David Cullinane (Waterford, Sinn Fein)

I do not need to be corrected. I know how the Dáil works.

Accountability and good governance have always been at the fore of any debate about the health service. There is much great work is done by our front-line workers who strive every day to do their best. The efficiency with which many in the health service work, particularly in overcrowded emergency departments and under-staffed wards, is genuinely never credited. Unfortunately, that good work is often overshadowed by colossal waste and mismanagement across the HSE.

Since 2020, the health budget has ballooned, but the return on that investment has been questionable. While it is true that more services are being delivered than ever before, waiting times are, at best, stagnating rather than coming down substantially in the way that was promised when the Government parties signed up the Sláintecare. That is why this legislation is so important in the context of bringing governance and accountability arrangements up to a higher standard. We must ask whether the Bill will achieve that or whether it is simply more window-dressing to allow the Government to pretend it is doing something meaningful. Unfortunately, this Bill is a wasted opportunity. I will outline why.

The substance of the Bill is dealt with in Part 2, which provides for an improved performance delivery plan - this will replace the HSE's annual service plan - to be approved by the Ministers for Health and Children, Disability and Equality and developed on the basis of the statement of health service priorities. The Bill also places new obligations on the HSE regarding its three-year corporate plan, which is already done on a three-year basis, and provides that the Minister for Health and the Minister for Children, Disability and Equality, Deputy Foley, will issue strategic direction statements to inform the HSE’s priorities. Given that this retains the annual approach to the service plan as the default and that the Minister currently issues priorities annually to the HSE through a letter of determination, this appears to be a rebranding exercise rather than any substantive change. Notably, it allows the Minister to extend the performance delivery plan over any period the Minister wishes, but it does not require a multi-annual plan by default.

The Bill also places an additional legal requirement on the HSE to exercise:

... the highest standards of prudent and effective budgetary management, including with regard to the achievement of value for money and recognition of the importance of managing within authorised financial and employee resources ...

One would have thought that this was already a legal responsibility for any public body.

The remaining substantive element of the Bill is the new process for ensuring that the HSE remains within budget and provides a legal basis for what is called corrective action proposals. There is already a requirement on the HSE to operate within budget. I do not think the CEO of the HSE allows the organisation to run over budget intentionally. This again seems to be rather meaningless. Notably, the Bill provides that where the HSE goes over budget, it must pay for this out of the following year’s budget. Where it makes a saving, it may, subject to approval, retain that money for the following year. There is a concerning stipulation in this regard. As we know, health services are demand led. If, after taking corrective action and every measure tolerable to the Minister and the public to curtail spending, the HSE still runs over budget, there could be severe knock-on consequences for services. Such a proposal would only result in us returning to a situation that we had last year where a deficit is accumulated within the HSE’s budget over a time period only to be bailed out after several years when it is no longer tenable to carry that deficit forward.

While these are important changes, they are nothing new. These amendments to the Health Acts are largely reflective of changes which have already occurred in practice between the Minister, the Department and the HSE. The truth is that this Bill does not implement any meaningful change. It seems to be a way for the Government to pretend it is being tough on the HSE for budget failures without providing the reforms that are truly necessary.

The Bill retains the shortsighted focus on annual-based planning. Year-to-year planning in the health service does not work. No multibillion organisation operates on a year-to-year basis in the same way that the HSE does. The Government parties signed up to multi-annual frameworks in the programme for Government, but they have failed to translate that into this Bill. That is deeply disappointing. While the Bill provides for a three-year corporate plan, which already exists, it does not provide for multi-annual frameworks in respect of funding, staffing and capital delivery. That is why, unfortunately, I see this Bill as a wasted opportunity. It is a wasted opportunity because of what is not in it.

When the health committee conducted pre-legislative scrutiny, one of our recommendations was that the Bill would provide for capital funding to be approved, indicatively on a multi-annual basis, to facilitate a proactive, multi-annual capital planning framework. That has not been incorporated into this Bill. While the HSE has to be expected and held accountable for operating within budget, it also must be enabled to make the very sizeable investments in digital infrastructure, bed capacity and primary care reform that are needed to make health spending more sustainable. The health service is inefficient by design. It is hospital-centric and working on pen and paper. Not only are there trolleys strewn across corridors, but there are also trolleys full of paperwork that are being pushed around.

When it comes to capital spending, there is a need to ensure that health is not forgotten in any revision of capital expenditure. We have to look at all of the needs across the health service over the next number of years. We had a good discussion in the committee today on digital transformation. That is going to cost a lot of money. The previous Minister for Health launched a comprehensive bed plan. That must be delivered and funded. We have all sorts of projects at a local level that every TD, whether in government or in opposition, will jump up and down for. They have to be funded.

The children's hospital has to be completed. The new elective hospitals will have to be built. The new maternity hospital will have to the built. Unless there is a substantial increase in capital funding, I do not see how any of that is going to be paid for. Then the focus will be on the Government, the Department of Health and the Department of public expenditure and reform to explain to people which projects will not be funded and what will not be done if health does not get its fair share of any increased capital expenditure.

There is an issue with accountability, even with regard to parliamentary questions. The purpose of the public-only contract that we put in place was to facilitate public work on weekends, but insourcing has allowed private practice in public hospitals on weekends, which is far more lucrative. When I asked the Minister for Health and the HSE about the level of Saturday activity happening on a public-only contract, the question could not be answered by the HSE. When I asked the HSE how much was spent on locum cover for consultants who are not able to fulfil their out-of-hours obligations, the HSE could not answer it. When I asked about how much individual consultants, in anonymised fashion, were making from private work on public lists through insourcing arrangements, I was told this information is not available at a national level. How can we know what is happening if we are not collecting the data? An awful lot more work needs to be done in that area.

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