Health Services: Statements

I welcome the Minister for Health, Deputy Leo Varadkar, to the House.

I very much welcome the opportunity to address Members of this House on the 2015 Department of Health budget and my priorities for the health sector next year.

Since my appointment as Minister for Health, I have said on more than one occasion that it is my first priority to achieve a realistic budget for the health service. I firmly believe we have achieved that in budget 2015, with an increase in the Exchequer allocation of €305 million when compared to the 2014 allocation. We have also identified one-off increased projected revenues of some €330 million and savings and efficiencies of €130 million. Taken together, this means that the HSE will have over €750 million more to fund services in 2015 than it did when we were preparing the service plan for 2014 this time last year. We are now entering a two-year process which stabilises the budget and allows for existing levels of service to continue, along with some targeted enhancements. Arising out of this, the spending ceiling for the Department of Health in 2016 has already been increased upwards by a further €174 million. This does not mean that all areas of concern across the health sector can be addressed immediately but it does make the funding situation more manageable. It also means that the cycle of cuts in health has come to an end.

Despite our additional spending power, next year remains a real challenge. There are enormous cost pressures. Drivers of demand and cost include our rising and ageing population and the increase in chronic conditions, and advances in medical technology come at a high price. Our progress in diagnosis and screening for cancers and chronic diseases means more people require treatments. Health services all around the world are struggling with the issue of rising costs and Ireland is by no means exempt. We must recognise the additional resource demands that come as a result of these new pressures. In overall terms, therefore, while next year's health budget remains challenging, its targets are achievable. This challenge will be reflected in the HSE's 2015 national service plan which will operate strictly within the resources available, deliver existing levels of service and provide for some targeted improvements. The service plan will also continue the programme of health service reform.

In 2015, we will have more control of our resources in the health service. I already mentioned that specific savings and efficiencies of €130 million have been identified. These are in the areas of procurement, drug costs, agency costs and clinical audit and special investigation. However, a significant change for 2015 is that where further savings or efficiencies are achieved over and above this minimum level, these will be retained and reinvested back into the health service rather than being used to reduce the deficit or reduce the debt. I hope that this new development can positively contribute to the reform and development of our health services.

The HSE will also have more autonomy on staffing and human resources in 2015. The end of the moratorium on recruitment provides greater room for the Department and its agencies to manage their own staffing levels. This decision was recently announced by the Minister for Public Expenditure and Reform, Deputy Brendan Howlin. It provides a basis for the health sector to take on more temporary and permanent staff in order to achieve savings on agency costs, subject to compliance with the overall pay allocation. This, in turn, provides the HSE with an opportunity to reduce pay costs where less expensive alternatives to agency personnel are available. I believe this will facilitate a more sustainable workforce and greater continuity of care for patients. The HSE has issued a memorandum to management on measures to reduce agency usage and costs across the HSE and HSE funded acute hospital services. It provides for the replacement of non-consultant hospital doctor and consultant agency posts with fixed-term purpose contracts, and limits reliance on doctors employed on an agency basis to two months. It also provides for the identification of nursing posts currently filled by agency staff which could be directly replaced by two year contracts of employment. These contracts will be offered to nurses currently participating in the nursing and midwifery graduate programme.

Greater autonomy and capacity to reuse savings for services must be accompanied by an even greater responsibility for cost containment and avoidance on the part of everybody working in health care. With this in mind, the HSE will continue to develop and strengthen its accountability framework when it is preparing its 2015 service plan. The management of health spending within available resources next year will require an exceptional management focus, with strict adherence by all services and budget holders to their allocations. The HSE's accountability framework will set out the responsibilities of managers and will detail the means by which the health service, particularly hospital groups and community health care organisations, will be held to account in 2015 for their spending, their efficiency and their control over service provision, patient safety, finance and human resources. It is important that budgets are put in place without delay across the HSE and its funded agencies so that monitoring of monthly expenditure against profile can commence from the start of 2015. This will help to ensure spending remains within budget and appropriate and immediate action can be taken where emerging trends give cause for concern. The return of the HSE Vote to the Department of Health from 2015 as part of this improved accountability framework will assist the HSE and the Department in monitoring health spending throughout next year.

We are continuing to make progress with the health reform programme. Next year is an important year in demonstrating the benefits of key reforms in this sector. We must work collectively to improve safety, quality and the patient experience for those who depend on our services. It is vital that qualitative aspects, such as the personal care and attention that patients receive, are the subject of focused efforts so that people's experience of the health service is safe, caring and pleasant. This can matter greatly to patients and their families. I want the HSE to take an integrated approach across acute, community and residential care settings to ensure patients are supported at all stages in the care setting that is most appropriate to their needs. This is most important in the context of the establishment and further development of the hospital groups and community health care organisations. The reorganisation of public hospitals into hospital groups is designed to deliver improved outcomes for patients. Each group of hospitals will work together to provide acute care for patients in their area integrating with community and primary care. The objective is to maximise the amount of care delivered locally, while ensuring highly specialised and complex care is safely provided in larger hospitals. The next phase of the implementation of the hospital groups will involve each group developing a strategic plan in 2015 for implementation in the years thereafter.

The Government remains committed to the introduction of activity-based funding. Under this model, hospitals are paid for the work they do in terms of case loads and quality outcomes. This funding model will drive efficiency and increase transparency in the provision of high-quality hospital services. The HSE intends to further implement this new funding model on a phased basis in 2015. The recent establishment of community health care organisations by the HSE represents an important step in improving how care in the community is delivered. The new structures will improve services for the public by providing better and easier access to services, closer to where people live, in which people can have confidence. I have been very impressed with the work of the national clinical programmes, which have greatly improved services in specialised areas like stroke and cardiology. It is planned to organise these national clinical programmes into five integrated care programmes. I hope to see the new integrated clinical programmes embedded into the HSE service directorates. It is important that they are at the centre of operational delivery and reform. While structural reform is never an end in itself, it is a valuable tool that can help us do more and better with the additional resources we now have. Better structures empower people to deliver better care.

In terms of services, my aim is to ensure that in 2015, the existing level of service is maintained and delivered and some targeted enhancements are introduced. I have signalled that the commitments in the programme for Government with regard to the extension of BreastCheck and the investment in mental health will be honoured. Additional funding of €25 million will be provided to tackle the issue of delayed discharges, which is having a detrimental knock-on effect on waiting times and emergency department overcrowding. We will deliver on the first phase of universal health care in 2015. Some 240,000 children aged six years and under will be able to access a GP service without fees. This accounts for 57% of the total population in this age group, some 43% of whom are already covered by a medical card or GP visit card. Approximately 10,000 seniors over the age of 70, who currently have neither a medical card nor a GP visit card, will be provided with GP services without fees. By the end of next year, almost half of the population - 49% - will have access to GP services without charges.

That is a major step on the way to universal health care.

Budget 2015 provides for an additional €35 million which is being ring-fenced for mental health services under the direction of the Minister of State, Deputy Kathleen Lynch. This will bring to €125 million the total investment by the Government in mental health services since 2012. The additional funding will enable the HSE to continue to develop and modernise our mental health services in line with A Vision for Change. This includes the ongoing development and re-configuration of adult and child and adolescent mental health teams, alongside other specialist mental health services.

Breast cancer survival rates in Ireland have improved significantly in recent years through a combined approach of screening, symptomatic detection and improved treatment. Additional funding is being provided to commence the extension of the BreastCheck screening programme next year to women aged 65 to 69 years of age. Screening of the extended cohort will commence towards the end of 2015 and will be expanded on an incremental basis. The additional eligible population is approximately 10,000 people and when fully implemented just over 500,000 women will be included.

Senators will be aware that there has been a continuing upward trend in delayed discharges since the beginning of the year, with 788 delayed discharges reported nationally as of last week. These are people who are well enough to leave hospital but do not have a nursing home or home care package in place for them to do so. They are often elderly people and should not be left in hospital where they are at a higher risk of falls, infections and medication errors by doctors and other staff. While there will always be delayed discharges, current levels are resulting in more people on trollies and more people having their elective admissions or surgery cancelled. In response to these concerns, the Government has provided additional funding of €25 million in 2015 to address delayed discharges. The funding will be targeted not just at nursing homes but also at community services and hospital services which can demonstrate initiatives to address the specific needs of delayed-discharge patients most positively and, therefore, improve timelines for admissions from emergency departments and waiting lists. These will include measures to place patients in more appropriate settings through the use of enhanced home care packages and intermediate and long-term care.

We are all very aware of the statistics on the rates of obesity, diabetes and other chronic conditions in Ireland. That is why improving the health of the Irish population must be our first priority in the medium to long term. My Department recently commenced the Healthy Ireland Survey. This will be a major nationwide survey to find out how healthy Irish people actually are. We have not had a comprehensive survey of Ireland's health since 2007 and there have been huge changes since then. Today, more people are aware of the importance of diet, lifestyle, health, well-being and mental fitness. However, as a nation we now face even bigger challenges when it comes to obesity, physical inactivity, diet and many other issues. This new survey will give us an up-to-date picture of the nation's health and will provide us with a baseline set of data telling us how healthy or unhealthy the Irish population is. The survey will provide us with a snapshot of key indicators which influence our health right across the population. These include nutrition, alcohol consumption, smoking, physical activity, weight management and general well-being. Participating in the survey is entirely voluntary. Nobody will be asked for their PPS number, by the way. I want to thank in advance everyone who agrees to take part as their participation is of enormous value. We can also then use future surveys to assess whether or not our policies are working.

It is of the utmost importance that patient safety remains an overriding priority across the health service in 2015 and this will also be reflected in the HSE's service plan. All health service staff, individually and collectively, will continue to have a responsibility for the quality of services they deliver to patients and service users in their care. It is important that they integrate a commitment to quality and safety into their core work and practice. Priority areas that were identified in last year's service plan will continue to be the focus of attention and include medication safety, healthcare associated infections and the implementation of the national early warning score.

The Health Identifiers Act 2014 provides the legislative framework for a national system of unique identifier for patients and health service providers for use across the health service, both public and private. Individual health identifiers are designed to make sure that the right information is associated with the right patient at the right point of care.

In addition, identifiers will help make our health service more efficient and will support health reform initiatives, including money follows the patient. Health identifiers are a fundamental building block in support of the eHealth agenda. The HSE is working to establish the necessary health identifier registers and will manage the operation of the identifiers system. The provision of identifiers will commence as soon as possible in 2015.

Patients benefit most from safe and cost-effective care. Therefore, we need suitable and appropriate facilities to support health care delivery. It is important to recognise and acknowledge that we have managed to deliver significant projects, both large and small, since March 2011 and that more have commenced. Investment in high quality health care infrastructure also has an important role in supporting communities. It sustains local employment because of the health care presence throughout the country. Progress to date and future planning demonstrate this Government's commitment to infrastructure developments in health care as set out in the programme for Government. The priority in 2015 will be to ensure that all projects remain on schedule and are delivered on time.

I take this opportunity to update Members on the capital developments which are ongoing and which will continue in 2015. Since the change of Government in March 2011, 42 primary care centres have been delivered, which is almost one each month. There are approximately 30 under way, including the 14 locations to be delivered by the PPP project and a further 50 locations where projects are at earlier stages of development.

The relocation of the National Maternity Hospital from Holles Street to St Vincent's hospital is on schedule. The design team has recently been appointed for the new children's hospital and is working to a demanding schedule. Planning permission will be lodged by the summer and I have asked that consideration be given to applying for outlying planning permission for a maternity hospital, thus achieving tri-location on the site. The strategic infrastructure development planning application was lodged with An Bord Pleanála in September last for the new mental hospital at Portrane. It is expected that a planning decision will be made in the first half of 2015, after which the enabling construction works and contractor procurement process shall commence, thus, at long last, putting us in a position by the end of the year to have work well under way on both the new mental hospital and the new children's hospital.

There has been considerable investment to date in the community nursing home programme when it comes to new build and refurbishment and this investment is much-needed and ongoing. Earlier this year, the HSE purchased the Mount Carmel campus and we hope to have it opened as a refurbished facility, providing much-needed capacity for the Dublin area and essentially providing what has been missing for a very long time in Dublin but present in all other parts of the country, namely, a place for transitional, step-down and long-term care for elderly people who can be admitted from hospital much more easily. Our objective will always be to provide high quality, safe and supportive settings across the nation.

I have recently written to the HSE outlining its funding allocation for 2015 and highlighting the key areas to be prioritised in the 2015 service plan. As Members will appreciate, it is not possible to prioritise everything and I am sure some people will be disappointed by what is in it and what is not in it. The next step in the process is for the HSE to approve and submit its 2015 service plan for my consideration. The plan will set out in detail the volume and type of health services to be provided next year within the agreed allocation. Considerable work has already been undertaken by the executive on the preparation of next year's plan. Once the service planning process has been concluded, the HSE will publish the plan and will immediately set to work on ensuring its full implementation.

I take this opportunity to pay tribute to health care staff who have taken us through some very difficult years. It is due to their hard work, commitment and dedication that the Irish health service has survived the most challenging period in its history. We still face many difficulties but there is every reason for optimism and believing that things can become more manageable next year.

I welcome the Minister and thank him for outlining the situation with the health budget. The choices made in regard to cuts in the health budget are the thin edge of the wedge. It took six months to get the facts and figures on ambulance cover throughout the country, including my county.

It is a stark example of where we are at in terms of being in need of an ambulance today in Kerry. Three people a day who are in a life-threatening situation, be it due to a car accident, a heart attack or stroke, might find they will have to wait for up to an hour. In some instances people must wait for twice as long as HIQA's standard of 18.5 minutes for an ambulance to arrive.

Apart from the issue of geography, the resources do not exist. Two years ago, four ambulances covered the area. The Millstreet ambulance, which covered north-west Cork and the east Kerry and Killarney area, was withdrawn and then Killarney’s second emergency ambulance was taken away, which meant that instead of four ambulances covering the area, there were two. Twelve months ago the second emergency ambulance disappeared and now two ambulances cover an area previously covered by four ambulances. If one has a heart attack, a stroke or one is involved in an accident in Kerry, one could wait for up to an hour. The situation is that three people every day do not get an ambulance to hospital within the critical time.

As the Minister is aware, when a person who has a heart attack does not get to hospital on time, the recovery period is longer and sometimes the outcome is fatal. Instead of leaving hospital early, such a person must stay longer in a high-dependency bed, and instead of going home, he or she is sent to a nursing home before eventually going home. The associated cost might have been alleviated had the person got to hospital on time. I am just talking about a small area in one county. If one takes the number of ambulances that have been withdrawn from the system, the knock-on effect is enormous.

I accept the Minister will examine the matter but I am aware the ambulance service has been told to cut costs. The long-term cost in terms of ongoing care for those who did not get to hospital on time is exponentially greater. I refer to the worst 10% to 20% of calls, the ECHOs and DELTAs, the critical emergencies, yet ambulances continue to be withdrawn. The Department should provide the Minister with the number of ambulances currently compared with three years ago. The figures are frightening and the outcomes are tragic.

In his address the Minister referred to service delivery. Another issue he could examine is a systems failure of monumental proportions. When one arrives at an accident and emergency department, one would imagine the ambulance crew would simply hand over the patient with data analysis and charts, but that is not the case. Paramedics tell me they must stay with the patient until someone takes the patient from them. Sometimes they must wait for between one hour and three hours, during which time the ambulance is not available to the community. That does not cost anything, it is just a systems failure, but if it were addressed by the HSE, more ambulance hours would be available and paramedics could deal with more emergency calls.

I am aware the Minister has been trying to address waiting lists but there has been an increase of 1,764 in the inpatient waiting list between January and August, bringing the total to 8,692. The question is how to address the problem. We have seen a 333% increase - 9,000 - in the number of people waiting for outpatient appointments, bringing the total number to 41,604. Not dealing with such patients early has disastrous consequences not only for the individual involved but for the health service in terms of how it can better deliver services and care.

If that patient is dealt with quickly it will not cost the service as much in the long term.

On the fair deal scheme, all of us have experienced situations where we were told the waiting time would be 12 weeks but it has now extended to 14 and 16 weeks. That is a waiting period of four months for an elderly person to get on to the scheme. There has been a cap on budgets and money allocated elsewhere but it is another systems failure whereby high dependancy beds in our acute hospitals, Cork University Hospital and others are not being freed up. That has had a knock-on effect on the waiting lists for inpatients because the beds are not available as a result of the fair deal scheme not functioning correctly, and not enough funding is being put into it.

Another knock-on effect has been on the ambulance service. Funding to the ambulance service has been cut so much ambulances do not get to patients in time. Those patients spend longer in hospital, which ties up beds. Our waiting lists with regard to inpatients has gone from 1,700 to 8,692. That is the domino effect of one issue on another. I ask the Minister to examine the ambulance issue nationwide because not only is it a problem in Kerry and Cork but all along the west coast. There is no doubt that distance is a factor. We hear talk of deploying helicopters and dynamic deployment. Dynamic deployment is a good way of saying we are guessing where the accident will happen. If those in the national ambulance service are asked what that means, they will give one a long explanation but it is really that they are dividing resources because resources have been cut. In the long run it is costing the health service and the Minister's Department more money than it should but it is also having a major knock-on effect on other services in terms of tying up beds and ensuring poor and in some cases fatal outcomes for the patient.

I thank the Minister for a comprehensive statement on the programme for 2015. There are many challenges but it is important to state that both the Department and the Health Service Executive are facing up to those challenges.

It is important to note that funding of over €13 billion is being put into this budget but that funding does not belong to the Government. It belongs to the taxpayer, and that money has to be collected from the taxpayer. Currently, the health budget is costing €260 million per week in real terms, which is a substantial sum of money. The question is about making sure we are getting value for money. The programme the Government had to do in the past three and a half years was to ensure that we worked on eliminating the inefficiencies in the system.

It is easy to be negative about the hospital services but we must examine the positives. My colleague on the opposite side of the House spoke about the negatives but one positive with regard to the first eight months of 2014 was that the total number of outpatient attendances was 2.14 million, which is an increase of 25% on the previous eight months of 2013. That works out at 63,636 outpatient attendances per week. That is the demand on the health service, and that is the demand that has been delivered on up to the end of August 2014.

My colleague on the opposite side spoke about the ambulance service. The national ambulance service recorded an increase in emergency calls of approximately 1,000 per month in the first eight months of 2014. Notwithstanding that, improvement in response times continued to be made, with ECHO calls reaching the target of 75.3% and DELTA response calls improving from 64% to 67%.

I acknowledge it has not reached all the targets but progress certainly has been made in this regard over the past eight or nine months, which I welcome. As for specialist palliative care, I note that 94% of specialist palliative care inpatient beds were provided within seven days of referral, which is also a positive development. The number of home help hours provided up to the end of August was 6.8 million, while home care packages have increased by 20% above the expected levels. Again, this is an area that is being dealt with but it is obvious that the Government must make sure it continues to ring-fence the funding and to increase it, because demands are increasing in this regard. The Minister has already outlined the status of the new hospital groups, as well as the Government's appointment of the six new hospital group chief executives. This is also reform the Government had promised, on which it is working and which is being delivered.

In respect of section 38 and section 39 organisations, I have raised concerns about this area going back to October 2013. More than 2,600 organisations receive funding from the Health Service Executive, HSE, in this manner and in both 2013 and 2014, more than €3.27 billion of the budget went to the aforementioned 2,600 organisations, which provide a good delivery of service in the areas in which they are working. However, there is also the issue of governance and accountability, which has been challenged and dealt with over the past 12 months. It has involved making sure that inefficiencies are dealt with and that moneys allocated are spent in a proper manner. Again, in recent weeks there have been instances in which problems have been identified and which are being dealt with.

I refer to one area about which I have concerns, have raised consistently and which will be a major challenge in 2015. The Minister referred to the memorandum issued by the HSE to hospitals about agency doctors and two-month contracts. I have concerns about that memorandum because of the number of hospitals that are completely reliant on agency doctors. If agency doctors are not available, difficulties will arise in providing replacements for them. I am aware of hospitals that are highly reliant on this structure of agency doctors, particularly in respect of non-consultant hospital doctors and while this should not have arisen, it has occurred. I am also concerned that the number of non-Irish doctors entering this country is not going to increase and, if anything, will decrease over the next 12 months. This will cause its own problems in the sense that the Government appears to have lost a battle in respect of retaining Irish doctors. Moreover, I am not satisfied that a sufficient amount of work is being carried out in respect of the MacCraith report. In fairness to the former Minister, he set up the mechanism to examine how the service could be improved with regard to the retention of junior doctors. I do not believe the HSE or the medical training bodies are acting fast enough. I also have concerns as to how the Medical Council is dealing with matters. I recently had a discussion with a senior consultant in a Dublin hospital, who had identified two good medical practitioners as candidates to come to work in Ireland. They have now run into problems with the Medical Council as regards their registration. I also have encountered cases of people who graduated in Ireland and worked in Irish hospitals for a number of years. They went to New Zealand and within two weeks of applying for registration in that country, secured it. When they tried to return to the Irish system, it took the Medical Council eight weeks to get them registered. This is unacceptable at a time when people are badly needed.

I also have concerns about an issue with which the Government must deal. It is unfortunate that the proposal put forward regarding the employment of medical consultants has been voted down by the Irish Medical Organisation, IMO. There are major challenges in this regard and what I am disappointed about is that I had tabled a question on this matter at the last health meeting. However, information was not provided to me on the numbers and locations of current vacancies.

Well over 250 consultant positions are vacant. It is unfortunate that although the HSE released this information to the media, I still have not received it even though the HSE promised it to me on 23 October. It is a major challenge as regards how we deal with the issue. One in four consultant positions are vacant in Waterford hospital and it shows the failure of long-term planning in the HSE over many years. It is a major challenge for 2015 and we must prioritise dealing with it over the next three to four years. The Minister has comprehensively set out the programme for 2015. It is extremely well planned and I hope we will continue to see the improvements we seek in the health service and deal with new challenges that will arise. We are working on it. I thank the Minister and his predecessor, Deputy Reilly, for the long-term planning he did while he was Minister.

Well done to the Minister on his statement on “The Pat Kenny Show” recently that a maternity hospital is to be co-located with the national children’s hospital and the fact that he has asked the national children’s hospital board to consider applying for planning permission for it. It is very much welcomed by us all. After 20 years of wasted time, nobody knows better than the Minister that many of those who were children at the start of this project are now adults, and we still have no hospital. The Minister is entirely focused on getting the job done for us. I am here because we are heading into a site that is crippled with flaws. Most of my questions come from the medical community, particularly someone who has been very helpful to me and who wrote a long letter to the Minister in September, paediatric oncologist, Dr. Finn Breathnach, formerly of Crumlin hospital, who is extremely concerned about the site.

The national children’s hospital board will have a very difficult job regarding planning permission. With the advent of the fact that the maternity hospital will be co-located with the national children’s hospital, we are going from 108,000 sq. ft. to 165,000 sq. ft. Justine McCarthy’s excellent article in The Sunday Times last Sunday mentioned that An Bord Pleanála considered a planning permission application for a private hospital in St. James’s Hospital a few years ago and the neighbouring Rialto association vehemently objected to a 29,000 sq. ft. hospital. There are no prizes for guessing that the local residents will be up in arms about the prospect of a 165,000 sq. ft. children’s hospital.

By whom and how was it decided that 165,000 sq. ft. was the appropriate size for the national paediatric hospital, the maternity hospital and their expansion space? The new Colorado children’s hospital is 134,000 sq. m for only 284 beds compared with the proposed national children’s hospital, which will have only approximately 100,000 sq. ft. for 469 beds. What strategy is in place for future expansion? A Texas hospital has twice doubled in size in the ten years since it was built. A Toronto hospital has doubled in size every decade since it was built.

Can the Minister assure us that everything in the project is in compliance with the public spending code of the Department of Public Expenditure and Reform? As part of the assessment and decision making process into the alternative sites on offer, as required by An Bord Pleanála, in particular the site at the Coombe and the greenfield site contiguous with Connolly Hospital Blanchardstown, such an evaluation should have compared alternative site options in relation to acquisition, decanting, planning, building and future running costs.

Millions of euro of public money was wasted due to non-adherence to this evaluation process in the case of the Mater site. In 2012, we were talking in terms of spending €485 million and now the figure has increased to €650 million. Expenditure of €485 million to €650 million is in the realm of telephone numbers. The cost of siting the children's hospital at Connolly hospital was estimated to come in at €500 million because of it being a greenfield site and close to the M50. The Minister knows the details as they have been stated time and again.

My third question is how can the Minister stand over his assertion that St. James's Hospital will offer the best adult hospital co-location and clinical outcomes for children given that major priority adult specialties identified by both the task group on location and the McKinsey report are not in St. James's Hospital? The local task group in 2006 found there was no evidence in the medical literature to support a claim of improved outcomes associated with adult co-location - that was stated by Dr. Finn Breathnach.

Some 44 of the most senior paediatricians in Ireland wrote to the Minister's predecessor, Deputy Reilly, in October 2012 stating that if we wish to improve the clinical outcomes for sick children, the most critical adjacency for the national children's hospital is with a maternity hospital. The Minister's Department admits in its press release of 2014 that these infants are often delicate and corridor transfer minimises the risk of destabilisation during an external transfer. In view of the clinical importance of maternity co-location, I greatly welcome the Minister's decision, as I said earlier. However, sadly, I note in an article on page 8 of today's edition of The Irish Times that a baby died following transfer between hospitals. The baby was transferred from Limerick to Crumlin, then to the Coombe and back to Crumlin again, but, unfortunately, that baby did not make it because ambulances are incredibly stressful for little babies.

I will move on to my fourth question. Numerous concerns regarding the feasibility of building the national children's hospital on the St. James's Hospital site have been brought to the Minister's attention. He will be aware that the plans for this site include a major national cancer centre in addition to the national children's hospital and a new radiotherapy unit and co-located maternity hospital. I understand that neither the Minister nor his officials have seen an up-to-date master plan incorporating these facilities for the St. James's Hospital site. For the sake of financial governance, accountability, transparency and public confidence, will the Minister and his Department absolutely reassure us and the public that the St. James's Hospital campus has been shown on a master plan to adequately accommodate all of these major developments and capacity for their future expansion? I note advice in the public spending code of the Department of Public Expenditure and Reform which states that where necessary, Departments and public bodies should be prepared at any stage, despite costs having been occurred in appraising, planning and developing a project, to abandon it on balance that its continuation would not represent value for money. I know for a fact that the Minister is a brave man. I know he does not do minute management but for the sake of the children of this country it is not too late to turn around.

I need to ask the Minister about three Jack and Jill Foundation babies who have come of age. He knows that we let them go at four years of age to the care of the HSE. These babies, Freya Doyle, Cillian Fottrell and Tom O'Leary, need 24-hour care; they are tube-fed and are prone to having epileptic fits. He has heard about them before. It is impossible for their parents to cope. On reaching their fourth birthday, our nurses try to negotiate with the HSE and it is proving impossible to get a home care package for them. I will write to the Minister and set out the details for him. Those in the Jack and Jill Foundation get very attached, naturally, to the children they care for and they are very distressed about this and they will issue a press release on this later this week.

I welcome the Minister to the House and I thank him for his detailed report. I admire that he is straight, honest and tells it as it is. That is a good trait. He does not flower it up, rather he tells it as it is and says things are not in a good state at times.

I am delighted to hear the Minister give a commitment for an extension of BreastCheck to women between the ages of 65 and 69. I have been campaigning for this extension for some time and I raised it on the Adjournment some time ago. Even though the figures provided by the Minister were disputed at the time by the Irish Cancer Society, I think the society will be very pleased to hear that this extension of the programme will be rolled out.

Senator Daly referred to the ambulance service in County Kerry. The Senator tends to be over-dramatic at times but there are problems with the ambulance service. We have had several meetings with the ambulance service in Kerry and in fairness the chief ambulance officers have always attended the meetings and given us detailed information on the service. However, I was told recently that a person collapsed in a nursing home and needed to be resuscitated. The ambulance service was telephoned and the information was given a few times that the ambulance was ten minutes away but it was 40 minutes before it arrived. At least people should be told the situation as it is - just like the Minister does - rather than fooling people by saying that the ambulance is only ten minutes away when it is nowhere near.

I cannot let the opportunity go without mentioning medical cards. I will not speak about the office dealing with medical cards because that issue is a broken record in so far as I am concerned. I welcome the Minister's statement during the week that terminally-ill patients will not be required to renew their medical cards. That is great news because it was devastating for families to have to provide information time and again and to ask a doctor to state that a mother, husband or wife was going to die. It is not nice. I am delighted that the Minister has addressed that issue.

However, in my view, we have to move away from the current model whereby a medical card entitles a person to a lot of supplementary items such as school transport. Why must a person with a medical card be given free school transport? Why is entitlement to school transport not decided by the Department of Education and Skills? I suggest that the Department could means test people to see whether they have an entitlement to free school transport as is the case for the back to school clothing and footwear allowance. Why must a person with a medical card be exempt from PRSI? The loss of a medical card entails losing so much more than medication or doctor visits, such as home help, a wheelchair and hoist equipment.

I know of a young man with muscular dystrophy who was refused a medical card but it was reinstated on appeal. However, the minute he lost the medical card the HSE contacted him to ask if he wanted to rent or buy a wheelchair and a hoist and the track for the hoist. That is a hard blow to anyone who has just lost the medical card. Thankfully, the young man's medical card was restored on appeal. We need to move away from the current model. These services as I have outlined should be provided independently of a medical card and these facilities should be available without the guarantee of a medical card. For example, the free fuel allowance or a grant for house insulation should be separated from the Department of Health and they should be administered by the appropriate Departments.

Last May I got together with a number of interested stakeholders to put a submission to the national framework for suicide prevention. We made a detailed submission including a call for the development of a national suicide prevention authority to consolidate and co-ordinate the objectives of the existing voluntary suicide prevention organisations with Government funding and sustainable leadership. We carried out research which showed that Australia was one of the first countries to develop a national strategic approach to suicide prevention and these efforts have contributed to a decrease in the rate of suicide. A key element of the success of this programme has been the commitment from the Australian Government to fund suicide prevention programmes. We propose that the national framework for suicide prevention be modelled on the Australian programme, Living is for Everyone - a framework for prevention of suicide and self-harm.

Will the Minister advise the House as to when the results relating to these submissions will be published and indicate the outcome in respect of them?

I welcome the additional €35 million in ring-fenced funding that is being made available in respect of mental health services. We must ensure this money gets through to service users. It is great that people are being moved back into the community. I agree with this policy but I am not in favour of service users being moved outside their own localities. There have been instances where people have been obliged to move many miles away from their homes, families and friends. That is not ideal, particularly in the context of receiving visitors, etc. We should debate mental health issues in the House but I accept this might be work for another day. I am sure the Minister of State with responsibility in this area, Deputy Kathleen Lynch, would come before the House for such a debate.

At a recent meeting, representatives from the HSE and Oireachtas Members discussed the lack of consultants in hospitals. We were informed that it is not the latter which increases the numbers of waiting lists but rather a lack of administrative staff to support consultants. It was also stated at the meeting in question that if given a choice between being allocated an additional nurse or extra administrative staff, consultants would opt for the latter. Consultants have not been able to replace administrative staff who have left their employ and this means there is no one to set up appointments, send out letters, carry out follow-up actions and keep records. This is giving rise to many delays in the context of granting people appointments.

I would appreciate it if the Minister could comment on some of the issues I have raised.

I welcome the Minister. I wish him the best in his efforts to try to reform the health service. The Minister does not need my advice in this regard but I urge him to remain firm and steadfast in respect of the national children's hospital. The decision has been made and the hospital should be built. As I have written and stated on multiple occasions - and I mean no disrespect to anyone involved when I say this - one cannot obtain an opinion from any professional commentator on this issue which is not tainted by institutional prejudice. I am not referring here to self-interest and I am not saying that people want to line their pockets. Rather, I am referring to the fact that people love and have loyalty to the institutions in which they work and they naturally have a desire to see these institutions being built up. At the time the relevant decision was taken, I believed that the right thing to do was just to rebuild Our Lady's Children's Hospital, Crumlin, on the existing site. When it was then decided to locate the new hospital on the site of the Mater, I also voiced my support. Through gritted teeth I indicated my opposition to the delay caused by what seemed to be an utterly irrelevant intervention on the part of An Bord Pleanála, which seemed to be offended by the fact that the view northward up O'Connell Street would be destroyed by the sight of a wonderful monument to our desire to care for our children being built near the site of what were some of the worst slums in the history of the State. Of course, the mortality rate among the children who lived in those slums was among the highest in the world at the time. Now that the decision has been made to build the new facility on the site of St. James's Hospital, I support it 100%. The Minister should go ahead and deflect it and should not allow anyone to deflect him in that regard.

At some quiet moment, the Minister should ask the people who made various statements at the time of the controversy surrounding Roscommon hospital to give him the relevant telephone numbers in order that he might issue quick and gentle apologies to Dr. Paddy McHugh and the staff of that institution. During the most recent general election campaign, Fine Gael pledged that Roscommon's accident and emergency department would remain fully open. When the decision in this regard was changed shortly after the general election, it was suggested that this was done on the basis of a report which showed an unconscionably high mortality rate among heart attack patients at Roscommon hospital. The then Minister, Deputy Reilly, to whom I gave great support, stated at the time that he felt he had no alternative other than to close the 24-hour accident and emergency service at Roscommon hospital and that patients who suffered heart attacks would be transferred to Galway, where they would be safer. It subsequently emerged that the figures with which the then Minister had been presented were entirely incorrect. I am not stating that the current Minister should revisit the issue of restoring the full accident and emergency service at Roscommon hospital. However, Dr. Patrick McHugh and the staff at the hospital, who built up the cardiac unit which it was suggested had an unbelievably high mortality rate among heart attack patients, are owed an apology. Roscommon hospital was completely neglected by successive Governments over many decades. The staff there went to great lengths to ensure decent care was available to those who suffered heart attacks. The record in respect of Roscommon must be put straight.

It was not the Minister's doing, but I have grave concerns about the graduate nursing programme. I note the Minister will try to plug some of the gaps which, ludicrously, are being plugged at present by more expensive agency nurses. Parenthetically, I have often attended going away parties of nursing staff in my hospital, only to return to work the following day to find them back working at their old job at a higher rate for an agency. It is one of the many dysfunctions I believe the Minister will attempt to address. The Minister is, perhaps, the straightest-talking politician I have ever encountered in Ireland. We need very firm assurance the graduate nursing programme has not, is not and will not be used as a means of replacing fully-paid experienced nursing staff with cheap labour.

Will the Minister philosophically address the issue of corporatism in the health service? The health service is the people's health service and not a separate corporation for which the people are some type of external threat. It sometimes seems this is the case. I understand there can be legal complexities in specific cases in the Department, but recently there have been multiple examples where it is very apparent people were badly treated by the health service. Even a good health service will occasionally get it wrong and there will be legal challenges and people will need redress. Something needs to be done about a corporatism which allows individuals to be kept dangling five, ten or 15 years, with multiple legal denials of wrongs which the health service and its lawyers know occurred. There must be a better, more efficient and more humane way to deal with this.

I would like the Minister's assurance that the recent disclosure of data about the spending policies of some aspects of Positive Action, which represented a group of women who were very shabbily treated by the State, was truly coincidental. The women it represented are hepatitis C sufferers, infected with the potentially lethal virus by the incompetence of actors of the State which, in some cases I believe, was covered up in a malfeasant manner by the actions of the State. I find the level of coincidence troubling, as it happened when agitation was being launched on spending money on drugs which could cure these women of an illness which, in many cases, the State gave them.

I have received multiple representations on medical cards for people with specific disorders. I was troubled when we heard some weeks ago that members of the expert group threw their hands up in the air, stated it was too difficult and they could not do it. Will the Minister tell them to go back and try harder? Recently I spoke to a mother of three children with muscular dystrophy, and the Minister knows as well as I do the inevitable decline of those who suffer diseases such as muscular dystrophy and Friedreich's ataxia. They will never be able to work normally or return to work. They will need maximum support. In the presence of some of these conditions people should automatically qualify for the full assistance of our health service.

Recently I spoke to a neurosurgeon who works exclusively in private practice in Dublin. He told me the combination of the elevation to €11,000 per month of the malpractice premium he must pay, with the fact the VHI has reduced its reimbursement structure for one of the bread and butter procedures he does, means the arithmetic no longer adds up. He has tendered his resignation and is moving to another country. One can argue this is the private sector, but all of the patients I send to him in the private sector will now go to the public sector. Stereotactic radiosurgery, an increasingly used treatment modality for patients with primary and secondary brain tumours, is available on a national level in Beaumont Hospital. I believe the system will go under when this particular private outlet is removed. I desperately ask the Minister to examine the circumstances. He is the sole shareholder of the VHI, which has partly contributed to this situation.

The Minister must examine the question of waiting lists. He is an impressive young man and I am an older dog. I believe very firmly that waiting lists are the business plan of the HSE. It is built into the structure. When people are on the waiting list they are free. When they come off the waiting list they cost money. This is the fundamental arithmetic of how a system such as ours is budgeted and financed. I ask the Minister to please remember he came into power with a Government which, more forthrightly than any before, put on page 1 of its election material the intention to reform the health service.

It was specific about the type of reform it would follow. We were going to get a Bismarck-style, insurance-based mixture of social democratic and private health insurance to replace the current State-funded scheme. That was one of the reasons that I and others so enthusiastically supported the Government.

I cannot begin to tell the Minister how crushingly disappointed and cynical it makes me about the process of politics when one views the trajectory of this issue's handling throughout the course of this Government, from an early statement following the election that, while the Government would do it, it would happen after the next election, to the recent disclosure of documents from the actual civil servants and bureaucrats whose job it would be to implement this popularly mandated and democratically authored policy with which the Government went to the people and for which the people supported the Government to implement showing that they did not believe it could be done. There were also recent disclosures to the effect that the Minister did not believe it could be done.

The Minister bears a greater responsibility than just fixing the health service. I am sorry if I sound like I am inflating the issue but, as a democrat, the Minister bears a responsibility for preserving the integrity of our democratic process, which has recently been shown to be under great threat. There is a tendency of people leaking their loyalty to democratic parties to organisations that have a thin veneer of adherence to democracy. The only argument that we can advance against people who do so is that truly democratic parties are better, more honest and more reliable and will do what they say. This is a part of the mantle that has been passed on to the Minister. I hope that he understands the seriousness of that responsibility.

I welcome the Minister to the House. I wish to raise the issue of the size and condition of the accident and emergency unit at University College Hospital, Galway. The unit was not built all that long ago in the grand scheme of things, but it is now unsuitable. Several matters are involved, one of which is the perennial shortage of beds in the main hospital ensuring that patients are backed up in the accident and emergency unit. While the situation is on the Minister's agenda, having been raised with him previously, I wish to refer to the building's physical size and layout. It is unsuitable for a modern accident and emergency unit. Even if there were dozens of beds available-----

I apologise, but Senator Naughton has mistaken this for a matter on the Adjournment. Could the Leas-Chathaoirleach check the schedule, please?

She is entitled to make a five-minute contribution.

These are statements on health. Even if dozens of beds were available in the hospital, which there never will be, the unit would still be unsuitable. To illustrate my point, the resuscitation unit is located immediately on the right-hand side as one walks through the unit's inner doors. There is a small room beyond that point. It is not a clinical space, but a family waiting room where those who lose a loved one suddenly are brought to view the person's remains after efforts to revive him or her in the room next door have failed. It is also the room where someone whom I know was brought to get an ECG on presenting to the accident and emergency unit, as there was no other space available. It is the same room where that person's loved one was laid out several years previously.

No one is blaming the hospital's staff. They do a wonderful job under considerable pressure. They simply have no other space in which to perform ECGs. Surely our hospitals should have suitable clinical facilities in which to carry out simple ECGs instead of having to use what are effectively mini-mortuaries. This is not caused by a lack of beds in the main hospital, but by the unsuitability of the building.

Since the accident and emergency unit of UCHG was remodelled, major changes have occurred in Galway. In terms of demographics, it is one of the fastest growing cities in Europe. The hospital's unit is also the trauma centre for the region's seriously ill patients. In recent years, smaller units in the region have closed due to safety concerns, leading to Galway being the first port of call. All of these patients are funnelled through a unit that is not designed to cope with such numbers.

UCHG is the designated centre of excellence for the western seaboard from Galway to Donegal. However, any cancer patient who becomes ill post treatment must present through the accident and emergency unit in the normal manner. This is not only traumatic for the patients, but places even more pressure on the unit. The Minister is familiar with the situation. The hospital needs investment. It is not designed to cope with the numbers being expected of it. I urge the Minister to prioritise capital spending for a new unit in Galway.

I call Senator Leyden.

I imagine this will be about Roscommon hospital.

I wish to share time with Senator Healy Eames.

Is that agreed? Agreed.

I welcome the Minister, Deputy Varadkar, to the House. I served in Hawkins House some time ago and I recognise it is a very difficult task in the Department of Health and I do not intend to make the Minister's task any more difficult.

I could have spent all of my time today talking about Roscommon County Hospital. I express thanks to Senator Crown. I welcome his genuine support for justice for one of the finest medical consultants this country has ever produced, Dr. Pat McHugh, and the staff of the medical section of Roscommon County Hospital. I want the Minister and his officials to check the file and avoid a prolonged legal case that would not really be feasible at this stage. The former Minister, Deputy Reilly, made allegations about the mortality rate at Roscommon County Hospital which proved to be totally inaccurate and Senator Crown has made a very persuasive case on this. I have not spoken to Dr. Pat McHugh, the retired chief physician at Roscommon County Hospital who had worked there since 1977. However, I met him during the election campaign and he was very hurt by the comments made by the then Minister for Health, Deputy Reilly.

As someone who was in that Department, I suggest that the Minister, Deputy Varadkar, should ask his legal department and his advisers to look at the file. I cannot speak for Dr. McHugh, but I know he does not want compensation or anything like that; he just wants to clear his name. The Minister is a doctor and he knows the feeling if somebody made allegations against him. The Minister was not in practice that much. As far as I know he qualified as a general practitioner, but I do not think he had much opportunity between politics and his medical career. However, the allegations were very hurtful and very unfair. I suggest to the Minister that after reading the file he should clear Dr. McHugh's name under privilege in the Dáil. He should point out that certain things were said during that debate and that now, as Minister for Health, he wishes to clear the decks.

I could spend a lot of time talking about Roscommon County Hospital. I ask the Minister to look at the situation. He was at the hospital during the campaign. He met the staff. He knows the feeling regarding the accident and emergency unit. The major ambition in Roscommon is to have that reopened. I welcome the endoscopy unit that is being built at the moment. I welcome any developments in the hospital. I want the retention of the acute psychiatric unit. When I was Minister of State in 1987 it was agreed that the psychiatric units would be part and parcel of the acute general hospital in Roscommon. That made it viable at the time to retain it as an acute general hospital. That worked then and it is working now. I am asking the Minister to ensure that is retained.

Regarding the urgent care centre, during the local election campaign a woman collapsed on a street in Lisnamult in Roscommon town and she hurt her leg. The ambulance came but the paramedics refused to bring her to the urgent care centre in Roscommon. I ask the Minister and his officials to check why she was not taken there. I asked the driver if he would bring her to Roscommon and he said, "Oh no. We've been instructed to bring her to Ballinasloe." They passed Roscommon County Hospital. To provide treatment for an injured leg on a normal day between 8 a.m. and 8 p.m. is quite within the scope of the urgent care centre. I ask the Minister to communicate through his officials with the HSE that where a person collapses in those conditions in Roscommon town or anywhere in the county during the day, the ambulance should be directed to Roscommon County Hospital in the first instance and not to Portiuncula or Galway.

I could have a lot to say but my main contribution was as a result of Senator Crown's intervention today.

The Senator has left one minute for his colleague.

We might give her two.

The Minister is very welcome. I wish to raise policy issues around the emergency unit in Galway University Hospital. The level of overcrowding is dangerous. I have received the following comments:

If this was any other workplace, it would be closed due to health and safety. It was like a scene from a film of a catastrophe or a warzone.

The previous Senator from Galway who spoke also mentioned the stress on the unit there. I believe the Minister mentioned that there are 46 primary health care centres around the country. What is he doing to incentivise attendance and reorientation towards the primary health care centres instead of the emergency room? That is a valid question to ask. Where is the promised primary health care centre for Oranmore? The former Minister for Health, Deputy Reilly, bumped it down the list in favour of Balbriggan; so the Minister, Deputy Varadkar, might look at that.

There is a serious issue with overcrowding leading to dangerous situations for staff to work in. I will give one quote from last week.

There are patients on trolleys and chairs if they could find them. Some were standing. It was so bad that there were three ambulances parked outside. Two ambulance staff were waiting in the waiting room with their trolleys, which were also full. One managed to get through the doors of the treatment room. I tried to get a drink of water, but I had to wait for staff to finish working in the small space between the chairs and the trolleys. The staff were fantastic. They apologised continuously and smiled through it all. They have nothing to apologise for.

The danger of infection in that environment is high - particularly cross-infection. In this case this was a cancer patient who asked me very simply why such patients when coming back for care are not admitted straight to the oncology ward? Surely that is a guideline from the Minister for Health.

The Senator's time is up.

In the event of a fire in an accident and emergency room how would people be evacuated safely?

How can the issue of isolation be addressed?

The Senator is way over time. I call Senator Kelly.

I ask the Minister to give us his thoughts on ways to improve the accident and emergency situation in Galway University Hospital.

I welcome the Minister to the House. I agree with Senator Crown's contribution on Roscommon County Hospital and the good name of Dr. Pat McHugh. I agree with his words on the Naughton family from Roscommon who have three children with muscular dystrophy. It appears that the Department of Health is doing nothing to assist them. The family are out fund-raising to save the lives of their three children. Not enough is being done for them.

As other speakers have mentioned, I wish to raise the frustration people feel dealing with the PCRS when trying to acquire a medical card. I was a community welfare officer for 28 years dealing with medical cards at a local level on Roscommon. There were no issues when they were being dealt with at local level. I was a county councillor when it was proposed to centralise it and I said it would not work. I was right; it has not worked. People are frustrated trying to get a medical card. In many cases they are frustrated when they are entitled to a medical card. I am not even sure if the Minister is aware of this. When a person applies for a medical card in eight out of ten cases either the PCRS will lose some of the documentation sent into it or will claim it never got it. It will write back to the applicant stating that he or she has 21 days to send it in again. When it is sent in again, it will not look at the file for 21 days. Then if something else is missing, it is a similar issue. So issues drag on and on when people are looking for medical cards.

I know of a mature student who has been trying to get a medical card for the past 12 months. There is correspondence going from my office to the PCRS and to him for 12 months and he still does not have a medical card. He has absolutely no income. He is not getting a grant. He is being supported by his elderly parents and is also being supported by the Society of St. Vincent de Paul. I have on file a letter from the Society of St. Vincent de Paul here in Dublin verifying that it is supporting him while he is studying law. With absolutely no income, he still has not got a medical card after 12 months. This is the kind of thing that is going on and nobody is addressing it. When I raised those issues with the HSE, I was asked if I would be prepared to go out to the PCRS and discuss these issues with officials there. I said I would, but I never got the invitation to go.

I wish to speak about those aged over 70. I recently met a 75-year old lady who exceeds the medical card guidelines by €9. She has many medical issues and is on a considerable amount of medication. She has frequent doctor and consultant appointments. As she is over the threshold by €9, she is not entitled to a medical card. If she was over by €1, she would not be entitled to a medical card. For her to be assessed on health grounds and financial grounds, a different guideline is applied to her, which is a guideline for a person aged under 70. This makes no sense; she is 75 years of age.

There should be a mechanism that if she is over by €9, in the same way as if she is under 70, and if she has medical expenses, that they should be added on to the €500 guideline to give her a chance of getting a medical card. I ask the Minister to respond to the issues raised.

I welcome the Minister to the House. I have a number of issues I would like to raise, particularly in the area of children's health. I apologise in advance because I will have to leave early as there is a meeting of the Committee on Health and Children at 5.30 p.m. on child protection which I need to attend.

The first issue I would like to raise is the issue of mental health. I know the Minister of State, Deputy Kathleen Lynch has responsibility for this area. However, it is the effect on the whole of the health brief that is very important. I would like to get comfort from the fact the money is secured. However, we heard this in 2011, 2012, 2013 and 2014. Money is ring-fenced for mental health but we are not seeing the delivery of the services. We have no proof of how this money is being spent. In fact, if anything, I am hearing from professionals - certainly in the children and adolescent mental health services - of it getting progressively worse to access services. I am very concerned - as the Minister knows and I know and everyone in the House knows - that the likelihood is that it is going to be during the teenage years when a mental health difficulty will first present. The majority are at that time. That first experience is critical. Yet we are seeing children having to wait four months, nine months, a year. This has an effect on their education, their community and their social environment - all those other aspects. However, it also has a huge effect on their whole lives, every time they experience a mental health difficulty.

We particularly see it in children in adult psychiatric wards. I have yet to meet somebody who agrees they should be there. However, we have seen an increase during the past year of the number of children in adult wards. I tried myself to understand why this is happening. My understanding is that some children and adolescent units are self-selecting the issues with which they will deal. They are saying - I can give an example, but I will not name the unit - they will deal with eating disorders but that is it. When there is a child with a complex or behavioural issue, they will not deal with that child. The child is moved on and pushed around the country. Can the Minister imagine that experience, without even having a mental health difficulty? Being pushed on because the person does not quite fit into the type of issue with which they want to deal. It is unacceptable.

We need clear national co-ordination, which is not happening. It needs to be considered unacceptable for a child to be in an adult psychiatric ward. Concerns are being raised by the Royal College of Surgeons in Ireland, RCSI. There are increasing waiting lists for child and adolescent mental health services. We can see the impact of this. We have seen it in recent HIQA reports into child welfare. Social workers cannot get children to access the mental health services. Where do these children go with all these complex cases? We see it also in the recent report of Carol Coulter from the Child Care Law Reporting Project, which provides details of the mental health issues of children who are ending up in the courts. It also deals with the issue of their parents with mental health difficulties. Children are going into care because their parents cannot access services. On that report, I was interested to see that the reason for almost 40% of children going into care is either addiction or physical or mental health issues. These are issues with which the health services are dealing. We very much need to clearly link and see the impact on services.

I welcome the Minister's statement on the GP services for children under six years of age and his recommitment to that and for people over 70 years of age. I note the Minister says this is to be without fees. Reports in newspapers today that fees will be charged are erroneous and misinformed. I have clearly heard the Minister say this and I read it in his statement.

The other issues I wish to raise concerns cardiac rehabilitation services and stroke issues. They are fragmented and poor. In particular, on the issue of strokes, there was a report compiled for the Irish Heart Foundation by the ESRI and the RCSI entitled Towards Earlier Discharge, Better Outcomes, Lower Cost: Stroke Rehabilitation in Ireland. It clearly shows that the savings from reduced hospital costs would outstrip the cost of early supported discharge. The difficulty, that the research clearly showed, is that community rehabilitation services in Ireland are appalling, with one in three discharged stroke survivors having no access to physiotherapy, half getting no speech and language therapy or occupational therapy and just one in ten having any psychological service despite the huge mental health impact a stroke can have on a person. This is something that is backed up by the Neurological Association of Ireland on many of the neurological conditions. I ask the Minister if he accepts the findings of this report and what plans are being developed to implement a national supported early discharge programme for stroke survivors in Ireland.

I wished to raise the issue of obesity as well, but I will have to do that another day.

I, too, welcome the Minister to the House. Listening to the contributions here today, he would probably need to be a magician in order to keep everybody happy. It is probably a unique ministry in the sense that it has such a big budget and there is such a varied level of responsibility from health prevention to dealing with crisis management, not just on a daily basis but on an hourly basis. I do not think anyone can envy the Minister for the task ahead of him. All we can do is wish him well and express how impressed we are with him in his initial few months as Minister for Health. The Minister's straight-talking nature has certainly given the public confidence that the health portfolio is in competent hands. That is to his credit, particularly during a period that is very difficult for the Government.

We are all going to talk about our own areas, to a large extent. The Minister has attend the House previously to deal with a Private Members' motion on the issue of a strategy for vision. It was a useful and worthwhile engagement. I would like to think that we are going to see a strategy for vision properly developed, with the Department as the core participant and the people who are going to construct it. Everybody has a right to retain their eyesight. If that can be achieved by a comprehensive strategy for vision encompassing all the stakeholders it would be a very worthwhile endeavour. We have spoken at length on that in the House before.

Today I wish to raise the conditions in the accident and emergency unit in University Hospital Limerick and how unacceptable they are. The Minister gets a bulletin on the number of people waiting on trollies three times a day. I know that he is on top of this issue. However, I invite the Minister to visit the Mid-Western Regional Hospital in Dooradoyle in Limerick unannounced some time. It is one thing to get figures printed on paper or on an iPad and it is important that the Minister does so. I know he takes them very seriously. However, it is another thing to see the consequences, in action, on a Saturday night when it is at its peak, and to see the heroic efforts that staff make to try to ensure that everybody is seen and the appalling conditions in which they are working. Seeing is believing. It would be a very useful exercise for the Minister to call unannounced as Minister for Health, the person ultimately responsible at political level for the delivery of health services in this country. It is something the Minister should do, and he should do it sooner rather than later.

I believe that the accident and emergency department in Dooradoyle is probably the worst in the country. There is a capital investment taking place and there will be a new accident and emergency unit, probably in 2016. That is very welcome and every effort is being made to accelerate it to ensure there is no undue delay and that it will be fast-tracked as much as humanly possible. That is acceptable. However, there are interim measures that can be taken. We need to think outside the box in terms of identifying ways of doing things in the meantime - for the next two years - for the thousands of patients who are going to need to use the service over the next two years. When I speak of thinking outside the box, I speak of looking at the possibility of extending the opening hours of the accident and emergency unit in Ennis Hospital to alleviate some of the pressure. Reconfiguration, we were told, is a good thing. Unfortunately, the capital infrastructure should have been there before reconfiguration became a reality.

It was not and the Minister must take a fresh look at both extending the opening hours and upgrading the service at Ennis Hospital's accident and emergency unit between now and the coming on`stream of the new building in Limerick.

I welcome the Minister and like other Senators, I heard his interview with Pat Kenny. One of the many good things in it was when he stated the sickness absentee rate among health service staff was now down to 4%, because that had been a scandal and I am glad it has been tackled. My metaphor for the health service, however, is that if I arrive in Heuston Station, I see a hospital across the road that is now inhabited entirely by bureaucracy. Between the mid-1980s and 2008, we doubled the number of staff in the health service from 55,000 to 110,000. It has fallen somewhat since then. Some staff have been transferred and there have been genuine productivity increases. I do not know what we were doing at that time but as for the appetite for more spending, more staff and staff in hospitals getting on to their politicians to claim the service is seriously underfunded and so on, we have had such a diet for quite long enough. According to the Department of Health's annual report for 2010, Health in Ireland: Key Trends 2010, the facts are that Ireland is a major spender on health services with expenditure of €3,793 per head of population. This is more than Australia, Belgium, Denmark, Finland, France, Germany, Sweden, Japan and Spain. I believe the Minister has real resource allocation issues in respect of how the system is operated.

I recall from the Milliman report that considered high VHI costs that we were keeping people who were insured by the VHI in bed for 11.6 days, against an average length of stay internationally of 3.7 days. That is a massive waste of expenditure and as the Minister noted in his speech, it is a danger to patients if they stay longer in that environment.

I support strongly the comments of my colleague, Senator Colm Burke, about the organisations that were funded by the Department of Health but which seem to have had a lifestyle most of us thought were reserved for the executives in Irish Water. I refer to the amount of alcohol consumption at a seminar to discuss liver disease and how the Department of Health has allowed these bodies to get away with it for so long, with people earning more than the Taoiseach while parading around as deeply concerned about the illness in question. It is necessary to get to grips with this budget because it is not a service that is starved of funds by the standards of any of the aforementioned countries. It is pretty good at making cases, putting patients upfront and saying these patients are dying because the Minister, Deputy Varadkar, or the Minister, Deputy Reilly, or whatever is the name of the Minister, is some kind of monetarist.

Members should simply look at the newspaper headlines stating pharmacists make huge profits from the State drugs scheme or Ireland has 50% more nurses than the OECD average. We passed the Health (Pricing and Supply of Medical Goods) Act 2013, which was to introduce a system of generic substitution and reference pricing, but what are the savings? While Members seek them now, as the end of 2014 approaches, that legislation was passed earlier. Members also passed legislation in order that the medical card list would be open to newly qualified doctors. However, Members asked the former Minister of State at the Department of Health, Deputy White, and I think probably less than a score of new doctors have been added. The local medical card doctor is a local monopolist and new people are not being allowed in. Banning new people from any activity is not a way to proceed.

Recent research by Paul Redmond that appeared on suggests again that Ireland is among the major spenders on health services. As for some of the Minister's own figures, the expenditure on health per head of the population in 1999 was €2,000, whereas by 2008 it was €3,500. I do not believe the ageing explanation, as there is evidence it could be a red herring. People live longer and are healthier when they so do. One only dies once and the big health expenditure is in the last six months of life. However, I do not want that to be used as a cliché by the Department to have laxity in the way in which it considers budgets.

I hope we will not have yet another year of derogation for the VHI from normal health insurance. The briefing provided to Senators in this regard states that the European Union's third non-life directive forced competition in private health insurance on a reluctant Department of Health. It spent years postponing this and I believe health insurance should be regulated by the Central Bank as a financial service and there should be a level playing field. Competing health insurers should be able to tell the Minister and me that they charge cheaper premiums because they get a better deal. The cliché in the Department of Health, supported by the VHI and by additional levies on the rest of us, is that the VHI's problem is its members are too old. That is not the case. If someone can tell the Minister and me that they will insure both old people and young people more cheaply then VHI, that should be allowed to happen.

I call Senator Gilroy. The Senator is way over time.

I welcome Mr. Boylan to the House and there are all sorts of developments in respect of pharmacy and herbalism. Let us extend-----

Senator, I must call Senator Gilroy.

There are many ways to become healthier. Let us not stick with this current model, because it is not working and is too expensive.

I thank the Cathaoirleach and welcome the Minister to the Chamber. It is sometimes not easy being a Minister for Health. I seem to remember a previous Minister for Health was criticised when he was accused of trying to put some primary care centres into his constituency. If one is to believe the Sunday newspapers published last week, the current Minister for Health is attracting some comment for doing precisely the opposite, that is, for not siting the children's hospital in his own constituency. I suspect the Minister for Health's lot is not always a happy one. While I have a considerable amount to say, I will go through the points quickly before reaching the main substance of what I wish to say. I wish to raise with the Minister part of his own opening address, in which he stated it is his wish and desire to see the level of agency staff being reduced. While I believe everyone shares that view, he also stated that where possible, nursing graduates would replace agency staff on a two-year contract. Is this the same two-year contract that was condemned roundly by nursing representative bodies last year and which has a starting pay rate of €22,000 per year or is this a different two-year contract? I seek clarity in this regard. I also wish to mention briefly an impending crisis in the nursing profession on foot of the recent announcement by An Bord Altranais agus Cnáimhseachais, The Nursing and Midwifery Board, of an increase of 50% in registration fees. I note the representative bodies are encouraging their members not to pay this fee and by January, several thousand pupils will find themselves unregistered. Is a contingency plan in place in this regard and does the Minister have an opinion on it?

As for the main point about which I wish to speak to the Minister, he may be aware that I have a particular interest in mental health. A debate has been scheduled here next week with the Minister's colleague, the Minister of State, and I am not always uncritical of those services. I wish to make two points with regard to the Mental Health Act 2001. They are not in any way locally focused and many might suggest they are a little obscure, but I have spoken about them several times. Section 59 of the Mental Health Act pertains to the administration of electroconvulsive therapy, ECT, to patients who are unable or unwilling to give consent. I believe this part of the Mental Health Act must be amended urgently. The Minister of State has given some indication that she is open to or at least predisposed towards amending this part of the Act but does not appear to have moved on it in any way. The benefits of ECT are contested and while there is some evidence of efficacy, it is not uncontentious. Surely, the agreement of two consultant psychiatrists should not be sufficient to give an invasive procedure to any patient? I do not suggest that ECT should not be used - I do not agree with it myself - but there is a case that it should be a requirement for any involuntary administration of ECT to be argued before the Circuit Court or perhaps the High Court.

Section 58 is another obscure part of the Mental Health Act, so obscure that I have never seen or heard of it during my 30 years as a psychiatric nurse or even during the 20 years before I entered the service. Section 58 of the Mental Health Act pertains to psychosurgery, which "means any surgical operation that destroys brain tissue or the functioning of brain tissue and which is performed for the purposes of ameliorating a mental disorder". I do not know what this provision is doing in a modern Mental Health Act, as psychosurgery has been discredited since the 1950s. I seek the Minister's opinion as to whether Members should attempt to delete it altogether. They should not simply amend it but should absolutely delete it, as I consider it to be barbaric in a modern mental health service that one would find oneself being comfortable in speaking about psychosurgery as an intervention in the treatment of mental health. As I noted, the Minister's colleague, the Minister of State, will come to the House next week and I will have some points to make, not all of which will be complimentary. Indeed, I will have a great number of very harsh things to say about mental health services, some of which have been addressed by Senator van Turnhout. I will raise some more next week but in the meantime, I look forward to the Minister's comments.

I welcome the Minister. It will be interesting to see how he will be judged at the end of his term of office. His predecessors have not been judged very kindly because they did not make the correct policy decisions.

It has been continually stated that the Department of Health is a poisoned chalice. That will only prove to be the case if the Minister makes the wrong policy choices. If, however, he is bold, courageous and radical during his tenure, he will be successful and he could potentially be the most successful holder of the position the State has had in a long period. Everything we have heard from him up to now can be characterised in two ways, namely, he has almost been apologising for the mistakes made in the past and he seems to be seeking to undo the big vision of his predecessor without setting out his own position and vision. That is a matter of concern.

I wish to paint a picture for the Minister with regard to the situation on in the south east because this provides a good reflection of the state of the health service nationally. Since 2007, University Hospital Waterford has lost 300 staff. Of these, 130 were nurses. There are fewer nurses, junior doctors and consultants at the hospital. As a previous speaker noted, we cannot fill many of the vacant consultant posts. Perhaps the Minister might be in a position to shed light on why there is a difficulty in filling such posts in the south east and Waterford, in particular. There are fewer beds open at University Hospital Waterford. In fact, we lost an entire ward there. Perhaps the Minister might do me the courtesy of listening to what I am saying. The hospital also lost two surgical theatres and overall capacity has been significantly reduced. What are the consequences of this? A number of departments at the hospital - including ophthalmology and orthopaedics - are a disaster. Sinn Féin's health spokesperson in the Dáil tabled several parliamentary questions relating to waiting times in University Hospital Waterford on my behalf. The position with regard to the orthopaedic department is an absolute disgrace, with people obliged to wait for up to four years in order to see a consultant. That should not be the case. An arrangement was reached with Cappagh Hospital and we were informed that people would be seen and receive the full complement of care. However, this arrangement was scrapped. I raised the matter on the Adjournment - the Minister was present to reply - but we still have not received a satisfactory response as to why the arrangement in question was ended. People were sent to Cappagh Hospital, some of them were seen but others were not and a number did not receive the treatment they require. I raise these various points because they provide a good flavour with regard to the problems that exist in the health service generally. As is the case elsewhere, services at University Hospital Waterford are stretched and front-line staff are under fierce pressure.

Another matter I wish to raise relates to the closing of the geriatric care facility at St. Patrick's Hospital, Waterford, resulting in the removal of 25 beds from the system. We were promised a new 50-bed unit but this has still not materialised and has given rise to a further capacity problem in the south east.

To return to the Minister's big vision and that of his party, Fine Gael has rowed back on promises in respect of primary care and free GP care for all. The latter no longer appears to be on the cards in the context of the Government's current term of office or, potentially, its next term. Despite the fact that he made a comprehensive opening contribution, the Minister failed to set out what is his vision. I will conclude by reiterating that he will be judged on the basis of what he does. His predecessor said a great deal but he was judged on what he failed to do and on the mistakes he made. I sincerely hope the Minister, Deputy Varadkar, will not follow in his footsteps. I also hope he will not be another failed Minister for Health who talked tough but who did not follow through with policies, reform the system properly, deal with the real issues or break - once and for all - the unequal two-tier health system that exists in this State.

I welcome the Minister and congratulate him on both his appointment and the steady and businesslike start he has made. I also wish to congratulate him on his budget negotiation skills in achieving an increase in Exchequer funding of €300 million and a once-off saving of €460 million. This means the Minister will have an additional €760 million available to him this year.

Despite the extremely difficult budgetary position in which the Government has been obliged to operate in recent years, significant progress is being made. The fact that 6.8 million home-help hours were provided up to the end of August and that the number of home-care packages has risen by 20% is significant. It is simply incredible that 2.4 million people attended outpatient clinics in the first eight months of the year. Despite the improvements in ambulance response times to which the Minister referred, I am of the view that a number of issues remain to be addressed and that some significant black spots remain in existence throughout the country.

One of the greatest challenges facing the health service is that of staffing in acute hospitals. Our dependence on locums and expensive agency staff and the difficulties relating to the recruitment of consultants is placing services at serious risk. I will provide one example in this regard. The decision of a consultant geriatrician not to take up a post at Portiuncula Hospital is a matter of serious concern. Stroke services have not been available at the hospital since 2013, following the resignation of a consultant. Patients must now be taken by ambulance to University Hospital Galway in order that they might receive lifesaving treatment. Why is it taking so long to fill the position at Portiuncula Hospital to which I refer? The authorities at the hospital have been obliged to suspend their thrombolysis service as a result of the resignation of the consultant geriatrician who led the stroke service. A locum consultant undertook to re-establish the service and organised training sessions for medical registrars and senior house officers for this purpose. The training in question was provided but, as a result of issues relating to continuity and agency doctors, the service was never reinstated. I have been informed that if a telemedicine stroke machine were installed in Portiuncula Hospital, it would allow consultants at other hospitals to make diagnoses in respect of the patients there. As a result, those patients could be treated on a 24-7 basis. It has been noted - the Minister can check this out - that seven such machines are sitting in boxes in Cork having never been installed. These machines constitute a significant resource and it seems incredible that they have never been put into use. Will the Minister investigate this matter or comment on it when replying?

I would also welcome it if the Minister could put an end to damaging speculation about the possible downgrading of the accident and emergency at Portiuncula Hospital. The Department of Health recently confirmed that it will not be downgraded and I would like the Minister to underline that confirmation. A great deal of damage is being done to the reputation of the hospital as a result of inaccurate speculation. The fact that it is handling much higher volumes of accident and emergency admissions in the aftermath of the closure of the accident and emergency department at Roscommon hospital highlights the need for the its own department to remain fully operational. I would welcome clarity in respect of this matter.

I welcome the Minister for Health. I have not yet had the opportunity to congratulate him on his appointment. I hope he has more fortune than his predecessor, a colleague of ours in the county of Fingal.

I concur completely with Senator Gilroy in respect of the matters he raised with regard to mental health services. The House will engage in a debate on that matter shortly. I do not have time to go into detail but I have raised various issues relating to mental health services on numerous occasions in the House.

I have been awaiting the opportunity to raise two matters with the Minister directly. The first of these relates to the multiple sclerosis, MS, drug Fampyra. There are 1,500 MS sufferers in this country and the HSE has been assessing the use of this drug - which costs only €270 per month - in respect of them. Fampyra gives certain people afflicted with MS greater mobility. The HSE has been assessing it since 25 July. There are women I know who are no longer at work as a result of the fact that they cannot access this drug. I ask the Minister to use his good offices by talking to the HSE and getting it to approve both the use of this drug and its inclusion on the drugs payment scheme.

The second matter to which I wish to refer is the plight of home help workers. These people are entitled to four and a half weeks gratuity per year of service on foot of two Labour Court recommendations.

I wrote to the Minister's predecessor, Deputy James Reilly, on 12 separate occasions in that regard. I refer to low paid workers whom the Minister will agree provide a very important front-line service in the health service. They are so important to the system but they are unsung heroes. They work in groups, the majority of which are funded by the HSE. The Labour Court recognised their entitlement to the same pension entitlements and in lieu of that, they were twice in the Labour Court. Two Labour Court recommendations granted them four and a half weeks per year of service as a gratuity. Many of the workers are on the minimum wage. I ask the Minister to urgently address the matter. I have written to the Minister twice but I do not know whether he has seen the letters. This is not a hill of beans in the scheme of things. The Minister is seeking an extra €500 million this year. On a countrywide basis it would probably cost approximately €8 million to address matters. The workers are due the money and should be paid it forthwith. If possible, I would welcome an update from the Minister this evening. The workers were promised they would be paid the moneys in 2012 but that did not come to pass. They should at least be given a timeframe for when the entitlements will be paid to them.

I would also appreciate an update on the situation with Fampyra or Fampridine, as it might be known in the Department, which has been a successful drug for MS sufferers. There are many other issues I could raise with the Minister but it is not possible to do so in the allocated three minutes. I raise issues on a daily basis in the House and I am sure the Minister is aware of them, but they are the two specific points I wish him to address this evening.

There is no limit to the time the Minister may take.

I will respond to two Adjournment debate matters following the conclusion of this business. I will try to cover as much as I can. A number of questions were asked about national policy issues and many others about individual persons or facilities, which could perhaps be better dealt with by correspondence or by means of an Adjournment debate than a debate on health policy and budgets. I am pleased to hear the Minister of State, Deputy Kathleen Lynch, is due to speak in more detail in the coming weeks in the Seanad on mental health.

One of the first issues raised related to ambulance cover and ambulance services. In recent decades ambulance services have improved immensely. Previously, all an ambulance did was drive one to a local hospital but now we have many paramedics in the system who can assist a person from the moment he or she is picked up by an ambulance until such time as the person is brought to hospital. One of the big improvements introduced by the Government is that we now have an air ambulance. It has been particularly valuable in the midlands and the west in getting people not to the nearest hospital but to the most appropriate hospital, for example, to provide cardiac catheterisation in the event of a heart attack or various other interventions in the case of major trauma. In many cases, the nearest hospital is not the best place to go and a specialist centre is required where one can be provided with the necessary care. An air ambulance is particularly important for non-urban areas.

That said, ambulance services in this country fall short of what is expected from a modern ambulance service. By and large, what still happens in this country, as Senators outlined, is that an ambulance is called out and the person in need of treatment is picked up and taken to the nearest emergency department. That is not what happens in other countries, where a person is triaged over the telephone and sometimes it is decided that an ambulance is not required at all. Protocols are in place to allow an ambulance service to appropriately decide not to send an ambulance. What happens in other countries is that while people are waiting for an ambulance they are given good advice over the phone as to what they should do while waiting for an ambulance to arrive. In some countries up to 40% of people are treated by paramedics who can be trained and many are already trained to deal with minor injuries or complaints and to discharge a person from an ambulance. Up to 40% of cases are dealt with in that way in other countries, and when people are taken in an ambulance they are brought to the right place, which might well be the local minor injury unit. A collapse can be caused by many different reasons but a minor injury, laceration or broken bone can and should be dealt with in a minor injury unit. However, that is not what happens in this country where one gets inappropriately taken to an emergency department and sometimes we take people to the wrong emergency department. If people have had major trauma, been in a major accident or perhaps has major head trauma, they should be looked after in an ambulance and taken to the right hospital not to the nearest emergency department where they are theoretically stabilised and then transferred with great difficulty, often many days later, following lots of phone calls between the two hospitals.

We have a significant distance to go in terms of improving the ambulance service in the coming years. What bothers me is that to a certain extent the debate in this Chamber is all about capacity; that we must have more capacity in the existing system and that we must have more ambulances and more resources. The fundamental problem with our ambulances is that they are not designed properly so just adding capacity to a system that is not set up in the right way would be wasteful and would not get us the results we need. That is true of many aspects of the health service where, time and time again, putting in more resources and capacity does not result in better outcomes because the system is not designed correctly in the first place. Modernising the system and bringing it up to the required standard will not happen quickly. When it comes to reconfiguring hospitals and moving centres from one hospital to the next we will have to make sure that ambulances are well organised and can get people to where they need to be.

Senator Moloney inquired about terminally-ill patients with medical cards. The system has changed somewhat. Initially, when emergency medical cards for terminally-ill patients in palliative care were introduced about two years ago, a six-month expiry date was put on the card. The definition at the time was that a terminally-ill person was not expected to live after six months, which obviously caused all sorts of difficulties when the person had the good fortune to live longer than his or her doctors thought he or she would. The system was changed some time ago to a review of 12 months and we are now going beyond that to a position where there will be no formal review any more if someone has a medical card on the basis of a terminal illness. There will not be a periodic review but there will be check-backs because there have to be. A serious issue would result if the system did not have to provide for audit or check-backs but there will no longer be a formal review or expiration of the card in the sense that there was in the past.

I strongly agree with Senator Moloney’s view on the fact that medical cards are connected to all sorts of other benefits which creates all sorts of anomalies and problems. In other health services the health service is blind to people’s income and everyone pays co-payments, for example, in some of the Nordic countries, and the equivalent of the Department of Social Protection covers the difference. We have a different system where we almost mix our health service with the welfare system. Once one tags people in a certain way based on eligibility they automatically get treated differently even if that should not be the case.

Senator Moloney made the valid point that if one has a medical card all sorts of other benefits are included such as school transport, an exemption from exam fees and, believe it or not, a lower rate of fee for freedom of information applications, and of course a lower universal service charge rate and therefore lower taxes. If we start giving out medical cards to more people based on medical need as opposed to income, a serious question of equity would arise. I can understand the reason a person should get a medical card in order to access certain medical services but one could ask whether he or she should pay lower taxes than someone who earns the same income. I do not think so. There is much work to be done to ensure medical cards are about medical services and do not have ten or 15 ancillary benefits attached, which is the case at present. The situation developed over time, as it was a very easy way of means testing; if one passed the means test for a medical card then one would pass the means test for anything else such as school transport or other benefit. However, if we decide to have more discretionary medical cards, and more medical cards based on medical hardship, we will create a whole new set of anomalies that must be addressed.

A very valid point which was well made during debate is that often those who apply for a medical card are actually seeking access to appliances or particular forms of therapy. We are hoping, in the course of the review, to be able to allow the HSE to provide these to people. In other words, the HSE, having determined that an individual is not entitled to a GP-visit card or a medical card could provide a particular therapy or appliance to that individual who either cannot afford or cannot access it.

I am aware of the case of a young child who had a GP-visit card and a long-term illness card. In order to help out, the HSE provided the rest of the family with a GP-visit card, even though they did not need it. What they did need was the one thing they could not get, namely, access to physiotherapy. There is a big gap there that we must address and I think we can do so. Problems arise when we run into a requirement for primary legislation which means that things cannot be done as quickly as we would like. We may need to take two or three steps in doing what I think we are all trying to do.

The issue of recruiting and retaining doctors was also referred to during the debate. Agency and locum work can be very attractive for doctors and other health service staff because the rates of pay are better, one can work whenever one wants to and one can take long periods of time off. However, it is not good for patients because they do not get continuity of care and not good for the taxpayer because it costs more. I was disappointed last week when the Irish Medical Organisation voted against the new payscale which would have provided a starting salary of €127,000, rising to €175,000 with incremental progression. That defeat was heavy which makes it very difficult to come up with a new solution. That said, I would point out that over 200 doctors have accepted contracts on the low salary and another 100 have provisionally accepted. It is not the case, therefore, that all vacancies are not being filled. An interesting pattern is emerging whereby posts can be filled in certain specialties but not in others. That is often linked to expectations about what one would be paid in the private sector or in other countries for the same work. Sometimes it is not just about money either. Applications for posts are also made on the basis of quality of services provided, the clinical environment and so forth.

I was a little confused to hear Senator Cullinane's remarks about bold and radical decisions and making the right decisions because as I understand it, it remains the policy of Sinn Féin that there should be a public sector pay cap of €100,000 or at least that there should be a very heavy burden of taxation on those earning in excess of €100,000.

That policy excluded consultants.

How very convenient.

Could the Senator repeat that please?

It excludes consultants.


I was going to point to the obvious flaw in that policy which is that if Sinn Féin were to pursue it, we would probably have no consultants in the country at all.

I have been helpful in not allowing the Minister to fall into that trap.

I did miss that detail although I had a good look at the policy.

The Minister should have another look.

If the Senator asserts that is the policy then I believe him but ---

Attention to detail is not the Minister's strong point.

--- if one believes in a good public service, one must pay people well across the entire public service. If the Senator thinks that it would only be for hospital consultant posts that we would have problems recruiting the highest quality staff, in the context of a salary cap of €100,000 or a tax rate of 68%, then he is quite wrong. We would struggle to find ---

That is not our policy.

We would struggle to find good IT managers, accountants, financial services personnel and so forth. That is already happening across the public sector now. We are struggling to fill the top posts because of the caps on ----

I will send the Minister a note on our policy so that he will have a clearer understanding of it.

Please allow the Minister to speak without interruption.

Another Sinn Féin policy which I am absolutely certain exists is ---

The Minister should stop talking about Sinn Féin policy. I asked him about his policies but he is avoiding the questions put to him in that regard.


Allow the Minister to speak, please.

I asked the Minister about his vision but he is talking about Sinn Féin.

Senator Cullinane also asked me to pay attention to him when he was speaking but now he will not let me speak.

Allow the Minister to speak without interruption, Senator Cullinane, please.

It is certainly Sinn Féin policy to transfer €90 million in costs to private health insurers which would essentially drive more people out of private health insurance, increase the demands on the public system and make the two-tier system even worse. That is very much Sinn Féin policy.

The health service is very difficult to reform and change. If it was like a ship, one could close it down, put it into dry dock and fix it but one cannot do that with the health service. One must rebuild the ship while it is still sailing. As we deliver reforms in the health service we need to make sure that we can keep the show running at the same time. That is what makes reforms very tricky. Like a lot of things in Ireland, we would not set it up the way it is currently were we starting from scratch now. However, we have the health service that we have now and we need to reform it in ways that do not make it worse. Unfortunately, some reforms have done exactly that.

The graduate nursing programme which also came up in the discussion is currently under-subscribed. I had hoped, in consultation with the nursing unions, to make it more attractive for nurses. It is proposed to offer nurses on the graduate nursing programme temporary contracts to work as nurses within the system.

There was a comment on Positive Action but I do not want to get into that too much because the matter has been referred to the Garda Síochána. However, I do not believe there is anything sinister in the timing of the release of information and believe it was entirely coincidental. I have no reason to believe otherwise.

Senator Crown mentioned muscular dystrophy and Friedreich's ataxia. I cannot imagine a reformed system which would refuse a medical card to someone suffering from either condition unless that individual was at a very early stage of diagnosis or had a very high income. When the expert group grappled with this issue, it was not the barn-door cases with which they had a problem but those in the middle. That is where it gets very difficult - deciding where to draw the line. That said, any set of clinical guidelines that takes cognisance or account of medical hardship and the burden of disease will not struggle to make the right decision when it comes to something like muscular dystrophy or Friedreich's ataxia. We will have to wait and see how the revised system works and potentially refine it as we go along.

Senator O'Brien had a lot of questions about the new children's hospital and in that context, Senator Crown made a very valid point. We are never going to have 100% consensus on the site and are always going to find members of the public, doctors and other interest groups who do not agree with the decision, no matter what that decision is. What we have now, at long last, is broad acceptance of the St. James' campus among political parties, the three existing hospitals in Dublin - all of which want to move as soon as possible - the universities, the staff of the hospitals, most of the unions, the parents' groups and the National Children's Advisory Council. Even groups that are ambivalent about the site are very keen to ensure that there will not be an additional set of delays. Such delays would be inevitable if the decision on the site was revisited. A lot of the questions posed were very detailed and would be better directed to the development board of the hospital. I will ask that the board provide answers to the Senator's questions. Obviously any of the planning and logistical issues will have to be considered by An Bord Pleanála in a few months' time. Part of the planning application will require the submission of a master plan.

I am uncomfortable talking about individual cases in public or in Parliament. As parliamentarians, we should consider whether we want to raise individual cases in the Houses. That said, I understand that with regard to the four individual cases mentioned by the Senator, a debate is being taken by the Minister of State at the Department of Health, Deputy Lynch, in the Dáil later today. I did not have time to look at it myself because I have three debates to take in this House today. The Minister of State will take that debate later and I know that she is also examining the suicide prevention strategy.

Administrative staff were also mentioned during the debate and both administrative and managerial staff in the HSE get beaten up very badly, in a verbal sense. If one looks at the figures, however, the number of administrative and managerial-grade staff in the HSE is actually at its lowest since the executive was established while the number of doctors and dentists working in the HSE is actually at its highest ever level.

If one spent too much time getting information from the media one really would not think that. Instead, one would think that there was a massive explosion in administrative staff with fewer doctors than before but that is not the case. We have fewer nurses than before but that is a separate issue.

There is one fewer doctor as Deputy Reilly is gone.

We need administrative staff. As somebody who has worked in hospitals for the best part of six years and in general practice for four, I know one needs somebody to answer the telephone, book appointments and look after medical records. Administrative staff may not be front line but one cannot function as a front-line staff member without administrative staff. They should not be dismissed in the way that they are. We also need a lot more IT and IT in the health service is way behind where it should be.

On the issue of universal health care and the bigger plan and vision, as referred to by Senator Cullinane, I want to be clear that I believe it can be done. Universal health care is achievable and it has been achieved in pretty much every other western country in different ways. I fundamentally believe it can be done. Some of the steps we are taking now are steps that do exactly that, such as hospital groups and community health organisations. It is a fact that we will, next year, take the first tangible step towards universal health care by extending GP services without fees to those under six years and over 70 years. The latter will be quite easy because we can use the existing contract but the under six initiative will be quite complicated because we will need a new contract. It is important that the contract be a better contract than the existing one and takes account of aspects such as asthma checks, obesity checks and so on.

We need an individual health identifier because we cannot follow people through the Irish health system at the moment. We are told, and it may well be the case, that there are 360,000 people on waiting lists of some sort but we do not know how many of them are the same people which happens all the time. I did it myself, as a general practitioner, where one dispatches a letter to three or four consultants in the hope of getting one who will see them first. There are people who are on waiting lists multiple times and because we do not have an individual health identifier we cannot track them through the system. Also, we do not know if they have already had investigations done perhaps somewhere else or only a few days ago. A big job needs to be done which is not straightforward but it can be done next year. However, it is important that we do things properly and do them well. We have learned from the Irish Water debacle that it is better to do things slowly, to do them well and to plan them.

Metering for water is pretty straightforward as one puts in the meters and then make charges.

It is not about that, Minister.

Health insurance and health care is very complicated.

Look how complicated water is.

What would arise, for example, if there was universal health insurance with competing insurers and people refused to give their insurer their PPS number? What would happen if one brought in compulsory health insurance and people refused to pay the health insurance contribution? Would we then refuse them treatment?

No, we would encourage people to join different parties.

There are a lot of things that need to be thought through, which is why we had a public consultation process. I will publish the results of the public consultation process soon. The ESRI and the Health Insurance Authority are doing their work on the costings and that will be published. I expect to be in a position towards the middle of next year to set out a revised roadmap as to how we might achieve universal health care in Ireland. If it takes a bit of time to do so then so be it. Better that it be done well than be done in a hurry.

Put it back in the revised five-point plan

I was asked about primary care centres and the incentives for people to use them over their emergency departments. Incentives do exist because the charge is lower for primary care centres than for an emergency department. If one attends one's own GP or primary care centre then one does not have to pay an ED charge at all. A big job must be done around educating people on where is the right place to go and when because they do not know. That is not their fault and we need to educate them.

We also need more investment in minor injury and local injury units. I have had the pleasure of visiting the hospital in Roscommon and noticed that it is possible for people in Roscommon to attend the minor injury unit and be seen very quickly in an hour or so. That is the same in Nenagh and Ennis. The units may not be open all night but they are open most of the day. People in Dublin do not have such an option unless one is willing to go to VHI SwiftCare and pay quite a lot to do so. We need some more investment in these injury units and also in the ambulance services.

A Senator mentioned the application process for medical cards. Yes, it is highly imperfect. There are different applications, as Members will know, for the doctor visit card, for the over 70s and the under 70s. It is proposed, under the revised system, to have one application for all types of medical cards, including for long-term illness. The first test, which remains the main test, is the means test. If a person does not qualify under the means test then immediately a secondary assessment can be done as to whether a person qualifies, based on medical need or medical hardship. That assessment will have the input of the local health office which is crucially important. Part of what was lost in centralisation was local input. None of this has gone to Cabinet yet so I probably should not say anything more about it.

Senator van Turnhout mentioned the ESRI-RCSI report for the Irish Heart Foundation on early supported discharge for stroke patients. It is a very good report and I would like to try it out in one region if the money can be found in the HSE's budget. It makes intuitive sense to me that if a patient is discharged early from hospital after suffering a stroke and rehab is done in the community or at home that he or she will do better. Like so many things in the health service when people present savings, on examination they turn out not to be savings at all. What is positive in that report is that it is cheaper for somebody to be given their rehab and so on in the community rather than in hospital. That is true but the saving only arises if one closes the hospital bed and lets the staff in the hospital go. If one keeps the hospital bed open and keep the staff in the hospital one still has to pay for them so one then gets two sets of costs. One often gets this argument as well with lay discharges - that it would be much cheaper for the person to be in a nursing home rather than, as they say, blocking a bed in the hospital. That is only true if one closes the bed in the hospital. If one does as one should do, which is use the bed for somebody on a waiting list then that means one gets an extra person into hospital and one is then met with both costs. In reality, that is often why savings do not arise when people posit them because what happens when one frees up hospital capacity is it gets used by other people who need it and people on waiting lists. If we do the right thing then let us do the right thing because it is the right thing to do and not because we think there will be savings that do not add up on scrutiny and detailed financial analysis.

Senator Barrett quoted my Department's annual report for 2010. I am not sure if those international comparisons are in the report because I looked at the World Bank's figures the other day on health spending per capita and Ireland was way behind countries like Australia and so on. For Australia it is US $8,000 per head but we have US $3,500 per head.

Often when one does make comparisons we do not compare like with like. For example, in Ireland, as we all know, the social care budget for home helps, and all the rest of it, comes out of the HSE but that is not the case in the United Kingdom which funds such services through local authorities. Also, when taking account of how money is spent in the health service one must take account of where all the money comes from. In some countries all the money comes from the taxpayer or the exchequer. In other countries, like Ireland, funding comes from a mix so there is some from the taxpayer, some from the insurance companies and, particularly in Ireland, quite a lot out of pocket. One must take account of all the different streams of money that go into a health service. They are not readily comparable. I suspect that Ireland is probably somewhere in the middle. We are not a high or low spending country on health but we are somewhere around the middle. We probably do not spend it as well as we ought to.

I ran out of space to jot things down at this point but I will follow up the issues of stroke services and telemedicine stroke machines being left in boxes that were raised by Senator Mullins. I am not aware, in detail, of the home help issue. Is it a retirement gratuity? I will check out the matter. I have not seen any correspondence on it yet.

What about the University Hospital Galway?

What about University Hospital Galway?

I will do my best to get around to them all. As Members will know, there are 47 acute hospitals in the State. That is just hospitals, never mind every other aspect of the health service. If I were to spend one day a week on visits it would take me a year to get around to the acute hospitals, never mind trying to get anywhere else. In the new year I will try to get out and about a bit more but my main job is to be here in Parliament, in my Department and with the HSE and Dr. Steevens. No amount of me travelling around hospitals, looking at them, will change health policy for the better.

We are not asking the Minister to come to Galway. We just want him to talk to us about it.

I am going to Galway in December.

It is useful to do it exactly for that reason; to see the reality. There are other Ministers who spend a huge amount of their time just seeing reality and touring the country and not actually getting down to their desk and being here in Parliament.

Hear, hear. The Minister is not wrong there. Good for him.

I want to spend 80% of my time here in Parliament, in my Department and with the HSE, and maybe 20% in my constituency and elsewhere. I think that is probably the right balance, but it means that I cannot get around as much as I would like.

On the Fampyra medicine, I do not know that one in detail. The National Institute of Clinical Excellence, which did a paper on it in the United Kingdom, was quite critical of it. For any medicine, a comparison is made between the medicine itself and non-use or placebo use. That study found that the medicine only worked well in a small minority of patients and therefore was not cost effective.

About 1,500 cases.

I can guarantee that the decision on which drugs are reimbursed will not be a political or ministerial one. That decision will continue to be based on clinical and economic guidelines. The first question is whether the drug is effective. The second is what its side effect profile is and the third is whether the price is fair. I can understand that clinicians and interest groups will always take the view that we should reimburse every medicine that is licensed and pay whatever the drug company asks, but we cannot do that from a public policy point of view. It would not be right to do so. I know of one medicine in my time that was refused by the HSE and the national drugs committee only for the manufacturer to come back a few weeks later offering the same product at a 60% discount. I will tell the Senator which one it was afterwards if he likes.

The issue is how long it takes them to assess it. It has taken from 24 July until now.

There is a detailed agreement with the IPHA on the assessment times and when they can stop and start again. It is always open to pharmaceutical companies to come in with new evidence or more evidence as to why a product is effective. It is always open for them to come in with a new price. It is always possible to introduce new options, for example, cost-sharing options where the HSE only pays when the drug works, not in the 10 or 11 cases where it does not, or other agreements similar to that. They are all options that are open.

I think I have covered pretty much everything.

The Senator, Professor Crown, and I mentioned the Dr. McHugh situation. In fairness, we asked the Minister to look at the situation.

The Minister has given a very comprehensive report.

I have no proposals to close any emergency departments in Ireland.

No, I am talking about Dr. McHugh.

I will look into that. I do not know the details.

The Minister has given a very comprehensive reply to the questions raised on the floor of the House. That concludes Statements. When is it proposed to sit again?

At 10.30 a.m. on Wednesday, 5 November 2014.