this situation significantly in terms of an agreement, in principle, that the building and ownership of the new national maternity hospital would remain in State ownership. That is quite significant. I will happily brief the Dáil but every capital project, and there are many significant ones, does not come to the Dáil for approval, but I am very aware of the sensitivities of this and I am more than happy to have the Oireachtas health committee or the appropriate committee briefed on this issue at the appropriate time. Very good progress is being made. We have planning permission for this flagship project. I will make sure that the asset, the hospital, remains in State ownership, in public ownership. The legalities in terms of how we utilise the site at St. Vincent's will be spelt out in the agreement. It would be premature of me to say anything further but I have given indications of how this has been done in other areas by way of leases or licences with nominal rents and I will certainly keep the House-----

It will be a lien - is the Minister confirming that?

No, I am not confirming that. I am saying that it is being finalised. I will brief the Deputy. I have used examples of how it is used. I do not wish to say anything on the floor of the Dáil to jeopardise this project and I am trying to provide the Deputy with as much information as possible.

The Minister's own statement was that it would be a lien.

I expect it will be.

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