Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)

I thank the committee for the opportunity to present this Supplementary Estimate for the Health Vote and for its ongoing engagement with me and my Department. I am seeking additional funding for 2025 of €300 million for current expenditure and €2.1 million for capital expenditure. The largest element, €250 million, covers a non-pay overrun across acute hospitals, community care and the primary care reimbursement service. This reflects the portion of last year’s supplementary funding not carried into this year’s base budget. Closing this gap through savings was challenging, as €633 million in savings and cost avoidance was already built into service budgets for 2024 and 2025. This €250 million requirement is among the lowest supplementary dependencies, excluding Covid, in many years, representing less than 1% of the overall health budget.

A further €40 million is a once-off payment to voluntary hospitals to stabilise their finances. This comes with a requirement for much tighter governance and controls, stricter recruitment, seven-day rostering, and adoption of national IT systems, such as IFMS and NISRP. Another €10 million is for the section 39 pay agreement, providing a 9.25% pay increase agreed earlier this year.

On the capital side, €2.1 million is for Brexit-related works at Rosslare Europort. These facilities carry out import checks and inspections on behalf of several State agencies, including the HSE which part funds it. It is important to reflect that despite this overrun, progress on budget discipline is being made. My focus remains on increasing service provision for patients, not reducing it to meet financial targets.

We have strengthened financial governance and control significantly, and continue to do so. The uplift in funding secured in 2024 means managers are now accountable for delivering improved services and staying within budget. Budgetary discipline among HSE managers is improving and must continue to improve in 2026.

We have also sharpened our focus on productivity and value for money. Over the past decade, input growth, specifically staffing, non-pay funding and capital investment, has been high, but activity growth has been slower. For example, outpatient appointments per consultant have fallen by approximately 30% over the past decade, and by another 6% in the past year, while consultant hours have increased by nearly 10% annually. Workforce growth has been substantial, with 25,523 full-time staff added since 2019, which is up 25%, together with an increase in infrastructure capacity, including 1,330 more acute beds compared with 2019. Notwithstanding this, productivity has reduced and activity has not kept pace with investment. Health already accounts for €1 in every €4 of Government expenditure. With the continued change in our demographics caused by population growth and ageing, we cannot meet future demand without substantially improving productivity. I refer Deputies to the ESRI report of this month on projections for regional demand and bed capacity requirements for older people's care, 2022 to 2040, which describes particular findings in respect of the population aged over 65. We might come back to that issue. The demographic pressure is real and increasing, and we have to do things differently with what we have.

In the context of our productivity focus and improvements, a key priority for me is improving productivity and deploying staff more effectively through seven-day rostering and evening shifts. This improves patient flow, safety and access, while making better use of our infrastructure and workforce. It is important to say that if you have a staff of ten people, it is much better to deploy eight people Monday to Friday and two at the weekends, rather than deploying all ten Monday to Friday and allowing a backlog to build up over the weekend that must be with, which causes the cancellation of elective surgeries on Monday and Tuesday. We must accept that principle. It is the basis of the agreements we have made. I have visited many sites around the country and am beginning to see signs of real improvement. For example, trolley numbers have been a huge focus and are a very visible piece for every patient in Ireland coming into a hospital in a vulnerable situation. Thankfully, there have been 7,800 fewer patients waiting on trolleys compared with last year, which is an 8% drop. That happened even as emergency department presentations went up again, with more than 1,100 extra presentations every week, which is a 4% increase. At 8 a.m. today, a total of 238 people were on trolleys. Over last weekend, there were at one point 57 people on trolleys nationally. This is completely possible. I am seeing variance between hospitals. I see improvements in hospitals. This is completely possible. To update the committee, 18 sites are green, eight are red and three are amber. Even St. Vincent's hospital, which has been struggling, performed well this morning, with approximately eight people on trolleys, which is well within the parameters. That is the case in November while we are beginning to experience the flu season. We are getting somewhere and need to continue. Yesterday was our best Tuesday this year, with the exception of a Tuesday after a bank holiday. We really are making progress.

I will give a couple of example, the first of which will relate to Tallaght University Hospital. In the past three months, it has not had a single red breach of its 8 a.m. trolley threshold. Earlier this year, it was averaging 16 breaches a month. It has become a completely different experience since July. There will be difficult days when a large number of people will present with flu or other things but the point is that the hospital was consistently in red and in difficulty and has been consistently good since a new manager took over in July. The impact on the hospital and the people working there is extraordinary.

Mayo University Hospital, which spent 80% of the year in a red situation, has improved enormously over the past six to eight weeks. It had an average of 24 breaches into red per month in the first nine months of the year, which was down to nine in October. That is, of course, nine too many but it is a substantial improvement, which reflects the process changes that have already begun in the hospital. Over the October bank holiday weekend, 14% fewer patients were waiting on trolleys at 8 a.m., which is 81 fewer people compared with the same weekend last year, even though presentations were 5% higher. These improvements have come from efforts by management to improve patient flow and the rostering of consultants and other key staff at weekends. As better data becomes available on changes to rosters, I will share it with the committee and publish it so we can all examine it.

Improved scheduling can unlock thousands of extra outpatient and theatre appointments. The new outpatient toolkit rolled out in Naas, Mercy and Kilkenny hospitals will deliver, based on the evidence to date, 10,000 additional appointments annually from existing resources. Other hospitals are now adopting the toolkit, and we expect to have full roll-out within 2026. That helps to address the underutilisation of infrastructure and staff, and can be replicated in theatres, diagnostics and primary care. There is a big opportunity for us not through additional staff but through the way in which we work.

Virtual care is a big piece. We are opening virtual wards in every region to allow patients to leave hospital sooner and receive care at home. This is better for patients and hospital flow. Kilkenny hospital just opened on Monday, joining St. Vincent's and University Hospital Limerick in having a virtual ward. The Mercy in Cork and Tullamore and Drogheda hospitals are going to be live by the end of the month. We are also implementing it in Galway. Though progress there is a little slower, I expect to see it open soon. Combined with the existing St. Vincent's and UHL wards, our virtual bed capacity will grow to the equivalent of 120 virtual acute beds by early 2026. We will continue to expand virtual capacity through 2026 and beyond.

It is not just about virtual beds. It is also about community-based wards based on the Cherry Orchard model of care, which will also be expanded in 2026 to help strengthen regional capacity and reduce hospital demand, delivering Sláintecare's vision of care close to home.

Surgical hubs in every region will support more efficient care and reduce waiting times, insulated from emergency pressures, which is extremely important. Digital transformation underpins modernisation. The HSE app, shared care records, progress on a national electronic health record and integrated systems for finance, HR and diagnostics are key pieces that enable a connected, efficient health service for patients and staff. We must build a resilient, efficient service through digital transformation, modern infrastructure, workforce deployment and skills. We all agree, and must be clear that we need to shift care from hospitals to the community and have more flexible funding models that will help by enabling resources to be spent where they are most needed in the region.

Our goal is clear: wherever you live in Ireland, we want you to have timely access to high-quality care. The challenge now is making sure that every health region continuously improves its performance to reach the same high standard across all services. Over the past decade, targeted investment has delivered real gains. We have faster diagnosis, improved outcomes and clearer care pathways. We are seeing, however, that those gains are unevenly distributed across the country. We need to do better than that. In some regions, patients are seen quickly. In others, access is slower. That is not fair. Community therapies, for example, psychology, face severe backlogs even in regions that perform well on other things. Let me give a couple of examples of regional contrasts. The south west meets targets for lung rapid access cancer clinics, which is great but it has some of the longest waiting lists for some primary care therapies, such as psychology and physiotherapy. The west and north-west region performs well for adult mental health, yet wait times for surgery and neurology outpatient appointments often exceed 12 months. This is an important change to how we structure our health services and 2026 is year one of that change. Health regions will have autonomy to prioritise resources locally to achieve and be accountable for ambitious targets and national standards. That builds on the progress we are already making with stronger financial controls and a greater productivity focus. It is the first step in devolving budgets alongside clear expectations that I have set out in my letter of determination to the HSE. To enable regional executive officers and national directors to deliver services, we must give regions the flexibility to invest where it matters most, based on national targets and standards. For example, one region might have longer waiting times for physiotherapy than other regions. That same region might also be performing well in a different area. It must balance that and reach the higher standard. We must align with international best practice. Ireland, in the past and up to now, has funded by rigidly separating the funding for services like prevention and early intervention, for example, screening, vaccination and so on, primary care centres, services for older people, hospitals and residential care. If you are the patient, you might need all those different things so separating the funding does not really work. It is a barrier to providing the best care possible for patients and we have been out of step with most of the other countries in the OECD, including France, Spain, the Netherlands, Italy, Canada and New Zealand. We must get to the best-in-class way of doing this.

The World Health Organization and the OECD both say that a more flexible approach to funding allows health services to better meet the needs of their local populations. I recognise that it is a change and that we are trying to meet World Health Organization standards and guidance. It is a change, and one that we need to go through together.

A big piece of this is strengthening accountability for outcomes. We keep talking about inputs but we have not had enough of a conversation about accountability for outcomes, so that means there will be clear targets for each region to improve services and waiting times. They will have regional plans to improve their existing services and move towards the national targets that have been set. They will be held to account for delivery of these targets. All of us together in the Oireachtas will be able to see how they are performing against national targets, such as the Sláintecare waiting times we have all committed to, and in comparison with each other.

Shedding light on the difference in performance in a structured way rather than randomly through pieces of research or a patient complaint gives us the difference and opportunity for regions to develop and learn from each other and to lift each other together form their shared experiences. The workshop I held in September with leaders from across the health service was the first time that they had all come together to listen to each other, learn from each other and to get ideas to see where improvements could be made. I will have further engagements like this in January and April 2026, when the winter period is over.

We also have to move away from the idea or the reliance on marginal increases in staffing being the sole solution to every problem. In the past, new development funding has been about 0.5% of the total budget. All the focus, including my own in the past, has been on this marginal increase as being the only way of improving our health service. The problem is we need to better utilise the other 99.5% of the funding we have in a complete way so that we improve our services. If there are 100 people working in a particular area that is already inefficient and delivering poor services because of the way in which it is organised, adding an extra five people will not be the panacea to that problem. We have to have the 105 people working differently to deliver that solution better. It is obvious that is the case in any other part of Irish life so we have to look at the way in which people are working and scheduled, deploying staff more effectively and using digital tools to improve this. If we do not deal with management capability and operational discipline where they are weak, more staff will not solve the problem. We have to do both.

We are rolling out the first step towards a population-based resource allocation model, something we have all agreed to and want to do. This is year one of a plan to move towards allocating funding based on the needs of the population. Our regions have different populations and different health challenges, whether this is an older population, a particularly distributed population because it is a more rural area or greater areas of social deprivation. We are working towards the regions getting a budget that reflects the health needs of their own population. It is not about ensuring efficiency for its own sake; it is about ensuring the money that patients - the taxpayer - have put into the health system is delivering for them in a fair, effective way.

In closing, I am asking the committee to approve the 2025 Supplementary Estimate of €300 million for current expenditure and €2.1 million capital expenditure. Our progress over the past number of years is visible. Our life expectancy gains are important. We have new and expanded health services. However, it is just not enough. The variations in accessing services is not okay and coupled with increasing demographic pressures we have to look at how we invest and use the resources in the phenomenal people we have in our health service in ways that enable them to deliver the best possible service in the way the absolutely want to.

I am asking for the committee's support to drive these improvements in regional services, in line with Sláintecare, enabled by the new approach to budget 2026.