Róisín Shortall (Dublin North West, Social Democrats) | Oireachtas source

I apologise for being late, but I was watching the proceedings on the monitor. I welcome the Minister's presentation and his very positive comments on Sláintecare.

I agree wholeheartedly with all of the Chairman's comments on concerns we all have about the slippage of the plan in its timescale. The starting point is the implementation plan. We have all been of the view that this is key. The lead was supposed to have been recruited in July. While there was slippage because of the change of personnel in government, I was very hopeful when I spoke to the Taoiseach in August because he said he was in engaging in the recruitment process that month. Unfortunately, four months later, we are still being told that the recruitment process is about to start shortly. I would like the Minister to clarify whether there is to be a public recruitment process or whether he is headhunting. Where exactly are we in the process?

I endorse the comments made by Deputy Joan Collins on what the Sláintecare report set out regarding implementation. On page 135 it outlines the steps that needs to be taken. It states: "These provide the big-picture blueprint for a project plan to be developed by the Programme Implementation Office as one of its first actions and against which the implementation effort will be measured." With all due respect to the very fine people in the Department of Health, there is institutional resistance to change in any major organisation.

This was supposed to be a detailed plan devised by the implementation office, not devised by the Department of Health. If the Department or the HSE were committed to change, we would have seen it long ago. We have not seen that kind of change, however. I do not discount the key role the political system plays in this either. It is a very important point that we should be recruiting an experienced person to lead and allow him or her to recruit a team and devise the detailed implementation plan. It is regrettable that it has not happened. The absolute urgency is to recruit that lead person. I hope there will be no further delay. I have received the same reply every month for the last four months on this and we would like clarification and action at this stage.

There is no doubt that there is a price tag attached to the health programme. The timescale of 15 years which had been proposed was completely unrealistic. The committee took the view that we should be spending to save. There is no doubt that ehealth would achieve considerable efficiencies and safety within the system and we reckon it should be implemented over a five-year period. While it is welcome that funding has doubled, the roll-out is not being accelerated sufficiently and certainly not in line with what has been recommended.

The Minister referred to progress on the impact study in respect of one of the key recommendations, which was to disentangle public and private medicine. This goes to the very heart of the problems within our health system. Coming to the end of the process, a number of members of the Committee on the Future of Healthcare came under severe pressure from outside to try to water this down or scrap the idea. There was a push to qualify it to some extent in calling for an impact assessment to be carried out. The final agreement on the wording was that there would be an impact assessment to assess the impact on public patients. That is because we do not want this process used as an excuse to hold up the disentangling of public and private medicine. That is what it looks like at the moment and I have a serious concern about it. We need to move swiftly to start that disentanglement. The vested interests that have maintained this very odd hybrid, which is unheard of anywhere else, are those people who are benefiting from the system as it operates at the moment. They are not acting in patients' interests.

This brings us to the revelations in last night's RTE "Prime Time Investigates" programme. There is a 2008 contract covering all consultants. Last night's programme found that a significant minority of consultants are not adhering to it. That is for two reasons. A number of consultants are going off site to spend more time doing private work than public work and they are not meeting their public hours commitments. Others are doing an undue amount of private work in public hospitals. The contract provides for 39 hours of public work. It is an extraordinary indictment of the system that no one knows whether consultants are doing 39 hours. We know plenty of consultants exceed those hours but those committed people are being very seriously traduced by the behaviour of those colleagues who are engaging in the gaming of the system which we saw last night. The fundamental issue is that the Department of Health and the HSE have no idea whether the contract is being complied with. This affects nearly 2,500 consultants, all of whom are handsomely paid by the public purse, but we have no idea whether they are doing their work. It takes "Prime Time" to put a number of those consultants under surveillance to find out what the truth of what is happening is. That is a serious indictment of the system.

We need the urgent implementation of the contract. A number of issues arise in that regard. The new contract provided for the appointment of a large number of clinical directors. These are consultants who were given the task of supervising their colleagues, for which they are paid an additional €46,000. What on earth are those people doing? Clearly, they are not doing their jobs. Is it time to sack some of those clinical directors or, at minimum, withdraw the huge €46,000 allowance they receive for work they are clearly not doing? What about the common waiting list? That is part of the contract. Is there a common waiting list in operation in any public hospital? These are the clear legal terms of the contract but they are not being enforced. What about penalties for consultants who breach the 20% limit? The arrangement was that they would repay the income they received from private practice. In the early days of the contract, we got some figures on the extent of the breaching of the limit and what those consultants owed. I am not sure any of that money was collected. Certainly, the Comptroller and Auditor General drew attention to the problem. That is part of the legal contract. Why are the Department and the HSE not enforcing it? Senator Conway-Walsh asked why the Department stopped collecting data which would have let us know what was actually happening. Why is that?

The Comptroller and Auditor General drew attention to the following a couple of years ago. In 2015, Mr. Tony O'Brien stated in a confidential email to the then Minister for Health, Deputy Leo Varadkar, that the 80%:20% split was a farce in practice. What did the then Minister do about that? Before the Committee of Public Accounts in 2015, Mr. Tony O'Brien referred to the private sector as having a parasitic relationship with the public sector. He said the information he had was that approximately 56% of admitting consultants in St. Vincent's private hospital were consultants whose contracts did not permit them to work there. We were to get an audit of all of that but we have not seen the results. Why has there been a two year delay in getting to the bottom of that when the evidence shows widespread breaches of the contract? We have a vastly expensive contract with approximately 2,500 consultants which is clearly being breached all over the place. That needs to be pursued rigorously. What exactly is the Minister going to do about that? The responsibility lies with the Department and the Minister to ensure we get value for money, which, clearly, we are not. The people paying the price for this are the 685,000 people on hospital waiting lists.

The NTPF was asked to carry out an audit two weeks ago of waiting lists in five hospitals. It found that the current waiting list situation was shambolic with widespread queue jumping and a failure to follow any of the protocols. The current waiting lists have no integrity. However, there was a big gap in the information provided, although I am sure the NTPF has it. We need to see it published. I refer to the profile of those people who are skipping the queue. The suspicion is that a large number of the people the NTPF found going directly onto waiting lists for procedures were not coming through outpatient departments. There is a suspicion that people are forking out €220 to see a consultant and then finding their way onto a list within the hospital and receiving their treatment earlier. We need to carry out that profiling of those people who are skipping the queue. Many of us have suspicions about it.

I refer to the NTPF and the initiative taken this year and last year which Fianna Fáil supports very strongly.

It is great to see people moving off the waiting list but if the Government takes an approach of incentivising a slowing down of work progressing through the public lists, it would create yet another perverse incentive for consultants to go slow when they could then be paid on the double if people access treatment by way of the National Treatment Purchase Fund. That is a knee-jerk reaction and response to a problem; it is not a sustainable position.

This is not the Minister's policy with respect to the 2008 contract, but it is the previous Government's policy of allowing public hospitals to breach the 20% limit of work. I recall that situation arising where a decision was taken at ministerial level to lift the cap on the amount of private work that could be done in public hospitals. That immediately created a perverse incentive for hospitals which are already strapped for cash to increase the number of private patients. As other speakers have said, the fact that hospitals were given stretched targets only exacerbated that. Hospitals were incentivised to take more and more private patients at the expense of public patients. That is a policy for which Fine Gael, under the previous Government, is responsible, and it must be tackled.

Ultimately, we need a new consultant contract that will be a meaningful one and that will give us value for money and treatment for public patients. All people should have the right to access treatment as public patients. That is what a good quality universal public health service is about but in the meantime the Minister needs to give us an assurance and set out a clear plan of action to rigorously enforce the existing contracts that are in place, and where people have been found to fail in that regard, action should be taken. They need to be made accountable.