Marie Sherlock (Dublin Central, Labour)

The answer may be that it is both. When we look at the individual issues within our health service, there are fundamental questions about the operability of, in particular, section 24 into the future. I am looking in particular at budget 2024 announced in October 2023. With the benefit of hindsight, it was a complete work of fiction. The HSE had to come out and effectively out the Government by saying what the budget was providing for 2024 simply was not enough. We had to have a summer economic statement. We had to have a supplementary budget of €1.5 billion in the middle of 2024 and an additional €1.2 billion this year. The Government obviously messed up its figures and did not adequately or appropriately account for very predictable and ongoing challenges within the health service.

If that was to happen again and the political system was to fail to take responsibility for the level of demand within the health service, on whose shoulders should that responsibility for the underfunding lie? Is it with the Minister for Health? Is it with the Minster for public expenditure? Is it with the CEO and the board of the HSE? Section 24 of the Bill is very much putting it on the HSE. Will cutbacks be the norm over the next number of years in order to try to meet the straitjacket of a health budget set down every October?

The other key question is in regard to the accumulated deficits, particularly within the voluntary hospitals, which is a very real issue. The accumulated deficits across a number of the voluntary hospitals were reported at €340 million. Efforts were made last year to reduce some of those voluntary hospital deficits. We have had media reports that pharmaceutical companies have had to put accounts on hold, in particular with regard to the Mater hospital because bills were not being paid on time. The Mater hospital itself is facing a deficit of almost €25 million. Beaumont Hospital is carrying forward €66 million. The reality is there have been bailouts. There has been some sort of agreement, but the reality is there is fundamental questions about the voluntary hospitals' continuation into the future and how the Department of Health is hoping to remedy that. We can have a conversation another day about whether we should have every hospital in the country run as a HSE-owned hospital or whether we sustain those voluntary hospitals but the reality is the State is severely reliant on those voluntary hospitals and how we keep them in operation. A critical question is whether those corrective measures apply to the voluntary hospitals or not.

The other elephant in the room for me relates to the National Treatment Purchase Fund, NTPF, which is not being addressed here as I understand it. This has been the subject of lots of committee hearings and interactions in the Dáil over recent weeks. However, there is a commitment now to ending insourcing, a very controversial measure to try to reduce waiting lists, albeit it has reduced waiting lists in some hospitals. The other thing is that some people have made a lot of money out of the use of State assets and HSE-directly employed staff.

There are very serious questions about who has been making money to reduce those waiting lists. The commitment now is that we will have it ended by next year, but who is going to make good on that money? This is a separate funding pot to the NTPF. Will the hospitals that have been appropriately using the insourcing funding get the additional resources to try to beef up with regard to staffing? To be very frank, the revelations about the period between the end of 2023 and start of 2025 in which sums of between €71 million and €91 million were spent are outrageous, particularly when we understand that a number of serving HSE staff are currently providing those services. Every company is entitled to provide a service, but there are real questions there about the duplication of work and incentives to work. I know the Minister has very eloquently been on the record calling this out and raising concerns, but the critical issue for those hospitals that have been relying on the NTPF money to reduce their waiting lists is what will happen to that funding.

There is a separate question with regard to Naas and Beaumont hospitals in how they have used NTPF funding for what we understand are routine activities. There is a separate question about the oversight of the NTPF and its oversight of its own activity. While a big song and dance was made about how it is overseeing waiting list validation, we hear much less about its oversight of what accountability is expected when it signs the cheque for the individual hospitals. What is it getting in return? There are very clear questions from me and the wider Labour Party with regard to this Bill and how it will deal with this sum of money.

One of my last questions relates to population-based resource allocation. This was the big idea last year. It is very consistent with Sláintecare, something the Labour Party hugely supports and is not well understood. Obviously, it is in its infancy. We still have to see a lot of the detail as to how population-based resource allocation will ultimately shape the allocation of financing within the health service.

Last year, the Secretary General of the Department of Health stated: "It is [very] clear that it is not sustainable over the long term to continue to increase health expenditure in line with demand each year." That is a particular perspective. How demand is defined is something in and of itself. However, the reality is that there is a huge amount of unmet demand in certain parts of our health service at the moment. We spoke this morning about dental care, which is on the brink of collapse. Last night, we talked about endometriosis. The Minister has heard me talk lots of times about the lack of supports within GP care and the patchy GP service we have throughout the country. The key question now is how this tightened financial control of the HSE will be consistent with the roll-out of the population-based resource allocation into the future. The ideal is that the money follows the need. If there is going to be a political decision about what that need is as opposed to the actual reflection of the need on the ground, one validated by our clinicians and everybody else on the ground, then there is real potential for a disconnect there. Sláintecare is about ensuring that money follows the need. That is one of my biggest questions that has arisen today.

We have not really had an opportunity to talk about population-based resource allocation, PBRA. Our understanding is that, in terms of the current plans of the Department, nearly half of all HSE expenditure is likely to be excluded from the proposed PBRA mechanism. Those exclusions will cover the primary care reimbursement service, PCRS, for GP and dental care and the fair deal scheme. That is a massive part of our health service and there is a lot of unmet need within it. Will we truly have a proper system of population-based resource allocation in terms of a model of funding if we exclude that whole swathe of the health service? That is a conversation for another day-----

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