Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 26 Nov 2019

Vol. 990 No. 1

Thirty-ninth Amendment of the Constitution (Right to Health) Bill 2019: Second Stage [Private Members]


"Go léifear an Bille an Dara hUair anois."

I move:

"That the Bill be now read a Second Time."

At the outset I would like to thank my office and in particular my Institute of Public Administration intern, Mr. Manfred Lau, for his excellent research assistance in drafting this legislation and accompanying materials and Dr. Charles Larkin, my policy advisor. The purpose of the Thirty-ninth Amendment of the Constitution (Right to Health) Bill 2019 is to insert a new subsection into Article 40 of our Constitution. This is a bold, ambitious and progressive proposal which challenges current thinking on health provision and places a right to health protection in our Constitution. It proposes to insert a new subsection, 40.3.4° into the Constitution as follows:

i. The State recognises the equal right of every citizen to the highest attainable standard of health protection; and the State shall endeavour to achieve the progressive realisation of this right.

ii. The State shall endeavour, within its available resources, to guarantee affordable access to medical products, services, and facilities appropriate to defend the health of the individual.

iii. The health of the public being, however, both individual and collective, the State shall give due regard to any health interests which serve the needs of the common good.

The purpose of this Bill is to give constitutional status to every citizen's right to health. It places an obligation on the State to realise this right progressively within its available resources and it gives equal priority to individual and population health needs. It puts a legal obligation on the State to be transparent in decision making and emphasises the principles of reasonableness and proportionality in any legal judgments. This Bill does not introduce any revolutionary ideas on health. It only reflects how we as a society and as a Government have come to acknowledge the superior benefits of universal access to health services. It is clear that the means test system is plagued with critical faults including unacceptable waiting times, weak Government accountability, no consensus on funding and neglected community and local care among many other issues. These faults were identified by the Oireachtas Committee on the Future of Healthcare, which published a report in 2017 detailing a strategic plan to reform the health system. Out of that plan arose Sláintecare which aims to give new life to Ireland's health system by instituting a universal, single-tier health and social care system where everyone has equal access to services based on need and not ability to pay. Sláintecare expresses the universal aspiration to enjoy access to affordable, high quality health services.

Health is an internationally recognised human right. Two thirds of global constitutions contain some form of provision for health. Without good health, our citizens cannot participate in Ireland's democratic institutions. Without good health, they cannot exercise the right to vote, to assemble, to worship, or the right to free expression; nor can they fully enjoy the rights and merits granted by the family, by education, or by private property. The State has as much of a duty to protect the health of the public as it does to protect other fundamental rights enshrined in Bunreacht na hÉireann. This Government has clearly voiced its agreement with the goals of Sláintecare. Ireland prides itself on being an international leader when it comes to the UN and EU sustainable development goals, including goal No. 3, which aims to ensure healthy lives and promote well-being for all at every age. Yet in the domestic setting there exists no fundamental, constitutional protection for the right to health. Health inequality is detrimental to well-being and can be a killer when inequality is extreme. The symptoms of this lacuna are manifested in the obstructed development of health policies. While the efforts of the Dáil and of Government in this area are commendable, difficult issues persist. Hospital waiting times remain at an all time high. There is a lack of bed capacity for acute care and soon the same will apply to elective care. Many permanent consultant posts and nursing posts lie vacant and the exodus of our health professionals continues unchecked. Sláintecare has been subject to a painfully slow process of implementation. Moreover, the budget forwarded by the Government in October failed to reach the necessary scale to implement Sláintecare's long-term changes. These criticisms do not prove that the Department of Health is not committed to the goals of Sláintecare but they do demonstrate that we have a long way to go before those goals are realised. There is always the concern that the State will simply sit on its promise to the public to deliver substantial and fundamental health reform and not do so. This Bill goes back to that promise and gives expression to national sentiment. It endorses the needs of the public and upholds the obligations of the State. In jurisdictions such as India and South Africa it has paved the way for health reform via the courts and the legislature by being framed as both a policy anchor and a legal right.

As a policy anchor, it generates new legislative initiatives. As a legal right, it protects the needs of individuals. Constitutionalisation of the right to health works beyond the domain of the courthouse by acting as a driver for institutional reform and new health policy. A legal right grants a legal foothold from which reform can issue.

I will clarify several aspects of the language of this Bill. It states that every citizen has an equal right to the highest attainable standards of health protection, rather than healthcare or health. We believe health protection is a more specific term than good health, and is a more inclusive construct than healthcare. The right to health protection is institutional, structural, societal and corporate. It cannot guarantee good health in and of itself, but encompasses interventions including healthcare and the environment in which good health is promoted. In everyday usage, it may be referred to as "the right to health", but these distinctions are crucial in delineating the legal scope of the proposed provision. This Bill also acknowledges that public health is both individual and collective. This means that collective health is not merely an aggregate of individual health factors, such as the total number of illnesses or injuries. While those are a part of the picture, public health represents more than that, including mental well-being, a work-life balance, clean air and water, sexual health promotion, a balanced diet, and traffic safety. It may not be the responsibility of the State to oversee each of these elements with the same dedication as with individual health interests, but the State must give them due regard insofar as they impact the common good.

An obvious benefit of this Bill is the ability to challenge State action or failure to act on to the right to health via the courts. This Bill is intended to be fully cognisable by the courts. It is modelled after the South African constitutional provision and the provision in the United Nations' International Covenant on Economic, Social and Cultural Rights, to which Ireland is a signatory. The South African court found its own reasonable standard of jurisprudence for the right to health, by which it was able to protect and enforce women's and children's access to antiretroviral treatments in at least one case. This decision spearheaded social movements to address and treat the country's massive HIV and AIDS crisis. It is hoped that Ireland's courts can come to similar health protection resolutions if this amendment to the Constitution is passed.

It has been suggested the constitutionalisation of a right to health would only lead to unrestrained litigation. In other words, individuals would sue the State over personal health claims, expecting courts to grant immediate relief, the waiting lists would simply transfer from the hospital to the courtroom, and nothing would be resolved. I respond to that claim by highlighting the deliberate language of this Bill, which states: "the State shall endeavour to achieve the progressive realisation of this right". It further states: "the State shall endeavour, within its available resources, to guarantee affordable access" to healthcare. The first condition of progressive realisation acknowledges the practical limitations to fulfilling a universal right to health, which is in practice already a goal of this Government. Nobody is made instantaneously healthy because a hundred words have been tacked on to an 80 year old document. While not instantaneous, the right to health will be realised with progression over time. It is not an excuse to drag one's political feet, but an immediate obligation to constant improvement by all means. The second condition, which stipulates that the State must work "within available resources", achieves a similar effect. It is already acknowledged that the health system is in need of expansion, and that a run on the courts would only drive it into further deficit. Therefore, this Bill would place public health protection high among the budgetary priorities of the State, such that its available resources are sufficient for significant progress, year by year, in the protection of public health.

A constitutional right to health is not just another avenue for litigation; it is also a key tool for public policy and for redirecting the political conversation. When an initiative such as Sláintecare is backed by a constitutional mandate, there are no more excuses for delays or negligence. The priorities remain the same even with a change of Government. Armed with this amendment to the Constitution, we can ask what is being done to fulfil the constitutional mandate, whether Sláintecare is on track to deliver by 2029, and what more we can do to progressively realise our State's duty. Litigation is not always necessary to instigate change. It is only when the failure of the State has reached a point of disproportionality and irrationality, and when the political process has failed the people, that the people have every right to take their adversity to the courts and bring the Government to account.

The right to "the highest attainable standard of health protection" is a fundamental and personal right. Decades have shown that a two-tier health system, based on one's ability to pay, is not equitable and does not work. The arguments behind the Constitution's lack of a right to health are not as compelling today as they were in past decades. This Bill does not violate the separation of powers. Separation of powers only has its basis in the Constitution, the same as any legal or political doctrine, and the preamble of the Constitution clearly aspires to attain true social order and champion the Christian values of justice and charity. Therefore, a constitutionally informed interpretation of the separation of powers understands that the Judiciary also has a role in protecting certain socioeconomic rights, such as the right to health. The Constitution has made explicit one other socioeconomic right, namely, the right to free primary education for children.

The right to health establishes accountability for State actions, gives a political and democratic voice to the marginalised, and preserves a crucial value of our State's fundamental law. When it becomes apparent that Bunreacht na hÉireann is lacking a fundamental provision, its amendment process provides a way to affirm the nation's foundational political and social values. The right to health belongs among our highly cherished fundamental and personal rights, and I expect that if this amendment proceeds to referendum, the public will voice their agreement with it. I look forward to a positive debate on this Bill.

I am happy to have the opportunity to speak on this Bill. The right to health is a fundamental human right. According to the World Health Organization, health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity. For the last number of years the health service has been in crisis. People are waiting long periods of time to be seen by consultants and outpatient clinics while their conditions worsen. Elective surgeries are being cancelled because of excessively long waiting lists and overcrowding in accident and emergency departments. In County Cork, overnight accident and emergency departments were closed in Bantry and Mallow as part of the reconfiguration of services. This left many people concerned that Cork city did not have the necessary additional capacity, and it is now clear that Cork city's hospitals are unable to handle these extra numbers. People say that hindsight is 20:20, but the cows in the field could have told the Minister that those closures would lead to such a situation. Counties Cork and Limerick have the longest waiting times in the country, and the numbers of people waiting on trolleys recently are record breaking. This is not good enough. I have no doubt that these waiting times have caused the deaths of many vulnerable people.

People throughout west Cork, from Mizen Head, Bantry, Castletownbere and all areas in between must wait a ludicrous amount of time for ambulance services to Cork University Hospital, CUH. When they get there, the ambulance service team have to wait to admit them because of the overcrowding in accident and emergency departments. The ambulance services then fail to meet the turnaround times recommended by HIQA and the HSE. This in turn causes even longer waiting times for people relying on the ambulance services. These problems are not caused by the hardworking staff, who are being worked into the ground because this Government is making no real effort to improve their situation. Nurses and midwives are the lowest-paid graduate professionals in our health services, which is not acceptable. It is no wonder that the health service has difficulty recruiting and retaining nurses. People are leaving the country in droves and are looking to improve their standard of living by travelling to Northern Ireland, Wales or the Continent.

I have taken 47 buses to Belfast with Deputy Danny Healy-Rae and people availing of medical procedures such as cataract, hip and knee operations there. I will be booking another five or six trips in the next few weeks because the demand is so high. It is unfortunate that these 15-minute procedures cannot be carried out in Bantry, Mallow, or anywhere else in County Cork.

People are being left to go blind on the Minister's watch. I invite him to accompany us on one of those trips. He will see first hand how people are suffering because they cannot access a 15-minute procedure in their own county. It is very sad. The Government has turned its back on those people, but Ministers are congratulating each other on the expensive hole in the ground which they are funding.

I welcome the introduction of Sláintecare but it is not working on the ground. The lack of community care, as evidenced by the embargo on new home help hours and the scarcity of step-down facilities, has led to many people remaining in acute hospitals for excessive periods even when medically fit for discharge. This, in turn, is causing significant overcrowding in emergency departments.

Ireland has an ageing population. The increasing proportion of elderly and dependent people, particularly in rural Ireland, will lead to greater demand for home help hours. How can we expect to meet future demand for home help hours when we cannot meet current demand? Demand is projected to increase by between 38% and 54% by 2030. The Government needs to look at providing better home care arrangements. It must do so now rather than wait until the crisis worsens.

Carers provide more than 6.5 million hours of care per week in Ireland. On average, they care for their loved ones for almost the equivalent of a 40-hour working week. Almost 9% of them provide full-time, 24-hour unpaid care without a break. Many must wait months from the time of their application for payment. That is outrageous. Many carers give up employment to care for a loved one, yet they are expected to survive without money until their payments finally come through. In some cases, the payment never comes through.

The area of mental health has been neglected and is in crisis. We need to address it urgently. The Mental Health Commission has declared that without investment and major change the level of care provided to vulnerable and distressed individuals will continue to be unsafe and substandard. The Government needs to address this situation at a grassroots level by appointing mental health advisers to support the implementation of a nationwide programme in primary and secondary schools on mental health promotion and well-being. There is an ongoing problem in this area. The lack of out-of-hours and inpatient services means that children are being admitted to adult mental health facilities, which is unacceptable and cannot be justified. I am particularly concerned by the waiting times for children and adults to see a consultant. These people and their families are distraught about the amount of time they must wait for a referral. Emergency response times to child and adolescent mental health issues should not be greater than 72 hours. We need 24-7 access to mental health services. Mental health issues do not take place on a 9 a.m. to 5 p.m. schedule. The current services are totally inadequate. The Government needs to fully realise its commitments and adequately invest to improve the mental health of adults and children and to look after the people working in this area.

The Government has let down people with intellectual disabilities in respect of waiting times for assessments and delivery of services. Some children are waiting up to a year and a half or more for an initial assessment and may have to wait another six months for the service to be delivered. Under the Disability Act, children born after 2002 have a statutory entitlement to an assessment of their needs within a six-month period. The Government is failing in its duty to these children under the Act. When children with intellectual disabilities turn 18, their transport to training facilities is withdrawn and they are given a free travel pass. However, many of them are incapable of using these travel services unaccompanied due to their disability. As a result, their parents or carers must drive them many miles to a training centre, which puts a huge burden on families.

There are waiting lists of up to two years for a child with autism to be assessed. There are no supports such as speech and language therapy for those awaiting an assessment.

The Government and previous Fine Gael and Labour Party Governments have presided over a shocking devaluation in our health service. I call on the Government to provide a legal right to health within the Constitution in order to protect our most vulnerable people.

I move amendment No. 1:

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

Dáil Éireann declines to give the Thirty-ninth Amendment of the Constitution (Right to Health) Bill 2019 a second reading in order to further consider the issues raised in the Bill, to allow for the supporting structures already in place around improving access to healthcare due time for implementation, noting the priorities set out in the Sláintecare implementation plan and the need to adequately and appropriately plan the move from the current system of limited eligibility to universal access, having regard to existing and prospective resources, workforce planning and service delivery arrangements; and noting that the Sláintecare Programme Implementation Office have a dedicated eligibility and entitlement programme of work, that the Bill would be considered as part of this work, that this consideration would include the recommendations of the constitutional convention on economic and social rights, and that they would report on this within 6 months to the Joint Oireachtas Committee.”

Before I address the Bill, I wish to correct certain remarks. Deputy Collins referred to the national children's hospital as a hole in the ground. That is not the case. Some 1,060 children have already received outpatient appointments at the first part of the hospital. Rather than invite me to Northern Ireland, he should accompany me to the site at St. James's Hospital to see what he referred to as a hole in the ground.

I will go with the Minister.

The ignorance of referring to it as a hole in the ground is breathtaking.

If the Minister comes with me to Northern Ireland he will see where the ignorance really lies.

I seek the protection of the Acting Chair.

He is goading us.

The Deputies should try to resist.

Deputy Collins referred to a definition provided by the World Health Organization, WHO. I am sure he and certain of his colleagues also understand its position on women's reproductive rights and the right to choose.


The Deputies should allow the Minister to speak.

I am allowed to comment politically in the House as I wish.

I am grateful for the opportunity to speak on the Bill. I very much appreciate Deputy Harty's intention in bringing it forward. I fully accept his bona fides and I share his ambition, as do all Members, to bring about universal healthcare through Sláintecare. I wish to make clear to the Deputy and the House that I have an open mind regarding the embedding of economic and social rights in the Constitution. Any comments I make in my contribution, even those critical of the wording of the Bill, are intended to be constructive and advance this debate because through the Bill, Deputy Harty is challenging us to consider whether we should ask the people of Ireland to insert these rights, whatever the wording may be, in Bunreacht na hÉireann. We need to carry out a significant body of work to arrive at the answer to that question. I am willing to engage constructively and keep an open mind on the matter.

New politics and the make-up of this Dáil is often criticised in the media and political discourse. One of the big successes of new politics and the minority Government has been that all sides of the House worked together on the Sláintecare report. Deputy Harty was a member of the committee and played an invaluable role on it. We now have a joint unified vision of the type of health service we wish to create. That vision is not mine or Deputy Harty's but, rather, is owned by us all. There has never previously been universal agreement in the Oireachtas on the direction in which we should travel. There will be more talk about universal health insurance or the model changing if the Minister changes. Rather, we share one vision.

I very much respect the motivation behind the Bill but I am advised that it requires serious consideration. That is no fault of the Deputy. The Bill was published last week and happens to have moved to Second Stage this week. In light of the significant impacts it could have on the State if ample time is not given to genuinely reflect on its provision, I have tabled a reasoned amendment which I discussed with the Deputy. It seeks to postpone the Bill for six months, during which time the Sláintecare implementation office of my Department which is considering the issues of eligibility and entitlement will consider the Bill in the context of its work. Consideration would also be given to the proposals of the Convention on the Constitution on this issue. Several NGOs, including Amnesty International, have put forward suggested wording. We would use the six months to consider all the issues and report back to the Joint Committee on Health, which is chaired by Deputy Harty. That would keep the issue alive and give a timeline to carry out what is a very significant amount of work. I hope the amendment will be accepted in that vein. No Deputy wishes to insert wording into our Constitution which could have unintended consequences. That is not the purpose of the Bill.

The Oireachtas Committee on the Future of Healthcare heard from diverse stakeholders and received many submissions before formulating its final recommendations. We now have its ten-year reform plan with unprecedented cross-party consensus and support for delivering a universal health service in Ireland. We should not forget that Sláintecare, to which we have committed, is a programme for reforming our health and social care services. Eligibility and entitlement, which are to the core of the Bill, formed a key part of the discussions and final recommendations. Although the Sláintecare report called for universal entitlement to a broad package of health and social care services, the committee recommended that this be achieved through primary legislation and acknowledged the need for phased implementation, with entitlement and waiting times being phased in over a period of five years. This approach recognises the need to build capacity in tandem with rolling out entitlement. Although there is wide-ranging agreement that Ireland should move in the direction of a universal-single-tier health service - God knows it is overdue - it is acknowledged that this goal presents several challenges and a significant amount of work. We need to give careful consideration to how we bring that about.

I am glad to highlight some of the work under way to achieve the Sláintecare vision of a universal-single-tier health and social care service where access is based on need, and not ability to pay. I hope the reforming agenda on which we are embarking is evidenced by our implementation plan, the new programme office, the reforms we have agreed with GPs and the publication of the de Buitléir report, which outlines that we wish to pay our consultants more and we wish for them to undertake public practice rather than private practice in public hospitals. I genuinely hope we are embarking on that agenda together and that it will continue through the lifetime of this Dáil and into the next.

In theory, a constitutional right to health sounds positive and I have no doubt it is intended as such. However, the scope and limitations of the right to health which the Bill sets out to guarantee have not been explicitly determined. I make these comments constructively and wish to put forward a few counterpoints. There is a lack of clarity on what an individual's right to health and healthy conditions would look like in practice. Although Deputy Harty has carried out a significant amount of research on developments in other jurisdictions, it is not as simple as transposing them into an Irish context.

I welcome and share the Deputy's overarching view of health under a banner of "health protection", which is intelligent wording. This would account for wider socio-economic factors and the importance of health promotion. We frequently talk about illness and its management, when the protection of someone is at the core of the right we want for all our citizens. However, we have a body of work to do for us to form a more coherent understanding of what a constitutional right to health protection would guarantee. In the absence of that, we could create problems down the road.

The Bill seeks to put only the right to health into the Constitution. Therefore, we would be making a conscious decision to elevate the right to health above other important social needs. When the Constitutional Convention and a number of NGOs looked at this, they took the view that we should insert a number of socio-economic rights into the Constitution-----

-----rather than inadvertently leading to a diversion of limited resources from other crucial areas.

In any informed debate we will need to consider, as I am sure the people would need to consider in the context of a referendum campaign, the profound impact putting any words into our Constitution can have on the workings of this place, on our democratic process. The proposed amendment would create unprecedented pressure on the effective separation of powers. I heard and note the Deputy's comments in this regard. We have a system of checks and balances which ensures power cannot be overly concentrated with the Legislature, Executive or Judiciary.

If the Deputy's proposed amendment was to be incorporated into the Constitution, the Government, the Oireachtas, and perhaps I, as Minister for Health, would give up responsibility for making decisions on how resources are allocated in the health sector. While Deputy Mattie McGrath might be happy with that-----

We could be asking but the Minister would be probably missing.

Rather than the Minister of the day, the Government of the day or the Oireachtas of the day, including Deputy Mattie McGrath, voting on a budget matter, we could run the risk of judges making decisions on how to allocate health resources. I am not saying I am fully convinced by all these arguments but I am putting them out to highlight the issues we need to tease through in any discussions we have. Any Government decision could easily be challenged in court. Our negotiating position on pricing with drugs companies could possibly be totally undermined with unknown resource implications. What other unforeseen repercussions could the Bill have for how we plan and deliver health services for people in Ireland?

We also need to adequately consider the complex issues that arise with the necessary revenue to provide for any ensuing expenditure. Any of the Deputies present could find himself or herself as Minister. Many Deputies have been Ministers in the past and others will be Ministers in the future. Of those present, I think only Deputy Kelly and I have been Ministers but I am looking into the future. This Bill would transfer to the Judiciary, which is unelected, the power to make decisions affecting the allocation of resources.

The proposed amendment creates the potential for significant diversions of resources into the handling of court cases, creating uncertainty about the state of the law while cases are processed. I believe our health service is better off when resources are allocated to essential health projects for the patients who rely on them.

I know Deputy Harty shares the view that a fundamental tenet of our democracy is that the people of Ireland have their voices heard on what their policy priorities are in each election, with our health service rightly being a key area of ongoing public attention. We remain accountable to the people. This amendment could compromise our power as elected officials to roll out health policy in a way that maximises the potential of the limited resources available.

In the interest of having an informed debate and moving this process forward, I want to put on record some of the views that could be articulated should this issue be taken further. We need to avoid any potential adverse and unintended consequences or rushing the Bill, which I know is not the Deputy's intention. We have seen this in the past. We do not want to put well-intentioned words into our Constitution only to find unintended consequences. Before embarking on any significant process of constitutional change, we need to tease out these issues.

Six months of hard work by my Department in the context of our Sláintecare implementation and our work on entitlement and eligibility, especially considering how this work dovetails with the good work of the Constitutional Convention in reporting to the Joint Committee on Health, would enable us to decide how best to proceed with this matter.

I acknowledge Deputy Harty's sincerity on this and the amount of work he and his team have done on it. I do not intend in any way to attempt to kill off this discussion tonight because it is a discussion our citizens want us to have. It is a very legitimate debate to have. However, I suggest we need to do some work to get this right and to report back to the Joint Committee on Health in six months. That is why I moved my reasoned amendment.

I compliment Deputy Harty on this Bill and his invaluable work as Chairman of the Joint Committee on Health. I welcome the opportunity to speak on the Bill.

Fianna Fáil's priority is to put in place permanent and sustainable improvements to our health service. For us the focus must be on what needs to be delivered and what is deliverable. We are committed to a strong public health service where the impact of public expenditure is optimised. We want quality services to be as close to people as possible and where all can benefit from new opportunities for improved care.

A public health system funded from taxation is more progressive as it ensures that healthcare can be prioritised for the most vulnerable and those who cannot afford to pay for their care. We accept the good intentions and motivations behind the Bill and given the current crisis that patients are enduring in our hospitals, it is understandable that people might wish to amend the Constitution. However, more debate is required and we accept the reasoned amendment put forward by Government.

Action, not constitutional amendments, is what is needed. We need investment, reform and real political commitment to ensure we have the health service that people deserve. The sentiments expressed in the wording of the proposed amendment are entirely in keeping with what Fianna Fáil believes we should be doing in health policy. We are committed as a party to the realisation of economic, social and cultural rights for all citizens in the State. We should all strive towards that goal. We recognise that many people are living at the margins of society due to poverty and social exclusion and that this has an impact on health outcomes. The failure of the Government to deliver on health provides a powerful argument for a constitutional amendment, for those failures are many and widespread.

The latest waiting list figures show that 178,320 have been waiting over a year for an outpatient appointment. Some 10,262 people had waited for more than a year on the inpatient day-case list in Irish hospitals last month. This contrasts sharply and very unfavourably with the National Health Service, NHS, in Britain where the waiting times for consultant-led treatment show 1,233 waiting more than 12 months.

A total of 13,466 people aged over 75 have waited on trolleys or on chairs in emergency departments across Ireland since the start of the year. The patient experience survey published yesterday showed that only 2,347 people, representing 30% of those who responded, reported waiting less than six hours in an emergency department before being admitted to a ward. The HSE recommends that the time spent in the emergency department should be less than six hours. The large majority, that is, 5,580 people, said that they waited more than six hours before being admitted. Of those, 331 people reported waiting 48 hours or more before they were admitted to a ward. Those 331 people sat on chairs or in beds on corridors for more than two days, which is shameful.

The pressure on the system in hospitals has resulted in a severe deterioration in ambulance turnaround times with paramedics being delayed in hospitals, preventing them from getting to new cases. The number of bed days lost so far in 2019 as a result of delayed discharges stood at 197,160 at the end of October. That is almost 200,000 bed days that could have been used to treat patients.

Figures issued by the Irish Nurses and Midwives Organisation show that for only the second time ever, the number of people on a trolley has surpassed 100,000. Frighteningly, this also includes almost 1,000 children. A total of 17,463 children are on a waiting list for hospital appointments. Shockingly, 30,600 of these boys and girls have been waiting for over a year.

On Monday, there were 85 people on trolleys in University Hospital Limerick, breaking the daily record, the highest figure ever recorded in an Irish hospital in a single day. This morning, it was reported that the country's three main children's hospitals have begun postponing elective procedures due to mounting pressure on the system ahead of the peak winter months.

With all this happening, it is entirely understandable that some would argue for constitutional change. However, at this juncture we do not regard this Bill, which would explicitly enshrine health rights in the Constitution, as the appropriate mechanism to address these issues. As Fianna Fáil has pointed out previously in this Chamber, Bunreacht na hÉireann, our 1937 Constitution, makes only limited reference to economic, social and cultural rights which are, by and large, referred to in Articles 40 to 44 of the Constitution. However, the courts have recognised that personal rights are not limited to those expressly set out or enumerated in the constitutional text.

Changing this to explicitly enshrine health rights in the Constitution is not the problem per se. The issue is how we define such rights and also the limits of such rights, while also having in place effective and efficient methods for the enforcement of those rights that this Bill would enshrine in the Constitution.

A fundamental issue that arose during the debates on this matter at the Constitutional Convention was whether enshrining socio-economic rights would mean handing over decisions on the allocation of Exchequer resources from the Oireachtas to the Judiciary.

This is a key question and requires further investigation. Another element would be the implications such a move would have for our court system. Would it result in a significant increase in the number of cases being taken against the State? What are the unintended consequences of enshrining such rights in the Constitution, including the financial burden that it could place on the State? Would it take responsibility for the allocation of resources from the Government and responsibility and power from the Oireachtas and, in particular, the Dáil for which people vote freely at election time? While laudable in principle, this Bill does not have specific definitions or clear proposals. Before such a change should be introduced, we need a thorough and careful analysis of what such a move would mean for the individual, society and the State as a whole. While economic, social and health rights should be viewed as more than an objective or noble ideal, the practicalities and consequences of embedding such rights in our Constitution cannot be discounted or neglected.

I compliment Deputy Harty on his work in bringing forward this Bill and I welcome the opportunity to speak on it. Fianna Fáil's priority is to put in place permanent and sustainable improvements to our health service. The focus for us must be on what needs to be delivered and what is deliverable. We are committed to a strong public health service where the impact of public expenditure is optimised. A public health system funded from taxation is more progressive as it ensures that healthcare can be prioritised for the most vulnerable and those who cannot afford to pay towards their care. As my colleague has just said, we accept the good intentions and motivation behind this Bill but we believe more debate is needed. We accept the reasoned amendment put forward by the Government.

According to new figures from the HSE, the number of bed days lost as a result of delayed discharges stood at a shocking 197,000 at the end of October. This calls for direct intervention. The figures are shocking and serve to support the calls my colleagues and I have been making about the urgent need for investment in step-down care and home supports. The monthly average has surged from 17,500 in the first three months of the year. As we all know, January, February and March are traditionally the worst months of the year in hospitals but the figure has surged to 19,700 per month. That the situation has deteriorated so badly over the spring and summer is very worrying and should act as a wake-up call. If the monthly average continues, 236,000 bed days will be lost in 2019, which would be an increase of almost 15% on last year. The numbers are truly shocking. At the centre of all of this are people - those who are being kept in hospital unnecessarily because the Government has failed to provide the supports needed to allow them to be cared for either at home or in their community.

A delayed discharge occurs when a patient deemed suitable for discharge from hospital by a doctor or consultant cannot be discharged because the step-down facilities are not available or are inadequate. This can involve the non-availability of home care supports, slow access to the fair deal scheme when approved or lack of community beds for respite care. The latest figures I have seen show 734 cases of delayed transfer of care. I accept some of these are complex cases and need specialised care that is not always available. However, more needs to be done. I was in University Hospital Waterford last Monday week where there were 21 cases of delayed discharge or delayed transfer of care. On the same day, 22 people were on trolleys. There is definitely a correlation between the number of people we cannot discharge from hospital in a timely manner and the number of people on trolleys. We need a centralised, co-ordinated approach to delayed discharges. Each hospital group should have a task force established specifically to identify where issues are occurring and to design a plan to ensure timely access of step-down care for these patients. We could vastly reduce overcrowding and the number of patients on trolleys if the Government got serious about and put a new focus on delayed discharges. While there is a system in place in the hospitals, if we got serious about delayed discharges, it would certainly help on the accident and emergency side. Older people want to be in their own homes with the correct wrap-around supports instead of languishing in a hospital bed simply because the correct step-down facilities are not available while hospitals and medical staff throughout the country struggle with continuous overcrowding and patients lying on trolleys, some for more than 24 hours. Planning for this winter should have begun much earlier in the year. We now have a plan that is only being rolled out in mid-November. I have grave concerns that despite the additional funding, the situation in our hospitals will get worse rather than better this winter.

We are facing a winter of discontent in respect of people waiting on home care supports. I received figures during the summer showing that the waiting list for home care supports was in excess of 7,300. The figures are enormously disappointing as they show the extent of the unmet need nationwide. The importance of home care supports cannot be underestimated. Without them, people are forced into lengthy stays in hospital despite being well enough to be discharged or moved into a nursing or retirement home. While the figures are deeply worrying, they are not surprising. Clear issues emerged over the summer with vulnerable people being unable to access home care supports. I accept that the budget for home care supports is substantial. The question that needs to be asked is whether we are getting value for money. Is the money following the patient? I stand open to correction but I understand that the budget for 2019 was €453 million, which is a substantial budget for home care supports. An increase of 1 million extra hours was announced in the budget for 2020. However, 100% of home care supports in Dublin are outsourced to private and voluntary providers. I received information that reveals high levels of outsourcing across all geographical areas, with 100% of home support hours in Dublin being outsourced. Unsurprisingly, demand for home support hours is high as more people are choosing to be cared for at home if the option is available to them. However, the HSE appears to be failing to cope. We already know that new applications have been restricted, which is a regressive and potentially detrimental measure, and now information supplied to me reveals that over half of all home support provision has been outsourced to private and voluntary providers. Private care can be more expensive than delivering the services through the HSE and these figures raise serious questions about value for money. The State already forks out hundreds of millions of euro a year on agency nursing and now it has emerged that the HSE has adopted a similar practice for home support hours. For example, in community healthcare organisation, CHO, area 5, which covers Waterford, where I live, and Cork, the figure is 26%. The figure in CHO area 4, which covers Donegal, is 19% while in CHO areas 6 and 9, the figure is 100%. I have the list here. The figures vary from 19%, which is the absolute best, all the way up to 100% in two areas. We are spending a huge amount of money. Are we getting value for money? Would it be worth looking at this to see whether it is the best value we can get and whether money follows the patient? We might then be able to do something about the 7,300 people who need supports.

Our population is living longer and we should be putting plans in place to cope with the demands that are coming down the tracks. As previous speakers stated, we need to shift to a more community-based healthcare service, as outlined in Sláintecare, rather than forcing people into hospitals and creating blockages in the system. Home support packages are a key requirement to ensure that people can stay in their homes for longer with the correct wrap-around supports.

I cannot talk about the right to health without mentioning the lack of cardiac care in the south east. Cardiac care at University Hospital Waterford, which serves 500,000 people in County Waterford and the south east, is time-restricted. The service is available from Monday to Friday between 9 a.m. and 5 p.m., with no service available outside these hours. I accept that, working with my Oireachtas colleagues in Waterford and the south east and the Minister, we have made progress and I am pleased that the planning application for the second permanent catheterisation laboratory was submitted at the end of November. We still have to go through several procurement stages and I hope to see the project completed within 18 months. This is only part of the problem because we also need a commitment from the Government to extend the hours to a 24-7 service. I understand that a minimum of seven consultants is necessary for this. We currently have four posts, with a fifth advertised. Access to cardiac care should not depend on where someone lives. When I stay in Dublin tonight, I can have access to a number of the 21 cath labs located in Dublin if I need it. However, if I need access in Waterford any night of the week, the only option available to me and many other people is to take an ambulance to Cork.

We know that all the hospitals are bursting at the seams. Once again, geography, postcode and address determine what care a person receives. This is simply wrong, unacceptable and should not happen. I am, therefore, happy to support Deputy Harty's Bill, which states: "The State recognises the equal right of every citizen to the highest attainable standard of health protection; and shall endeavour to achieve progressive realisation of this right."

I thank all healthcare workers, including nurses, doctors, consultants and all the auxiliary staff, who work in our hospitals and are tonight working hard while we are here speaking about the issue. Confidence in the health service is, unfortunately, at an all-time low. Staff are under pressure. They work hard and should be complimented on that. By working together, we should be able to improve the situation but if we could improve transfer of care from one end of the hospital, we would be able to increase capacity in emergency departments.

Ar dtús, cuirim mo bhuíochas in iúl don Teachta Michael Harty as ucht an Bille tábhachtach seo a chur os ár gcomhair. Caithfimid bealach nua a fháil chun an fhadhb seo a réiteach.

Sinn Féin fully supports this Bill. It wants the right to health protection enshrined in the Constitution and, consequently, to have all future legislation framed with this fundamental right as the baseline. This debate is one of those occasions in this Chamber when we will learn a great deal about the Government's outlook on, and attitude to, healthcare provision. Who should it serve? Should it be public or private? At what point are a person's basic rights violated due to a lack of healthcare? Who would stand up, as a Minister, and deliver a speech arguing against a constitutionally-enshrined right to healthcare based on need? Has the Minister done so? We will have to go over his address again to be sure.

We have heard many arguments as to why this Bill will not work, among them that the Government may be open to legal challenges that may be time-consuming and costly. If the recommendations of the Sláintecare report were to be implemented in full, there would only be the remotest chance of a constitutional challenge from any citizen. If the goal of the Government was to achieve the very modest aims set out in the schedule of this Bill, the doomsday scenario of backlogs in courts and bureaucratic nightmares would dissipate like a puff of smoke.

The recent budget presented an opportunity for the Government to show that it is real about implementing Sláintecare. We now have an implementation plan and an office associated with it to ensure that key target dates are met. That is what we are told. The Government committed an additional 6.3% current funding for the health service which is far below the level of funding needed to deliver current services and any additional or new services scheduled to come on-stream. Sláintecare itself recommended that the current health budget needed to be increased by at least 7% per year.

The Minister for Health has stated his support for Sláintecare. Why, when everything appears to be in place, are targets not being met? What is missing? Is it political will? If that is the case, we need some mechanism stronger and more enduring than unchecked political goodwill. Put simply, this Government cannot be left to itself to implement a plan for universal access to healthcare.

My party colleague, Deputy Eoin Ó Broin, has tabled a Bill seeking a referendum to enshrine the right to a home in the Constitution. His motives for doing so were very similar to those of the proposers of this Bill. This was in response to ever-growing numbers of people and families homeless and with housing waiting lists increasing in every local authority area across the State. We also stated that this was not a silver bullet for housing. Similarly, tonight's Bill is not, and will not be, a panacea for our difficulties regarding healthcare capacity. The right to healthcare protection is denied to so many, especially in a timely way, and should rightly be seen as a failure of the State.

It is more distressing still when some of our youngest citizens are failed in this manner. Postponed and delayed surgeries and drug treatments have, in many cases, had lasting negative impacts on the lives of Irish children. As was referenced earlier, figures were released today that show the true picture of the numbers of children waiting to be seen. There are in the order of 86,000-plus children waiting to see a specialist in hospitals across the State, many for essential surgery. Some 46,000 of these are seeking access to services and procedures in the three main children's hospitals. I understand that postponing surgery is sometimes done due to how dangerous things have become in these hospitals for both patients and staff. However, cancelled surgeries will increase the numbers on these waiting lists, as well as the length of time that children have to wait.

Hospitals are crippled due to a lack of nurses and consultant doctors across a range of specialties. The unions representing front-line medical staff have been raising this issue for years but it has not been addressed. The Government has rolled out the usual lines, including that the flu is responsible for the pressure on hospitals; how often have we heard that? We have had eight years of Government led by Fine Gael, which has had control over the health services for all of that time with the most recent four budgets agreed with Fine Gael's colleagues on the opposite side of the Chamber in Fianna Fáil. Despite that, we hear voices from both parties expressing surprise at the flu and winter-related illnesses arriving each winter. How can they keep saying that? It is absolutely pathetic.

A new departure is needed. Fianna Fáil cannot claim, as it did during Private Members' business last week, that it stands ready to take the radical action needed to safeguard the public health system. I, and many others, will never forget that the current Fianna Fáil leader and aspiring Taoiseach was the Minister for Health who dealt the deadly blow to services at the once proud Monaghan General Hospital. The people of Monaghan should never forget that fact.

If members of whatever political persuasion are serious about the need for a new dispensation in healthcare, they will vote in favour of the Bill. Let us see, and let the people see, where we all stand on this most fundamental issue. I, and my Sinn Féin colleagues, will give the Bill our wholehearted support.

As Deputy Ó Caoláin has said, Sinn Féin will give the Bill our wholehearted support and would like to compliment Deputy Harty on bringing forward this proposal to put healthcare into the Constitution as a fundamental right that people deserve in life. There should be a structure in society to keep people healthy.

One of the founding documents of democracy was The Republic by Plato. In it, he wrote about health and justice as two of the fundamental things that any society should be able to provide for its citizens. That is exactly what we need to be able to do and it is more than appropriate that an entitlement to healthcare be in the Constitution.

There has been some talk of legal issues. I read the digest and much of it was about the legal nightmare that the Bill could create. The reality is that, if the Bill is worded properly, that will not be the case. As Deputy Ó Caoláin referenced, if the Sláintecare model is implemented in full, as has been committed to by all in this House, we have nothing to fear by putting healthcare as an absolute right in our Constitution.

The difficulty is, of course, that currently people's experiences around the country are negative when it comes to delivering healthcare for all. A recent example only came to my notice today. In the Sligo, Leitrim and Donegal areas of the north west, people are waiting to see a counsellor under the primary care model and, at the moment, that waiting list is growing out of control because the budget that was in place for it has been spent and there is no budget to continue it.

People are being referred by GPs for counselling but those referrals are not being processed. We have a major problem in that area alone but it is an example of problems in many areas.

An aspect of healthcare that often goes under the radar is community mental health services. That is a primary right that people should have and it should be deliverable within the context of the type of legislation before us. An example in that regard is the clip on YouTube by Leah Cull, which the Minister said he would watch, about health services. She lost both her brother and her father because of the failure of the mental health services in the north west. Those failures are what drives people like Deputy Harty and many of us to come into this House and say that the right to health should be a constitutional right for every citizen, that every citizen should be protected by the State and to ensure that it is delivered. No Government can hide behind statistics, a lack of money or a problem with this, that or the other. The Government must not hide from its obligation to its citizens to provide healthcare for them.

The Government amendment will kick this issue six months down the road.

We all know where we will be in six months; we will be on the other side of a general election. That is the reason this amendment has been tabled. I am disappointed that Fianna Fáil has said it will support the Government amendment. It is saying the same thing, namely, people have a right to health but not yet. The time has come to make that an absolute right for everyone in our society. For that, I commend this Bill and congratulate Deputy Harty on bringing it forward.

I congratulate my fellow mid-west Deputy on this Bill. It is an issue he fundamentally believes in as a practising doctor. The Labour Party will support his Bill on the basis that we should allow it go forward to the next Stage for discussion and to see where we can go with it. As drafted, it is not in any way perfect. I presume the Deputy understands that but I fundamentally agree with the principle of the Bill. I am always nervous about the manner in which we bring forward amendments to the Constitution in particular. We will need to do so carefully but the principle of doing this is right. We should do so, as other speakers, and particularly the last two speakers, stated.

We have a long-standing reluctance to constitutionalise socio-economic rights in this country. We have changed tack on that to some degree in recent years but this is a fundamental change , which I would welcome. Those rights tend to deal with issues such as health, childcare and housing. Those issues are sometimes controversial. People with different philosophies may not agree that they should be enshrined in our Constitution. We should never have to use the Constitution to secure basic rights such as the right to health. Such rights, in any civilised society, should be natural; they should just exist. One would expect the Government, with relatively bountiful resources, to be able to provide such basic services to our citizens. Unfortunately, and I am jumping out of the realm of party politics, collectively, as a body politic and as a society, we have numerous examples over many decades of our failure in this area. The rest of the EU is able to provide adequate services to their citizens. Unfortunately, I look with some jealousy at how that is done. Collectively, we may be able to improve on that and Deputy Harty's Bill will inspire us to do that.

On the specific issue of health, the EU Charter of Fundamental Rights states: "Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices." We all accept that. The Minister referenced other parts of the EU charter and I agree with his sentiments. Likewise, Article 12 of the UN International Covenant on Economic, Social and Cultural Rights states: "The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."

These treaties, to which Ireland is a signatory, affirm that good health is a prerequisite to public activity and private freedoms. That is what we are discussing. It is about reaching a baseline whereby everyone is equal and everyone is protected and can participate at that level. By inserting that in the Constitution in the appropriate way, having discussed it, we would end up doing that.

Despite espousing these values on paper, Ireland remains the only western European country not to provide universal health coverage in primary care. That is despite repeated Government promises and a clear pathway laid out in the cross-party Sláintecare report. As the Minister will be aware, I am passionate about Sláintecare. I spent 11 months on it. I fully endorse it, as does Deputy Harty. Sláintecare is our future. It is an across-politics future. In many ways it is the embodiment of what this constitutional change would mean because if Sláintecare was in place, we would all benefit from it. We would all benefit from the charters to which we signed up, and we would all have universal access and a standard of care that citizens should enjoy.

Collectively, we need to ensure that the ten-year programme of work is ramped back up to where it should be because where we are now, unfortunately, is tokenistic. I refer to the volume of money being put into it, the milestones that have not been met, the resources that need to be put in from a strategic point of view, the front-loading that will have to come in the next couple of years in respect of achieving certain infrastructure. Those milestones will not happen. That is unfortunate. It is a failure on all of us but, as the person who his holding the shovel, it is a failure on the Minister. That is worrying and embarrassing for us.

Because of the impact of the past 48 hours in dealing with the most horrendous situations I have every dealt with as a Member in respect of healthcare, I want to plead with the Minister for one last time. I had no intention of doing this until about an hour or two ago. I plead with him to put in place a specific plan for University Hospital Limerick for the coming months because people are going to die. I have intimated this previously but not as clearly as this. Consultants are saying that catastrophic events will happen. In many ways, the inspiration behind Deputy Harty's Bill is his experience of his own work in the mid-west. However, we have never seen the situation this bad. There are short-term solutions. I guarantee I will support the Minister 100%. We need a specific plan for the mid-west. What is happening has never been seen before in this country. There are historical reasons for that. They are not all the fault of the Minister. I refer to TEAMWORK, the Hanly report and all the issues in Nenagh and Ennis hospitals that should never have happened before the infrastructure was in place. The Minister of State who is sitting beside the Minister knows the history, given his own family connections in the area. I will not lecture the Minister. I beg him to please put a team together to specifically look at this issue. I refer to the volume of people in that hospital tonight and the trouble they are in. A number of consultants and people I have spoken to at senior levels are at a loss as to how they can prevent people from suffering and, unfortunately, dying unnecessarily over the coming months.

Cuirim fáilte roimh an díospóireacht anocht. It is very opportune coming after the many debates and discussions we have had on health recently, including Deputy Pringle's motion last Tuesday on personal assistance.

Today we have so much knowledge and awareness and we know what to do, why we should be doing it and how to do it, but the problem is implementation. We have theories, visions and principles that sound lovely. Deputy Harty's comprehensive briefing outlined today that the Department of Health's strategic objectives allude to supporting people to lead healthy and independent lives. Sláintecare sounds so lovely, as do "universal single-tiered health and social care system" and "equal access to services". There is a wonderful phrase, "based on need and not ability to pay". When we move to the questions of accountability, goals and timeframes in which to achieve goals, however, there is a totally different scenario. Every Deputy knows the reality of this. We are all being contacted about it. My most recent case in this regard was raised by a married couple in my constituency. The man has been diagnosed with a rare disease. The couple's problem is the lack of clear information from the HSE, the consultant and the registrars. The word the couple used about the attitude towards them was "patronising". The couple does not want to be bumped up the list; they just want clear information on their current situation. That is not taking from the excellent care patients get in the system. There are examples of best practice but they are not universal.

We live in a democracy. Equality is supposed to be the cornerstone but citizens and other residents are not treated equally. This is what Deputy Harty's Bill is trying to address. The inequality begins long before the person gets to the doctor, hospital or clinic. We have the statistics and reports that show that one's socio-economic background has a major impact on one's health and life expectancy. This is very evident in parts of my constituency. The Bill is trying to address that by focusing on equal rights, affordable access and the common good. This is connected to the point on healthcare and healthy conditions. The reality is that there are so many living in unhealthy conditions, overcrowding, dampness and unhygienic conditions, not to mention the particular health needs of certain groups, such as Travellers in certain types of accommodation and rough sleepers.

An example I know so well concerns people with an addiction who want to take the first step towards recovery. If they have private health insurance, they get quicker access to residential treatment. Without it, it is a different matter. We are aware that the projects in the inner city are doing so well. The Minister for Health, Deputy Harris, was in SAOL recently. Soilse, Crinan and Chrysalis are all on reduced budgets that have not been restored. The Recovery Academy has a wonderful event every year on Merrion Square. It is so uplifting and positive. Once one person gets into recovery, the knock-on effect on the family and community is unbelievable. There is a payback for others who are trying to get into recovery.

Sláintecare and the strategy require something like Deputy Harty is proposing in order to turn the visions and objectives into reality. It is incredulous that we are having this discussion in a country that is relatively wealthy, that has a thriving economy and that has a relatively small population. It is unbelievable that we have not got it right for everyone. Constitutionally enshrined rights to health and to realise the vision are required.

The Bill has been crafted carefully to prevent punitive legal proceedings. Transparency is central. The onus is on the State to explain its inactivity. It is really about being proactive, not reactive.

I fully support the Bill. It is worthwhile. Rights to health, to education, to life and to live life to the full are what all citizens should be demanding. The State and Government should be ensuring everybody has these rights. I proposed economic, social and cultural rights twice in the Dáil. My Bill was to enshrine rights in the Constitution. Dr. Harty's Bill is along the same lines. I welcome that. It could be expanded to include all economic, social and cultural rights but since the Government will probably not accept it, my point will not make any difference. It is very encouraging, however, that many members of the Opposition are putting forward Bills to have rights enshrined in the Constitution. There is no doubt that citizens need them. Deputy Maureen O'Sullivan highlighted in her contribution the need to have these rights protected across the board.

Fianna Fáil and Fine Gael will not enshrine these rights in the Constitution because they want to control budgets and how people access services. They want to make it a political gift to give rights to people and extend services to them. It should be within the gift of this Parliament to give everybody what I propose.

In their day-to-day work, Deputies note that even the Head of State pushes for citizens to have health insurance. I believe this is a crime and that the €1.5 billion spent on health insurance could be put into health services to create health services for everybody. I do not believe I should use my tax to supplement other people's health insurance. My tax should be supplementing a health service that everybody can rely on. Nobody tries to break down the detail for people. How many people feel threatened or under pressure to have health insurance in this State? They do not realise the reality. In the past year, a number of people came into my constituency office complaining about health insurance, saying that if they wanted access to treatment, they would have to have health insurance. People do not have to have health insurance. If one has a medical card, the maximum cost will be the cost of seven or eight days of hospital care. All one's treatment will be free. That message has to go out very strongly to all citizens. The contention of politicians and health insurance companies that people must have health insurance is basically a scam. People have healthcare and entitlements, and they should be allowed to proceed on that basis.

In contributions in the Dáil today, Deputies referred to information provided by the Irish Cancer Society indicating people cannot obtain medical cards because they believe their income is too high. The medical card is based on income, not illness. That is reality. No matter how ill people are, they have to go through the whole process of showing their income is over the limit. Only then is the illness considered. In a normal society in which people are treated fairly, medical cards would be given on the basis of illness. This should happen.

I am sharing my time with Deputies Eamon Ryan and Shortall.

I welcome the opportunity to speak on this Bill. I confirm my support for it. It is particularly important when we think of its background, including the chaos in our health services, the overcrowding, long waiting lists, the lack of mental health services, dysfunctional disability services and, of course, the two-tier health system in which ability to pay trump's access to medical services based on medical need. Also part of the background is the unanimous agreement on the Sláintecare report.

The Bill, as Deputy Pringle implied, is similar to a Bill he and I introduced in 2014, namely, the Thirty-fourth Amendment of the Constitution (Economic, Social and Cultural Rights) Bill 2014. I welcome Deputy Harty's Bill as it is necessary. It is well-intentioned and I will certainly be voting for it but I do not believe it goes far enough. As Deputy Pringle said, economic, social and cultural rights should be enshrined in Bunreacht na hÉireann. I refer, in particular, to the rights to work, to have just and favourable conditions at work, to form trade unions, to join a trade union of choice, to social security, to the widest possible protection and assistance for families, to an adequate standard of living, to adequate food, clothing and housing, to the highest attainable standards of physical and mental health, to education, and to take part in cultural life.

It is almost 30 years since Ireland ratified the International Covenant on Economic, Social and Cultural rights, in 1989, yet these rights have still not been enshrined in our Constitution. In fact, since 1989 the UN committee responsible for implementation has written to the Irish Government on a number of occasions asking that its measures be implemented. They should be implemented urgently.

I commend Deputy Harty on introducing this Bill which the Green Party is supporting. The primary reason for that is because we want to see the implementation of Sláintecare and we see this Bill as a step towards achieving that objective. I am following UK politics at present and it seems that one of the few things that can be agreed upon over there is the huge achievement of introducing the National Health Service. I see the full implementation of Sláintecare as providing a similar radical step change in the way the health system and society works.

I read the Minister's speech and he argues that Sláintecare is being implemented and it takes time, which I accept, but our assessment is that we are not seeing the step change on a scale and form that we agreed unanimously in this House under the committee chaired by Deputy Shortall and involving others. We need something to unlock that. I understand the Government's concerns about ending up with a system that is completely managed by the courts but, to be honest, that fear is exaggerated. The courts themselves recognise that there is still an executive function in terms of managing the allocation of resources. The courts cannot decide to the nth degree on how a particular budget is allocated, but it would allow patients to seek recourse under the Constitution in cases where the system was not delivering. It would move from being a system that is run by the healthcare professionals themselves, not first and foremost in the interests of providing healthcare for all.

I agree with what Deputy Pringle and other speakers have said. Our dual system is not working where a large percentage of people have private insurance that would be unnecessary if we were to manage to make the leap and achieve a universal healthcare system. We support the Bill which will send a clear signal that we as a people are going to change the way our health system works through the implementation of Sláintecare.

I commend Deputy Harty on bringing forward this legislation. I know he has put a lot of work into it and he has gone out of his way to bring everybody else on board in terms of briefings. The Bill is an important piece of work which very much replicates work that has been done by other Members in recent times, in particular Deputy Pringle.

There is a very strong desire on the part of many Members of this House to take a rights-based approach to the provision of services. In an ideal system, there would be a recognition of the principle of equality and the importance of treating all citizens equally and fairly. Unfortunately, that is not what we have seen since the beginning of this State. Whichever of the main Civil War parties has been in government, neither of them at any point has set out a course of action in government to uphold people's right to equality and access to services.

One might say, politically, that should be the ambition and the determination of any civilised modern government but, unfortunately, we have not seen that kind of approach to the rights of individuals at any stage within this State by ruling parties. For that reason, at this point, and in the area of health in particular, there is no excuse given that we now have the Sláintecare plan, an agreed all-party plan for a universal single-tier health service. The plan is there and, in theory, all parties have signed up to it yet we are not seeing it implemented. The only way that we can approach this, if we are serious about having the kind of fair, universal single-tier health service that responds to people's needs for health and social care, the same kind of service that is available in every other European country, is that we would expect all Governments and parties to be enthusiastic and active on its implementation. Unfortunately, that has not happened and because of the failure of this Government and the other Civil War party to take a rights-based approach to the provision of healthcare, which is one of the most fundamental public services and one of the most fundamental rights that any civilised society can have, I believe we have no choice but to pursue the constitutional route. I wholeheartedly support the approach taken by Deputy Harty. The Social Democrats are proud to support this Bill.

It is a national scandal that our health service is becoming a crumbling mess due to the lack of urgent intervention by the Minister for Health. That is extremely unfair to patients and the hard-working nurses, doctors and consultants in hospitals. The fact that there are now thousands of children waiting more than a year for hospital appointments and healthcare is upsetting and distressing for many families. It is adding to their distress that operations in three main children's hospitals have been postponed and the fact that 117,000 people are awaiting healthcare treatment, hospital appointments and procedures, which includes 30,000 children waiting for more than one year. That is unacceptable and must be addressed urgently.

Elderly people are also being failed by the health system. They are forced to lie on hospital trolleys day in and day out. Up to the end of October this year, 13,466 people aged over 75 years have endured emergency department waits of more than 24 hours. That is one third more than in the same period last year.

The actions that need to be taken by the Minister for Health are recruitment, increased bed capacity, step-down facilities and home help hours made available and fairly distributed among the regions. Currently, many elderly people and people with disabilities are trapped in hospitals while they wait for the allocation of home help hours. That is escalating the crisis in hospitals. A total of 2.5 million home help hours must be made available urgently within the system because it is chaotic. It is unfair to the well-being of elderly people who are suffering on trolleys and within hospitals waiting for services.

People in Laois and Offaly are being badly failed by the Government and the Minister for Health as there is a chronic shortage of home help hours. Every day of the week I am guaranteed to get a few phone calls on the need for home help hours for people who badly need them.

The Minister for Health must step up to the plate and address the very serious deficiencies in the health system. Capacity must be built before we devise any type of policy. Currently, the basics are not in place. I worry that we have not addressed recruitment or bed capacity. People are being sold short and are being treated unfairly. There must be more focus on investment in GP services, including the funding of chronic disease management and the expansion of GP out-of-hours services. The chronic shortage of GPs in rural communities, which is an issue I have raised on the floor of the Dáil, must be addressed urgently before we talk about any other policy. We need to get the basics right and fill in the gaps first.

It was highlighted today on Midlands 103 radio station that cancer patients are not being given any financial supports. Medical cards have been raised already. Recent research by the Irish Cancer Society found that cancer patients are spending an average of €756 every month. The research also found that those patients are also at the loss of approximately €18,000 in earnings every year. Such a huge burden on those patients is unacceptable. I ask that something be done because it is unbelievable that is happening in 2019 to the most vulnerable and sick people.

Another issue in our health service is the unacceptable uncertainty that exists in terms of hospital services. I was only contacted earlier in the week about Portlaoise hospital. It has been brought to my attention by many people in Laois that there are still no assurances regarding the accident and emergency department at Portlaoise hospital. It was raised a number of years ago and they still have not been given any assurances. I hope the Minister will also get back to me on the maternity unit at Portlaoise hospital, as uncertainty also hangs over it. I understand the Minister for Health will visit Portlaoise very soon. I call on him to give the people fairness and to be honest with them. He should give them the assurances that their services are going to be protected going forward in Laois. This is unfair. It has hung over the area for the last few years.

I salute the work of my colleague, Deputy Harty, who has been a serious, dedicated and passionate advocate of health reform in this State since his election five years ago by the good people of Contae an Chláir. Deputy Harty has made clear that he understands the purpose of this Bill. In the main it is an attempt to strengthen the rights of citizens and in particular those who are sick or ill, the weakest of us, to ministerial and Government accountability if the right to healthcare protection is violated. Who knows better than a GP who sees them every day of the week? It is a principle I strongly agree with.

I welcome the Minister of State, Deputy Finian McGrath, if he can listen to me a minute. The Minister, Deputy Harris, has left the building obviously. Unfortunately, as we know the issue of accountability in all Departments, not just in health, is more noticeable by its absence than by its presence. I only said it here last week to the Minister, Deputy Harris, when I asked what it would actually take for him to resign. I am not talking to the Minister of State but am repeating what I said to the Minister, Deputy Harris, last week. What disaster will be sufficient in order to make him resign and say to himself that he is not up to this job. He is clearly not up to the job or any other job either.

This Bill is complex at the constitutional, the political and the economic level. I accept entirely that there are consequences which need to be teased out, but not rubbished or buried for six months and the Minister buying six months. He told us earlier, that he wanted to engage and everything. He knows he will not be in the job. I know he will not be in the job and Deputy Harty knows it as well. The fact that there are difficulties and the issue is complex should not deter us from investigating if the Bill or the principle behind the Bill has merit. I think it has. I might not agree with everything Deputy Harty has in the Bill but it needs discussing and appreciation and respect. That is why I would have liked the Bill to go forward to Committee Stage or for greater pre-legislative scrutiny, where some of the main areas of tension could be resolved or explored in a reasonable and forensic manner. That is the least we would expect for the Chairman of the Oireachtas Joint Committee on Health, the man who led the campaign for Sláintecare. But no. Throw him under the bus. The Government does not want him.

Speaking to the general thrust behind the Bill, I will simply say that we urgently need a radical and profound cultural shift in this State in terms of how we hold those in positions of power accountable. They are not accountable by any shape, make or form. At present those who fail to deliver or even actually hinder the delivery of healthcare protection are almost anonymous. They hide behind the Minister. We know the Minister and we know the Government and we can hold them to account, both individually and collectively. We can place motions of no confidence in them although many might not vote for it. We had it in the Minister, Deputy Harris, who should have been voted out of office. Even if they are successful, how does that help the person denied access to vital care? Many have died waiting. The Minister of State knows that. How does that help the child who has been denied access to life saving medication or treatment and those conditions that may be irreversible? It does not. We have to be totally sanitised for a minute and examine that. Removing the Minister will hold him accountable and that is a good thing politically, but it does not advance the rights of citizens to greater levels of healthcare.

That is what I think has motivated Deputy Harty in his presentation of this Bill. His experience as Chair of the Oireachtas health committee has given him valuable insight into the systemic failures of our health system and how it continues to deny what should be a right of access to so many desperately ill people. We need greater accountability. We need to act and protect and vindicate the rights of most people. The Bill has the potential to kick-start a valuable conversation in that regard and I commend Deputy Harty for bringing it forward.

I do not commend the Minister, Deputy Harris. Tá sé imithe anois. He just could not be scathing enough. I at one stage just interrupted briefly to comment. He went back to the referendum about the eighth amendment. Is that going to be his only mantra for the rest of his life, wherever he ends up? It will not be in here, I am sure. The people of Wicklow will tell him. They will banish him to wherever but that is up to them. I will not say that. He is the most inept, useless, toothless and fruitless Minister for Health that ever came into this House. He knows nothing but worse than that - none of us knows a lot. I am not saying-----

It is not personal.

It is factual. You talk to the people-----

You talk to the people lying awake on the trolleys. It is not personal.

This is outrageous.

I do not need to talk to people, Deputy. I am going to call you to order.

Are you listening to me?

I am listening to you. I want to tell you Deputy, you are out of order. You are using the House to personally attack somebody. You are not entitled to do that. You are out of order. Resume your seat, Deputy. You will resume your seat. You are out of time as well. You are out of order, not for the first time in your life. That was a disgraceful carry-on.

It is outrageous.

The Acting Chairman should not be interrupting me.

I call the Minister of State, who has ten minutes. There are no more speakers.

I thank all the Deputies who have contributed to the debate in a very positive and constructive way. I would like to particularly thank Deputy Harty for bringing forward this Bill and this issue for debate, as it has provided us with an important avenue for discussion on our own ambitions for health. I would also like to acknowledge all of Deputy Harty's work as Chair of the Oireachtas Joint Committee on Health and as a member of the Committee on the Future of Healthcare, which was so central in the direction of travel for health provision and planning through the Sláintecare report.

While there is no doubt that the Bill we are discussing this evening is very well intentioned, I do not believe it is the appropriate way to drive progress in this area. The Private Members' Bill before us seeks to embed a right to health in the Constitution. I respectfully suggest such an action would leave us open to many inadvertent and unintended consequences, ones which cannot be foreseen at this juncture. Further thought should be given to this issue in a measured and informed manner, with all options fully understood and considered. There is the additional point that to pass this Bill would be to disregard the significant consideration that has already been given to this topic through the aforementioned forum of the Oireachtas Committee on the Future of Healthcare, with its final recommendations on this issue proposing a universal single-tier health and social care service guaranteed on a primary legislative basis. This is something that I strongly support. Additionally, while I appreciate the desire to deliver on this aim as quickly as possible, the Sláintecare report equally emphasised that such a shift requires a phased approach to implementation, so that we all can be assured that we have adequate capacity and ability to deliver this.

For these reasons, the reasoned amendment declines to give the Bill a reading on Second Stage for the various reasons I have outlined, as opposed to disagreeing with the overall principle of what the proposer of this Bill is trying to achieve. As the Minister, Deputy Harris, said earlier, we can look forward to working with all Deputies in the House on the underlying principle of the Bill, that of driving our health service forward and closer to the vision of Sláintecare. I ask the House to allow the programme of work on eligibility and entitlement that is currently ongoing time to manifest its aims, with the assurance that the issues debated here tonight will be considered through the Sláintecare programme implementation office and that it will provide a report to the Joint Oireachtas Committee on Health within six months.

I thank the Acting Chairman. I acknowledge what the Minister said at the beginning of his contribution, which was that the speed of progress of this Bill has been rapid. It was introduced on First Stage last Wednesday and it is being debated on Second Stage tonight, which is lightning quick compared to what normally happens in the House. I accept that the Government has not given ample time to consider the ramifications of the Bill, much as I agree with its sentiments.

The legislation challenges accountability for the progression and the progressive realisation of health by placing a right to health in the Constitution, which is an important right that should be in the Constitution. It would be added to the right to primary education, a socio-economic right that is already in the Constitution. There is, therefore, a precedent in the Constitution to provide a socio-economic right. There should also be a socio-economic right to health.

The Bill also proposes some safeguards to prevent excessive rushing to the courts regarding this constitutional right to health protection. It requires transparency from the Government in progressing a realisation of the right to health. It is a fundamental proposition of the legislation that there would be transparency. It gives the Government the opportunity to be transparent on how it will realise the progressive right to health.

Within this constitutional amendment, there is the proviso that any right to health should be within available resources and that is an attempt to prevent people rushing to the courts but it also enshrines within the Constitution the principle of "for the common good". These are all protections against a rush to the courts. It places on the courts a requirement that there should be reasonableness and a proportionality to any judicial case taken on the vindication of people's rights to health. I believe I have inserted in the constitutional amendment protections against such an excessive legal action.

A number of arguments were put forward in opposition to this. The first opposing argument essentially claims the goals of the amendment are being achieved by Sláintecare. As stated previously, if the State is on track to fulfil its goals as this is laid out in the Sláintecare report and the 2019 action plan, it would satisfy this amendment's provision for progressive realisation. There is no additional burden on the State to speed up the transition from the current health system to one of universal access but only for the State to continue this endeavour within its available resources. If the Government wants to show a commitment to a universal single-tier needs-based health system, it should accept this constitutional amendment for what it is: an expression of modern Ireland's fundamental principles. Any other reaction to this Bill would be an attempt to avoid accountability and responsibility.

The progression of Sláintecare has shown that there is no strong accountable mechanism in place to ensure the timely delivery of its objectives. The Bill proposes a constitutional imperative on the Government to drive change forward. It is also important to note that Sláintecare has been thwarted by a lack of resources by this Government in not providing necessary funding to enable structural reform of the health system, as outlined in the Oireachtas report. Only €25 million has been specifically allocated to the Sláintecare implementation office to implement change. This is a fraction of what the Sláintecare report proposed to drive health reform forward.

The second opposing argument states that a constitutional and legal right to health would violate the separation of powers. There is no violation of the separation of powers on two grounds. First, separation of powers is justified in a constitutional democracy only by constitutional principles and the Constitution clearly gives the State an obligation to uphold a commitment to social justice and inclusion in its preamble. It is, therefore, more constitutional to acknowledge the role of each branch of government, including the Judiciary, in achieving the "dignity and freedom of the individual", "true social order" and "Justice and Charity" by protecting certain socio-economic rights. This is recognised in the Constitution with Article 42.4 stating, "the State shall provide for free primary education." The case law in this regard plainly achieved the protection of this socio-economic right within the traditional and constitutional bounds of authority endowed upon the Judiciary.

Second, the language of the amendment is deliberately designed to facilitate the restrained jurisprudence seen in right to health cases decided by the South African Supreme Court so as not to violate the separation of powers. The South African provision was drafted by a student of Trinity College Dublin and South Africa, like Ireland, has a British constitutional legacy, being one of the only states with such a legal origin to have a constitutionally enforceable right to health. South Africa's landmark cases enabled the courts there to judge the reasonableness and proportionality of its government's health policies without forcing the rearrangement of government resources. Only when its government failed to address South Africa's HIV crisis, visible to the public and the international community, did the court as the last institution of appeal, mandate that treatment be made available when it was well within the government's resources, and where its refusal to make this treatment available was clearly unreasonable.

It is not within the realm of the courts to interfere in the political process of resource allocation, but it is very much a power and duty of the courts to make sure as to whether a person's rights are being protected or violated. Opponents of this Bill on the grounds of separation of powers have not shown how this amendment would result in anything other than the acceptable jurisprudence found in South Africa, or in the long-established judicial attitudes of Ireland's rights to education cases, or in the creative remedies put forward by recent cases such as the NVH v. the Minister for Justice and Equality, or PC v. the Minister for Social Protection.

I see no valid reason to reject this Bill. Public opinion on health policy is not what it once was. It is no longer the case that a universal, no-means-test health service represents the "socialisation of medicine"; it represents the shared vision of all parties of the Oireachtas for the future of health protection.

The views and vested interests that led to the downfall of the then Minister for Health, Dr. Noel Browne, and the mother and child scheme in the early 1950s no longer hold the same sway. This era of almost 600,000 people on waiting lists and record-breaking numbers on trolleys vindicates this Bill. Noel Browne's Bill fell because the medical profession and the religious institutions opposed the socialisation of healthcare. The Minister of State, Deputy McGrath, will very much understand that point coming as he does from that background.

Sláintecare aims to do much more than provide free public health services for mothers and under-16s as proposed by Noel Browne. This legislation does not undermine Sláintecare; it strengthens it. If the State truly intends to reform our national health system into one based on need rather than the ability to pay, there is nothing to fear from a constitutional call to accountability, nor from putting the question to the people of a constitutional mandate to protect their right to health.

I thank the various speakers who supported this Bill, including Members of Sinn Féin, the Labour Party, Deputy Healy, Deputy Maureen O'Sullivan on behalf of the Independents 4 Change, the Green Party, the Social Democrats and Deputies Mattie McGrath and Carol Nolan. I understand, however, that Fianna Fáil will not support it and that the Government is putting forward a reasoned amendment.

I am willing to accept the reasoned amendment rather than see this Bill be defeated on the floor of the Dáil, on condition that this constitutional amendment is discussed as part of the Government's constitutional convention on economic and social rights and that it would report back to the Joint Committee on Health within six months. I understand that six months may be the remaining length of this Government. Who knows what will happen? I sincerely hope that a report will be produced within six months that will take into account the genuinely held conviction that I have that there should be a constitutional right to health. By accepting its amendment, I fully expect that the Government will fulfil its commitment to produce a report in six months which will take into account the principles that I have proposed in the Bill. Rather than let it die, I am willing to accept that reasoned amendment.

Aontaíodh an leasú.
Amendment agreed to.
Aontaíodh an tairiscint mar a leasaíodh.
Motion, as amended, agreed to.
The Dáil adjourned at 9.35 p.m. until 10.30 a.m. on Wednesday, 27 November 2019.