Brian Stanley (Laois, Independent)

I welcome the opportunity to speak on this Bill. I will do the easy bit first. I have gone through the Bill and welcome a lot of what is in it. It is welcome that the service plan will be replaced with a performance delivery plan. It is welcome that we will be able to measure things. The Minister for Health is to prepare a strategic direction statement in respect of health service priorities to guide the HSE in preparation of its corporate plan. That is welcome. The Minister for Children, Disability and Equality is to prepare a similar strategic direction plan in respect of community-based disability services. That is laudable. The Minister for Health will also prepare an annual statement of the health services' priorities. That is very important. The Minister for Children, Disability and Equality will undertake a similar task. The performance delivery plan will be due within 28 days of the receipt of the determination of the maximum net non-capital expenditure that can be incurred. That is all good. Importantly, the CEO will be required to inform the board, the Ministers for Health and Children, Disability and Equality if the HSE is likely to exceed the capital and non-capital budget allocation for any particular year. That is all fine.

As I stated previously to the Minister, there is a substantial budget going in and I have no argument with that. Coming from a left republican position, I welcome that. The more we can put in the better. Outcomes are the whole thing.

The following is the hard bit. The most recent health sector employment report was published by the HSE in March. In December 2019, 18,851 staff members were listed in the management and administration category. In March 2024, that number had increased to 25,477, which represented a substantial increase of 35%. When we track it, we can see that the numbers employed in those grades are increasing at a faster rate than the numbers of clinical, care and front-line staff. That is a big issue I have with the HSE. I am not saying that all managers are bad or anything like that. I know managers in the HSE who are doing their best. What I am saying is that it has become very bureaucratic. There are several layers. I understand there has been a big ship to steer. Health systems are complicated and the HSE is a big organisation with 120,000 workers. It can be hard to manage. I understand that. However, we must keep an eye on the services and the budget provided for them.

A situation was highlighted recently in respect of clinical insourcing. On many occasions we have complained about outsourcing, but I am talking about insourcing. It was interesting when that report came out. Surgeons were taking patients who came to them during the week out of the public system and doing private work through a private company they had established so they could do the work at weekends and receive a different price for it. That became a cash cow for those individuals and companies. The bewildering thing about it was that the hospital's own facilities were being used. If it were a private facility, that would be fair enough. If a private hospital wants to operate, let it operate. That is grand. I do not have any particular grá for privatised health services but if a private hospital wants to operate and people want to pay for it privately, it is grand. However, we must disentangle that from the public system, which we were supposed to be doing with Sláintecare. It was clear that what those surgeons were doing was exploiting public facilities and scarce taxpayers' money that needs to be going to front-line services. We must move away from that.

I welcome the fact that the Department and the chief executive of the HSE, Mr. Bernard Gloster, has managed to get weekend work operational in hospitals. They must work seven days a week. There is expensive equipment. We do not have enough equipment and we have a growing population. I get all that. For now, we need people to work at weekends. I welcome the fact it is happening.

I know that the numbers on the public-only contract are increasing. That needs to continue and to accelerate.

Again, that is nothing against people who want to work in private healthcare - that is fine and dandy - but we have to disentangle the two systems. This is a clear example of the public system and public facilities being exploited in terms of their use for private profit.

I refer to the lack of transparency in outcomes and delivery. The Minister was a member of the public accounts committee when I was the Chairperson of it and she was fairly good at drilling into things - I will give her that - as regards disabilities and so on. She focused on that a lot, as well as on health services, and she made a good contribution there, as did many of the members, but I remember her focusing in particular on these issues. We need to really give attention to this. The lack of transparency in outcomes and delivery damages the reputation of the healthcare system and can cause long-term financial problems. It restricts the public information. We must have full transparency to see how hospitals and services are performing and to get a better insight into waiting lists. Without that, public trust will be eroded.

I know the Minister was unavoidably absent this morning - the Minister of State, Deputy Butler, was here in her absence - but I hope she gets a chance to read some of what I said, and indeed other contributions that were made because they were made sincerely. I raised the issue of dental care and, in particular, the public dental schemes. There is €230 million going into that per year. It is clear that we are not achieving what we need to achieve in terms of the schemes. It is clear that the dental treatment services scheme, DTSS, for medical card patients is non-existent in many parts of the country, including in County Laois, where no dentist is taking patients under it, except one on the edge of Carlow town. The dental treatment benefit scheme is also very limited. Up to 2009, a range of services were provided under it but now it is just cleaning and examination. I suggested that we should examine a voucher system for that, which is in operation in other countries, to give a better service for workers paying PRSI, USC and PAYE.

I will say what I said this morning just to bring it home to the Minister. There is a particular problem with children and adults with special needs who need treatment under anaesthetic. There is over a two-year waiting list and there are some awful examples of young people and adults in desperate need of dental care on long waiting lists and going nowhere. I have had family members come to me about this and it is terrible. They cannot be treated. Some of them are suffering with toothache and some are suffering with oral dental health problems. That will all cause further health problems down the line. I ask the Minister to really take that on board because they are a very vulnerable group.

The issue of agency staff is in some ways an old chestnut but it is one we have to deal with. When he took over, Bernard Gloster said he was committed to trying to pare that back, and I know that is easier said than done, but the over-reliance on agency staff is concerning, with €276 million spent in 2024. It is a lot of money spent on services, recruitment agencies, etc. That €276 million was only for 11 months of last year. The HSE's records showed that this finance was spent on services such as administration, management, nursing, medical, dental, and paramedical services and supports, as well as maintenance and technical supports. In the Midland Regional Hospital, in Portlaoise, a relatively small but very busy hospital, almost €20 million was spent in 11 months last year. Some €19.7 million was spent there on agency staff in 11 months of last year. As I understand it, that spend has never been higher.

The Minister will be doing the capital development plan. She will be swotting around the Cabinet table over the next week with this. I know there are hard decisions to be made. The cake has to be divided up. I ask her to do what she can about primary care centres and health centres because we all know that if we catch people, and if we are able to help people in the community and provide services at community level, it keeps them out of expensive hospital care.

In particular, I ask the Minister about the primary care centre for Portlaoise. It is promised and it is agreed that it will happen, and everybody is on board with it. It needs the cash - the capital allocation. Portlaoise town now has a population in the region of 30,000. There is a huge catchment area around it. It is probably the only town of its size in the country that does not have a primary care centre. Some of the smaller health centres - in Mountrath, Borris-in-Ossory, Rathdowney and Graiguecullen - need some upgrading as well, and I ask that they not be forgotten about. They need works as well.

We have had the ambulance services before the Committee on Public Accounts and we have had reports from them. I do not care what the senior staff in the ambulance services say about dynamic deployment. There are ambulances chasing from Portlaoise to Waterford or to Wexford. When they are within a mile or a couple of miles of where the accident or the patient is, they get a call telling them to turn back as another ambulance got there before them. Meanwhile, back in Laois, somebody is after having a heart attack and there is nobody to pick them up.

Whether we like it or not - and I know there are no easy solutions to this and that nothing is perfect - we have to get to a system. The optimum is to keep the ambulances within a 45 km or 50 km area. By all means, ambulances should be able to cross county boundaries. Portlaoise ambulances should be able to go into south Kildare, west Carlow, north Tipperary or east Offaly. Of course, there has to be flexibility there, but we cannot have them chasing literally to Cork, which is happening. That needs to change.

I welcome the start of the midlands hospice. This has been going around since I came here 15 years ago, and I would say before that. I welcome wholeheartedly the fact that that will now be done. It is located in Tullamore and not in Laois, but people will live with that. This is a service in the midlands, a really important end-of-life care facility, and I welcome that.

I started by saying there is a big shift this year as regards the health system. I understand that. Bernard Gloster has done a good job. I know of some changes he has made. He has made some good changes to this. The Minister is taking a very hands-on approach to it. We may differ sometimes on ideology or other things, but what is really important is that we shorten the distance between budget and delivery and that we can see that it is a straight line. We must remove the diversions that allow people to talk around issues, sidestep and get around this. In big organisations, we need to shorten the distance between the money going in and the top of the organisation and the service delivery on the ground. We must remove all places for people to hide and keep this in a straight line. Let us make sure we get value for taxpayers' money and improve public services at the same time.

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