David Cullinane (Waterford, Sinn Fein)

This is an annual Bill that renews the risk equalisation mechanism, which supports the community-based health insurance market. Obviously, I recognise the fact that many people rely on health insurance, so for that reason, we will be supporting the Bill. However, as in previous years, I will be critiquing what I see as a two-tier system and an insurance market system that I fundamentally do not agree with.

Many people take out private health insurance because they feel they must. There are some people who will take out private health insurance for other reasons, but the vast majority of people I represent have private health insurance because they cannot depend on the public system and they are waiting too long on waiting lists for things like a diagnostic scan, sometimes for elective procedures, planned procedures especially and maybe for some key issues like cancer or cardiac where they can be seen in private hospitals. Most complex work is actually done in our public hospitals. It is the planned elective procedures where there is an advantage if one is a private patient.

I accept that risk equalisation is important from the point of view of protecting certain cohorts of customers, which is why I am supporting the Bill, but we as a Parliament and as a people accepted when we signed up to Sláintecare that we wanted to move away from a two-tier system and embrace a single-tier health system, which exists in many countries in the world. They may not be perfect systems - no system is ever perfect - but I believe that universal healthcare systems are better than having a two-tier system.

We are finally getting to the point where I can see, even in recent weeks, private healthcare is being removed from public hospitals. That is a positive step. I have always believed that public hospitals must be for public patients, where people are treated on the basis of equality and where we do not have, in our public hospitals funded by taxpayers, any form of two-tier entry or two-tier access. We are somewhat moving in the right direction in that area.

There has been some progress made in recent years in relation to reducing the cost of healthcare. I would have proposed many of the measures that were brought in by the Government, and I supported them, but we are still a long way from where we need to be. For example, we do not have free primary care. Many people still pay for many primary care services, including GP access. I note that even the GP visit card, which was extended by the previous Minister, is not being taken up. Part of the reason is because it is very complex for people to understand who qualifies. Even I, with my so-called wisdom, had a look at it and was still not able to figure out whether some families were entitled to the GP-only card. That needs to be simplified and better explained because it is far too complex for people to understand.

The biggest reform we need to bring into the health service, if we are really interested in reform and dealing with waiting lists, is to build the elective public-only hospitals. That would be the biggest game-changer. It would be reform with a big R for a number of reasons. The primary advantage for anybody with private health insurance is that they can get a hip done, a hernia operation done, a cataract surgery done and all those day case procedures, which are the low-lying fruit for the private health insurance market if we are being honest. That is where private health insurers step in by covering lots of those procedures and making lots of money on them. The logic of the elective-only hospitals is that we would have four of those, two based in Dublin, one in Cork and one in Galway. They would do these procedures on scale and rapidly, so people would be seen within a couple of weeks as opposed to waiting years.

I am dealing with an elderly gentleman in my constituency of Waterford who needs two cataracts done. He has already been waiting eight months. I contacted hospital management and they said he could be waiting 15 more months. He cannot see out of either of his eyes, so his quality of life is affected. His options are to go to Belfast, get it done there and recoup the money or he can get it done elsewhere through the National Treatment Purchase Fund, NTPF, which the hospital has now kindly agreed to. Why are people waiting so long for procedures like that? A new cataract unit was put into the hospital in Waterford, yet we still have people waiting. I have people almost every day asking how long more they are going to have to wait for their hip or hernia operations to be done. These are simple procedures where people should not have to wait for years. I submitted a parliamentary question last week asking about the number of patients waiting for a diagnostic scan. The reply said 300,000 people were waiting for a scan - a CT scan, an ultrasound scan, very basic stuff. If somebody has private health insurance, they can go into a private clinic and get a scan or a scope done in a couple of weeks. If they are a public patient, they are waiting months and sometimes up to a year for a simple diagnostic scan. In fact, there are over 40,000 patients waiting over 18 months for a diagnostic scan. That is a shameful situation for us to be in. I told the Minister for Health in the Oireachtas health committee last week that, while I support the roll-out of the surgical hubs, we also need a roll-out of diagnostic hubs, which would be a sumilar system.

It is a similar system where diagnostic hubs on site or close to public hospitals carry out diagnostic tests which are important in terms of patients' healthcare journeys and provide results much more rapidly.

Another benefit of elective hospitals is that we separate scheduled from unscheduled care. That will be a huge game changer. Every time we have a surge in our emergency departments, which we know happens almost every day in some hospitals and almost every other day in almost every hospital, one of the first casualties is elective procedures. That is the only option open to a hospital manager because they need to use all of the capacity in a hospital to deal with the surge of patients on trolleys. Separating scheduled from unscheduled care makes perfect sense.

The surgical hubs which are being rolled out will help somewhat in that regard but the biggest game changer will be elective hospitals. I have raised with the Minister, head of the HSE and Secretary General of the Department of Health the fact that €9.5 billion in capital funding was given to health up to 2031. I met all of the officials, including those responsible for capital investment in the Department of Health, before the last election. They told me that what was needed was €13.5 billion. They have to finish the national children's hospital and the new national maternity hospital. There is digitisation and the roll out of measures which could cost up to €1 billion or more, and money has to be ring-fenced for that. There are climate action measures. There are regulatory requirements, which comes under the remit of the Minister of State. HIQA costs money. The former Minister, Stephen Donnelly, promised 3,000 beds, half of which have not been funded. That was another mirage by a Minister who made loads of announcements but never followed through on most of what he announced and left a mess, including the roll out of free HRT.

I referenced GP only cards and hospital beds, most of which have not been and will not be funded. There are other elements of the health service which require capital funding, including every acute hospital and mental health and disability services. The money does not go.

At a meeting of the health committee, we were told the best we can do for elective hospitals is get them to planning by 2031. For me, that is a massive failure and lack of ambition from the Government. It also tells me that this is a Government that is happy to see people continue to pay private health insurance. I have no doubt that if people had rapid access to elective procedures like those I mentioned, namely, day case procedures, that would negate the need for many low and middle-income families to take out private health insurance. It would be the fastest way to eliminate that for many families and reduce the sphere of influence of private insurance companies.

We talk about efficiencies in health care and the fact that we are spending record amounts of money on health, which we are because health inflation is high and we have to spend between €1 billion and €1.5 billion every year just to stand still. This is the reality of the health service at the moment. It is very difficult to get new money for new measures. While that is happening and families are paying for private health insurance because they cannot depend on the public system, this year €800 million will be spent on agencies.

My partner is a nurse who left her job in Castlebar to move to Waterford about three months ago and is on a waiting list to get a job in a public hospital. There is still no offer of a contract. She is one of many people due to the strict embargo and bureaucracy that has been put in place in respect of staff recruitment. Workers like her were told to work for an agency and get a few shifts here and there. A premium of 30% is being paid. It is not ideal for the worker, taxpayer or anybody but that is what we are dealing with. We are going to hit a spend of €800 million on agency staff, yet nurses and other healthcare professionals who want to work in the public system cannot be hired, which makes no sense.

Insourcing is going through the roof. It has now been stopped because of potential conflicts of interest but hundreds of millions of euro are being spent. The same is happening with outsourcing through the NTPF. We are not building elective hospitals and will not fund 3,000 beds. Elective hospitals, which are a big game changer, will not happen. Agency spend is up. Inefficiency is everywhere in the health service, yet patients are waiting for basic procedures. It does not make sense. It is wrong. They are the key issues that need to be sorted.

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