Peadar Tóibín (Meath West, Sinn Fein)
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It is commonly believed the Health Information and Quality Authority, HIQA, is used by the Government to hold investigations to enable the latter to close services. When there is a serious risk to health in a particular hospital, however, HIQA refuses to hold an investigation if it does not fit in with Government policy.

Last month, Deputy Adams, a local GP, Dr. Ruairí Hanley, and I submitted a request to HIQA to carry out an investigation into the ongoing serious overcrowding in Drogheda. There are consistently between 45 and 55 patients on trolleys and chairs in Our Lady of Lourdes Hospital. This is the highest number of inpatients without beds in any hospital in the State. In a further development last week, three patients and an unspecified number of staff at the hospital were screened for TB. The significant pressure on the emergency department represents a clear threat to patient safety and welfare. HIQA's reply ignored the central point that overcrowding in the hospital was a health risk that demanded an investigation.

We have seen what happens when regulators get too close to the Government - the system breaks down and there are serious ramifications for the State. In this instance, HIQA's dangerous maladministration and regulatory negligence could have a grave effect in the mid-north east. I call on the Minister for Health to initiate a full investigation into the overcrowding at the hospital. I also call on him to comment on the Peyton report, which referred to Navan hospital.

Dessie Ellis (Dublin North West, Sinn Fein)
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I have been a Deputy for a short while and was a councillor for 12 years. During that time, I have witnessed constant attacks on hospital services. With my colleague, Mr. Paul Donnelly, I have been involved in the Save Connolly Hospital A&E campaign. Connolly Hospital has been a lifeline for people in Finglas and on its borders. It covers Dunsoghly, Blanchardstown and Castleknock, which form part of my catchment area. It also caters for more than 330,000 people across counties Meath and Dublin and on the commuter belt. Thousands of new homes were bought by people who moved to the area in the expectation that the services available to them in Connolly Hospital would be second to none.

In the past 20 years, there has been an incremental erosion of public health care services. It started when we first introduced charges on patients attending hospitals. Ever since, the public health care system has suffered. The system 20 years ago was not perfect, but it was better because it was public. Privatisation has driven us to this point. The selling off of hospital beds and hospital lands and the use of public health care services for private patients have been scandalous.

The Fianna Fáil-Green Party Government and the Fine Gael-Labour Party Government are one and the same. They have followed the same hospital policies. Some €20 million has been cut from Connolly Hospital's budget of approximately €108 million. That is a full fifth.

Paudie Coffey (Waterford, Fine Gael)
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Sinn Féin has done a fair share of that in the North.

Dessie Ellis (Dublin North West, Sinn Fein)
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The Deputy should remember that we have a different system in the North.

James Reilly (Dublin North, Fine Gael)
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Sinn Féin sure does.

Dessie Ellis (Dublin North West, Sinn Fein)
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Nearly 2,000 beds have been closed in the country's hospitals, approximately 50 in Connolly Hospital, because of the cutbacks. The Minister for Transport, Tourism and Sport, Deputy Varadkar, is a Deputy for Dublin North-West and used to work in the hospital. In 2010, he criticised the previous Government for taking the view that budget targets should be achieved by closing services. He stated: "That is not the way it should be". I agree with him.

Last year, the current Minister for Health, Deputy Reilly, stated that "the impact of the closure of hospital beds would lead to more patients suffering needlessly on trolleys and more patients waiting at home in pain due to cancelled operations". He has since changed his tune and is presiding over widespread closures. Recently-----

Michael Kitt (Galway East, Fianna Fail)
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I must call the Deputy's colleagues. He should conclude.

Dessie Ellis (Dublin North West, Sinn Fein)
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Sinn Féin will continue to challenge the dismantling of health care services. Unless a halt to closures is called, people will have a fearful winter. They are suffering and dying. Will the Minister wake up? We cannot afford this.

Sandra McLellan (Cork East, Sinn Fein)
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The health service is in crisis. It was in crisis under the Fianna Fáil-Green Party-Progressive Democrats Government and is in crisis under Fine Gael and Labour. Across the State, people have become painfully accustomed to the familiar HSE approach to so-called reconfiguration. It starts with a series of cuts, the non-replacement of staff, a little bit here, a little bit there. Along comes a report claiming the hospital or department is no longer fit for purpose or with some story about an insufficient throughput of patients. This is usually followed by the promise of a "local" centre of excellence some 50 miles away. Following this comes cutbacks, downgrading and closures and the centre of excellence never materialises.

In Cork East, the centre is still Cork University Hospital. It has received no extra beds, facilities or staff. Indeed, fewer staff are doing more and more in more dangerous conditions. This is just October - imagine what it will be like in December and January.

The Government is intent on downgrading emergency services in a number of rural hospitals, including at Mallow. The blueprint was provided for in the HIQA report and piloted in Roscommon. The process cannot be allowed to continue. In addition to this onslaught on hospital services, pre-hospital emergency services are being devastated. The proposed reconfiguration of the ambulance service in the HSE south area could leave Youghal without ambulance cover. This is unacceptable. These proposals, particularly in the context of the devastating cutbacks planned for the emergency department at Mallow, amount to an unprecedented assault on acute emergency health care in the region. A rapid response vehicle manned by paramedics is not the same as an ambulance manned by advanced paramedics.

It is clear to the dogs on the street that the Government's strategy makes no sense. Services at every level are being slashed. Out of hours primary care, emergency care, pre-hospital emergency care and convalescent care are under attack with no sign of replacement or alternative services. All of the evidence indicates that these moves will cost lives. The time for words and five-year reprieves is over. People need to see real change and improvement.

Jonathan O'Brien (Cork North Central, Sinn Fein)
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I thank the United Left Alliance, ULA, for submitting this comprehensive and well considered motion. The Members should be congratulated.

The motion refers to a recent announcement regarding the impending closure of the accident and emergency unit at South Infirmary-Victoria University Hospital. While the announcement was being made, the HSE insisted there would be no loss of accident and emergency services in Cork. The plan announced, which also involves the transfer of orthopaedic services from St. Mary's Hospital to the South Infirmary Victoria Hospital, is wrong. Under the proposal, the accident and emergency department at the South Infirmary Victoria Hospital will revert to a 12-hour service in December with full closure in April. That will mean that 15,000 patients who use the South Infirmary Victoria Hospital every year will have to make alternative arrangements.

A HSE manager in the Cork region, Ger Reaney, told us that by next April Cork University Hospital, CUH, will able to cater for the increase in emergency demand resulting from the closure of the department in the South Infirmary Victoria Hospital. CUH has 48,000 patients a year going through its accident and emergency department. The HSE claims that it can cater for up to 60,000 patients a year. If the Minister were to ask anyone in Cork if the CUH could cater for another 12,000 patients every year, he would be laughed out of the city. Yesterday, there were 23 people on trolleys in the accident and emergency department in the CUH, yet we are supposed to believe that it can cater for an additional 32 people a day on average.

One of the arguments put forward by the HSE and the Department regarding the closure of the department in the South Infirmary Victoria Hospital hangs on a vague proposal to open a new urgent care centre at St. Mary's Hospital. Only a few weeks ago when we discussed the orthopaedic hospital, I asked what services would be provided in the hospital to replace the orthopaedic services and at that stage there was no definitive plan in place. However, when we have an announcement on the closure of the accident and emergency department in the South Infirmary Victoria Hospital, the promise of an urgent care centre is being dangled. If the Minister is asking the people of Cork to believe that they will get an urgent care centre in the orthopaedic hospital when only a few months ago members of his party gave cast iron guarantees that the transfer of orthopaedic services from St. Mary's Hospital would not go ahead, he is coding himself.

Some 88,000 people currently attend the three accident and emergency departments in Cork. They are overcrowded, operate under intense pressure and are bursting at the seams to cope with the demand. The Government has put forward the solution that it will close one fully operational accident and emergency department with the promise of an urgent care centre to replace it but no definitive timeline has been given as to when it will open, if it will open at all.

The whole debacle reminds me of the film "Downfall". I do not know if the Minister saw it but it is set in 1945 at the end of World War II and all the German generals are inside in a bunker strategising, plotting and moving imaginary divisions on a map from one area to another. I have visions of the Minister in a bunker in the Department of Health with his officials moving imaginary services-----

James Reilly (Dublin North, Fine Gael)
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That has unfortunate parallels from the Deputy's background.

Jonathan O'Brien (Cork North Central, Sinn Fein)
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-----from one area on the map to the other. In both cases the outcome was more hardship-----

Michael Kitt (Galway East, Fianna Fail)
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I will have to call the next speaker.

Jonathan O'Brien (Cork North Central, Sinn Fein)
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-----because they did not change course. It is time the Minister changed course before more people suffer under this Fine Gael-Labour Government.

Michael Kitt (Galway East, Fianna Fail)
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The next speaker is Deputy Simon Harris. The next time slots are of four minutes. I note the Deputy and six of his colleagues are next to speak and ask them to adhere to the time allotted.

Simon Harris (Wicklow, Fine Gael)
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I will. I welcome the opportunity to speak on this Private Members' motion and I thank the Technical Group or the United Left Alliance for tabling it. Any opportunity we have to discuss the issues in our health service are very much to be welcomed.

The Minister, Deputy Reilly, has been in the job for a very short time, yet seems to have to accept responsibility for everything that has ever gone wrong in the health service and many of the legacy issues which we inherited. The Government has quickly come to terms with what the people know, namely, that throwing millions and billions of euros at our health service, as was done by the previous Government, did not work. It is some turnabout that there is not one representative of that former Administration in the Chamber to contribute to the debate or, at least, to listen to the contributions. Throwing money at the problem did not work. We now have to review the services within our health system and this is the attitude that should have been adopted when we had more money. We now have to examine how our hospitals are to interact and the role for smaller hospitals. In that regard, I very much welcome the comments by the Minister, Deputy Shortall, in her contribution to this debate where she outlined that smaller hospitals have an important role to play in local communities.

There are lessons we must to learn from what our predecessors did and one in particular is in regard to the order in which any change, reform or reconfiguration happens. In the past we were told that services would be downgraded or reconfigured in one place or that services would be closed in one area and a new better, shinier service would be opened at a location at some point in the future. It is important that the sequence of events when it comes to reconfiguring any of our hospital networks is correct.

In that regard, I refer to the hospital that serves my constituency and that of the Deputies Boyd Barrett and Doyle, namely, St. Columcille's Hospital in Loughlinstown. It is essential, before there is any altering of the service at that hospital, that issues regarding the capacity of St. Vincent's University Hospital in Dublin and the paramedic service in County Wicklow are rectified. We have received confirmation from the HSE that capital of approximately €600,000 has been allocated to these two hospitals and that much of that capital is to expand the accident and emergency department in St. Vincent's hospital while further capital is to upgrade the wards in St. Columcille's Hospital in Loughlinstown to make it more appealing and desirable for day surgery. From a political point of view, I ask the Minister to give me, the people of Wicklow and the House an assurance that he will hold the HSE to this commitment in terms of the order in which things are done. That is really important.

I want to comment on the HSE in general. That bureaucracy is continuing to run riot and I take the example of trying to keep people out of hospitals. However, in my constituency of Wicklow carers who look after elderly relatives and try to keep them out of hospitals have been handed this sheet, which is a bladder record chart, and are expected to weigh incontinence products. I accept this is not a national directive and the Minister's Department has confirmed that for me but middle management in the HSE, unelected bureaucrats, are making these unilateral decisions. I welcome the commitments in the programme for Government and in our party manifesto that we will set about disbanding the HSE and bringing political accountability back to the health service. I commend the Minister on the job he has done to date.

I will always take advice on the health service serving my constituents not from politicians or bureaucrats, but from clinicians and in that regard the changes proposed for St. Columcille's Hospital in Loughlinstown, if carried out in the right way, will provide a better service for my constituents, the people of County Wicklow.

James Reilly (Dublin North, Fine Gael)
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Well done.

Peter Fitzpatrick (Louth, Fine Gael)
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I welcome the opportunity discuss the crisis that has arisen due to overcrowding in accident and emergency department of Our Lady of Lourdes Hospital in Drogheda. The debate on this motion is opportune as a delegation of the HSE visited the hospital last week. Its remit was to assess the situation with regard to the overcrowding at the accident and emergency department. The planned visit of the delegation arose following the meeting of the regional health forum for Dublin and the north east on Monday, 26 September. It is hoped that its visit will result in it seeing at first hand the crisis in the hospital and that this in turn will lead to a recommendation and, more importantly, to a national plan being devised and implemented to ease the situation at the hospital.

I do not want to pre-empt the findings of the delegation, particularly as it visited the hospital last week. I would be interested to hear its recommendations, particularly regarding the people who were on trolleys when they visited or for the 58 people who were on trolleys the week before that. I understand that figure was a new high for the hospital.

A number of factors have led to the increase in the number of patients in this department at the hospital and before I outline them it is important to recognise and compliment the front line staff at the hospital on the tremendous work they do under severe conditions. The level of care they provide is of the utmost professional level and I met three people over the weekend who confirmed this. The level of care within the hospital should be commended. The staff do great work under stressful conditions to alleviate the suffering of patients and aid their speedy recovery.

Moving on to some factors that have led to the crisis, Our Lady of Lourdes Hospital serves a large geographic area that includes not only Louth and Meath, but north Dublin, Monaghan and Cavan. The hospital is under pressure from the demand from these catchment areas. In addition, there was a shortage of staff, particularly doctors, throughout the hospital. This shortage has led to an increased workload and the slow release of patients from the main hospital; they are not being released as quickly as necessary and beds are not being freed up. In addition, people are presenting themselves at the accident and emergency department who do not need to be there. The idea that a hospital is a first port of call when illness strikes must change. Only persons with acute problems should be there. Essentially, the accident and emergency department is being clogged up by those who could be seen in other facilities. For example, I come from Dundalk where there is a fantastic hospital with a minor injury unit. I plead with people in Dundalk and the surrounding areas to think twice when passing the hospital. I know they are under a bit of pressure and everything else, but it is a fantastic hospital, it is open 12 hours a day and I would appreciate if the people would call in. Also, if the people call to their local general practitioner, and are referred to the hospital, there is no additional charge.

It is important that the hospital system works quite well when one is admitted. The problem, or bottleneck, appears to be at admissions. When one is admitted, the attention and care works well. Perhaps an element is freeing up beds quicker. In addition, there needs to be an examination of the private versus public sector in the allocation of beds. This may free up more beds in the main hospitals.

I await with interest the report finding from the HSE delegation. In addition, I would welcome the opportunity to meet and discuss any proposals they make to alleviate the problem in the north-east leading hospital.

Andrew Doyle (Wicklow, Fine Gael)
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This is a pertinent and relevant issue to discuss. If it was as simple as more money, the health service in this country would be one of the best in the world. In the good old, bad old days when there was growth and inflation of 5% or 6%, inflation in the health service was running at 10%, extra funding was going into it and the problem still persisted. The Minister and myself sat on the old Eastern Health Board followed by the Eastern Regional Health Authority, which split into three boards, and then we all were booted off in the infamous centralisation of the health service with the establishment of the HSE. We have seen more money thrown at it in the first four or five years of the HSE, and it is still no better. It is not quite simply a matter of funding.

Other countries that have adopted a fair care model of universal health insurance are spending far less per head of population than we are. There are reasons for it other than management. There are certainly many reasons for it with the way we do our business as a health service provider.

The principles of building a proper primary care structure, of having the money follow the patient - in other words one gets paid for the service one provides and if one does not provide it one does not get the money - and of having a system of universal health insurance are ones to which we should aspire. I note the motion states the plan is in chaos but it does not state that it is a bad idea.

We should remember that right throughout the years of significant extra funding going into the health service, accident and emergency services, in particular, did not get any better. Many other areas of health care improved and others have not improved, but accident and emergency, in particular, did not get any better.

In the case of the hospital closest to me to which Deputy Harris referred, St. Columcille's, the clinicians are the ones who are recommending a change of configuration, but it will only be effective if the proposals are implemented along the lines Deputy Harris outlined. One must put in the extra infrastructure. One must manage the flow of patients between both hospitals, and who goes in to each hospital. By doing that one can improve services in both places but one cannot do one without the other. The one commitment - we met members of the HSE management last night - that none of it will be completed until such time as the clinicians approve of it is key. There are different cases across the country in other areas where there was a split between those who were involved, the health clinicians themselves, and the HSE as it was. They all are individual and every case is different. However, in this case it is the clinicians who are recommending it. In the first instance, it is not a cost saving measure; it is a cost efficiency measure and what is best for the patients. We should bear that in mind.

It is easy to make a political football out of everything, but I plead with people to take the advice of those who know best, which is not the politicians nor the bureaucrats. If it is those who are involved in the delivery of the health service, please listen to them.

Damien English (Meath West, Fine Gael)
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I thank my colleague for the chance to say a few words.

I know by the motion that those who put it down understand that the Minister will try to tackle this because most of the stuff to which they refer is decisions made in 2008, 2009 and 2010 - all before his time. I accept all those decisions have made an impact and need to be addressed, but it is a bit unfair of them to state that the FairCare health reform document is in chaos. It is not really helping the debate.

For once, a potential Minister in a general election set out a seven year plus plan to fix the health services and did not promise a massive quick fix. He did not promise everything would be fixed in six, seven or eight months, but put forward a plan for once that could fix this over seven years, and he will stand by that.

As one who in opposition criticised my party's health spokesperson and ask him the detail of this document, and kept an eye on him over this document asking could it work, etc., in fairness, now that he is in office, he is implementing it. As someone who spent years looking at that document that he prepared over a couple of years based on the Dutch model but adapted to suit the Irish model, I have no doubt it will work. However, it will not work by Christmas, or even Christmas 12 months. Probably, it will take the seven years, but I am confident it will work.

The reason I am confident is because it was phased, and phase one clearly set out setting up the special delivery unit, which is in place since May and is working. I accept it is not working in every hospital, because it is not in every hospital and it cannot be. However, it is getting there. It has already recommended changes to Our Lady of Lourdes Hospital which will solve or help the problem there. In other areas, it has been very successful. That is a start. They now have a plan to tackle the problem in Our Lady of Lourdes Hospital in my constituency, and in Navan hospital. There has been overcrowding there for years and no-one ever said he or she would fix it. This Minister will fix it. I, like the Deputies who proposed the motion, wish it happened yesterday. It did not happen yesterday, but it will get there.

In that regard, the special delivery unit is the way to go where one goes to a place, clears the obstacles out of the way like one does in any business, fixes it, and gets the waiting lists and waiting times down. That will happen because the hospital in my area is suffering like every other hospital.

The Minister gave a commitment that he would bring back surgery to the hospital in Navan. It is not yet back, but that is not his fault. The motion is in place, the HSE agrees with it and it is now down to sorting it out between the staff and the HSE, but surgery is on its way back as promised.

On accident and emergency, the Minister stood in front of a number of people and stated that department would not be there forever. It does not make good health sense, and even some financial sense, but he admitted to everybody that it would not be there forever. However, it will be there until we sort out some of the overcrowding problems in the neighbouring hospitals. People accepted that. General practitioners accepted that it makes sense, maybe at some stage, to remove that service.

Michael Kitt (Galway East, Fianna Fail)
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One minute remaining.

Damien English (Meath West, Fine Gael)
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Naturally, we will fight to keep it for as long as we need it and as long as we can for many other reasons, but the medical practitioners who advise us state this is okay if it is planned properly.

In fairness, the Minister has stood up to most officials in the HSE stating that with any more closures, he wants to know about it and we will plan it and do it properly. Closures, rearrangement or transformation etc., will be done properly in a planned way in which they can work, not in an ad hoc way that is not part of any greater plan.

I believe the plan of using the smaller hospitals is the right way to go. We should take out some of the services that are causing overcrowding in the big hospitals and bring them back to hospitals such as the one in my area of Navan. We should put them to good use. Those small hospitals are underperforming because they are not being let perform to their potential. We should let them do their job and give them more of what they can do locally on their site. In cases of overcrowding in accident and emergency departments in some hospitals, perhaps we need to look at smaller hospitals in the short term to ease that as well.

The FairCare document, which is criticised in the motion, will eventually lead to a one-tier health system that is fair across the board. I accept that many on the other side of the House would rather that it was funded completely out of the public purse. We are going down the health insurance route. Either way will achieve the same result - a one-tier health system. Everybody, no matter what money is in his or her pocket, goes through that door. One will get treated for whatever health service is there because one will be of benefit to that hospital. Whether it is the person's cash, health insurance cash or whoever's cash, when the person goes through that door he or she is coming with money because money will follow the patient.

Michael Kitt (Galway East, Fianna Fail)
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I thank Deputy English.

Damien English (Meath West, Fine Gael)
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It is already working in some hospitals in my area. The concept is right. It will be worth the hospital's or medical centre's while to take you in because every time you come through that door to get something done, you will earn it money. That is a one-tier health system that can work because it will be equal.

Michael Kitt (Galway East, Fianna Fail)
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I call Deputy O'Donnell.

Damien English (Meath West, Fine Gael)
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I accept there are different ways of funding it, but we are going down one route. It will be equal, and that is the bottom line. It will take more than six months.

Michael Kitt (Galway East, Fianna Fail)
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I call Deputy O'Donnell.

Kieran O'Donnell (Limerick City, Fine Gael)
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I am delighted to contribute to this debate on the health services. Dialogue and open discussion is the way to reach a point where people become familiar with the changes and improvement in the health service.

I am a Deputy for Limerick city. I refer to the accident and emergency department of Limerick Regional Hospital whose staff do such good work. The Minister has established a special delivery unit and a report has been done on the hospital. The staff of this unit will work alongside existing management and staff to improve the service and to make it more efficient. This is not privatisation but seeks to bring about efficiencies by working hand in hand with existing staff and management and with the same reporting structures as in any other hospital.

The Minister is aware of my views on the situation in the mid west and in Limerick. In my view we are not getting our fair share of the pie. I refer to a meeting of the Committee of Public Accounts on 29 September. The chief executive officer of the HSE, Mr. Cathal Magee, was in attendance and I put it to him that, since 2006, the per capita funding for the mid west has fallen by 5%. The mid west area of the HSE west region has seen a drop in funding of 13%. The average funding is €2,830 and the mid west now receives €2,709 with the HSE west region at €3,095. The average funding for the mid west has fallen by 5% and the overall funding to the HSE west region is 13% lower. Our allocation since 2006 has fallen as a percentage from 31.56% of the funding to 29.73%. This is 1.83% of a decrease. This may not seem to be a significant amount but a 1% decrease in funding equates to €21 million. That 1.83% is a reduction of €38 million in the allocation to the mid west as a percentage of the overall the HSE west region allocation in the past four to five years. I welcome the fact the Minister is carrying out an overall review of funding and how it is disbursed within the HSE. We must examine the practicalities of providing health care and how the HSE distributes funding. There are inequalities within the system and the mid west suffers in this regard and also Limerick Regional Hospital and St. John's which both provide a tremendous service to Limerick city.

I compare the funding given to Limerick Regional Hospital and to University College Hospital Galway, both of which are in the HSE west region. The funding to Limerick Regional Hospital has decreased by 7%. A 1% reduction equals €2.42 million. Funding to the Mid-West Regional Hospital has seen a decrease in funding of approximately €17 million. The special delivery unit will do vital work and bring about efficiencies but we must look at how the HSE works internally. Limerick city and the HSE west region overall are getting a raw deal. I look forward to the finalisation of the Minister's deliberations on the allocation of funding. I want to see how Mr. Cathal Magee and the HSE intends to deal with the issue of funding. I wish to acknowledge the great work of the health professionals, the nurses and staff in Limerick hospital in these difficult times but we are moving in the right direction.

Seán Conlan (Cavan-Monaghan, Fine Gael)
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I welcome the opportunity to speak on this Private Members' motion and to talk about health care reform. However, to table such a motion at this time, given the chaos that was caused to the health service as a result of the policies of previous Governments, is unwarranted. I welcome the Minister's efforts to reform our health care system and it must be stressed that he needs time to complete this process. It will take considerable time to fix the terrible legacy of the past.

There are some amendments to this motion dealing with health services in the Cavan-Monaghan constituency. I welcome the fact that the Minister has begun a process of looking at the possibility of putting a medical assessment unit into Monaghan General Hospital. In fact, I proposed this when I was first elected and I am pleased the Minister is advancing this process. If he delivers a medical assessment unit to Monaghan, he will be the first Minister in many years to enhance the services provided by the hospital because over the past 14 years, successive Ministers for Health, including the current Fianna Fáil leader, Deputy Martin, have stripped maternity, ICU, medical and surgical services out of the hospital. I note that the HSE has announced a temporary reduction in the hours at the Monaghan minor injuries unit with effect from 1 November 2011. I strongly urge the Minister to reconsider this decision. I believe it is not warranted and I welcome his comments that he will review the decision in the new year when he has a new budget at his disposal. I am encouraged that he has previously stated he will not allow the HSE to undertake a reconfiguration of services at Monaghan hospital by the back door.

As a Deputy for Cavan-Monaghan, health is one issue that is always foremost on my mind and on the minds of my constituents. Today, 19 people are waiting for a bed in Cavan General Hospital, having been admitted for inpatient treatment from the accident and emergency department. There are also 34 people on trolleys at Our Lady of Lourdes Hospital in Drogheda. Cuts at Monaghan hospital minor injuries unit will, in my opinion, lead to even greater numbers on trolleys at Cavan and Drogheda hospitals.

Outpatient antenatal clinics in Monaghan also need to be restored to the levels agreed to by the HSE when the maternity unit was closed. Originally, there were three consultants with three clinics per week in Monaghan hospital. However, since last year this has been reduced to only one clinic per week with two consultants alternating every week. The concern locally is that the HSE is trying to remove this service and this must not happen. I welcome the fact that the Minister and his officials are looking into this matter for me.

The deluge of flood waters in County Monaghan on Monday and Tuesday of this week left a great many roads impassable. The road network across the region is poor. Many people in County Monaghan would have found it impossible to travel by car to Cavan General Hospital these past days. This shows up a glaring inadequacy which has resulted from the reduction of services at Monaghan General Hospital. Severe weather conditions over the coming months will cause similar patient transportation problems.

I have previously asked the Minister to carry out a manpower plan for the Cavan-Monaghan hospital group and within the wider HSE north-east region and an investigation to determine the feasibility of merging or reducing in size the number of senior managers within the north-east Health Service Executive region in order to reduce payroll costs and to protect front line services in the Cavan-Monaghan hospital group and in particular to protect the opening hours of Monaghan General Hospital minor injuries unit. I appeal to the Minister's knowledge of the health care system and also to his common sense to recognise the detrimental long-term consequences of the decisions the HSE has made regarding the health care provision for the people of County Monaghan. Alternative cost-saving measures which do not attack front line services must be explored. The people of Monaghan have given enough and deserve more.

Brian Walsh (Galway West, Fine Gael)
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I welcome the opportunity to speak on this motion and to offer my support to the Minister for his initiatives introduced in the short period of eight months since he came to office. The motion proposed by the Technical Group condemns the Minister by declaring that his plan has failed and is in chaos. The motion is high on rhetoric and it contains plenty of condemnations but offers no solutions. The motion is silent as regards any suggestions as to how the health services might be transformed or improved. This is a very poor reflection on the authors of the motion. Whether one is the Minister or a lowly backbencher like myself or a member of the Opposition, we are all here with a common purpose which is to serve the people who sent us here. This motion offers nothing by way of a solution for those people who feel vulnerable, who are suffering and those who are anxious about the future. The motion suggests the Minister's plan has failed. These comments are premature. They serve only to demonstrate a complete and utter lack of understanding or appreciation of the scale of the challenges the Minister faces.

It must be acknowledged, as we begin our reforms, that problems still exist in our health service. However, anyone who suggests these problems should or could be solved within an eight-month period is deluding him or herself. The scale of the challenges facing the Government in reforming the utterly dysfunctional health care system we inherited earlier this year cannot be underestimated. Sprawling waiting lists and overcrowded emergency departments have long characterised our ailing health service and the days are gone when we can or should attempt to bury these problems simply by firing money at them. That is not an option for us any more, but even if it were, it is a policy that has miserably failed us in the past.

Many of the inefficiencies that exist within the current system are a legacy of that policy, which was employed by previous Administrations. What is needed now is a departure from this failed policy of the past, radical reform of the way we manage our hospitals and an element of thinking outside the box I am pleased the Minister has demonstrated he has the capacity to do that on several occasions during the short period he has occupied his Ministry. Real and measurable progress is being made. The Minister has made a series of credible and commendable reforms as we move towards the Government's vision of a single-tier health care service through universal health care insurance.

The special delivery unit he has established is addressing waiting times in emergency departments, waiting lists in acute hospitals and the problem of inefficient bed management within our hospitals, particularly our acute hospitals. This is a model that has been proven to work elsewhere. The special delivery unit has already resulted in enhanced accountability and efficiency within the system and it is working with consultants and hospitals to improve the key markers of hospital performance. I welcome this initiative.

In my constituency of Galway West, the problems of the city's main hospital, University Hospital Galway, have been well documented. Consistently, it has been the worst performing hospital in the country in terms of the HIQA health statistics published regularly. I am glad the Minister is also addressing these issues and difficulties here. There is no reason University Hospital Galway should be the worst performing hospital in the country. We have exceptional staff, state of the art facilities and equipment there and have excellent clinicians and an excellent university close by. There is no reason we are in this position in Galway, but I believe it reflects the way the system is administered and managed. I welcome the move by the Minister to introduce a new layer of management on a temporary basis, which represents a departure from the remedies that have been tried and have failed in the past. This new initiative and the new management team the Minister will introduce there and in Limerick will beef up the existing management team and help identify and upskill existing and potential management.

These are just two of a number of positive and innovative initiatives that have been introduced by the Minister towards what will be the most profound reform of the health care system this country has ever seen. Change will not happen overnight, but will take time. I look forward to the introduction of universal health insurance and a funding model where money follows the patient and our public hospitals are paid in accordance with the number of procedures and services they provide. There is no doubt these are difficult times and there are sizeable challenges ahead, but I am confident that with this innovative and reforming Minister at the helm, for the first time in a generation our health service has been harnessed and is being steered back to the right path to reform. I support the Minister's amendment to the motion.

Clare Daly (Dublin North, Socialist Party)
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I will share time with Deputies Joan Collins, Mick Wallace, Luke 'Ming' Flanagan and Mattie McGrath.

We heard comments from the Government yesterday and today to the effect that reform takes time and that there is a bit of a disconnect due to the changeover, but that basically the Government is heading in the right direction and dealing with the issues. The comments suggest those of us on this side of the House do not know what we are talking about and have nothing to offer. The Government side should have read the motion. It clearly states the Government should stop doing what it is doing and do the opposite. It should reverse the cutbacks and invest in a publicly funded health service.

We are not making this up. We are articulating the views of those at the coalface, the staff and patients who must, on a daily basis, deal with the crisis in our health service. Yesterday and on a number of other occasions, the Minister referred in a positive light to Tallaght. I would like to focus on the situation in Tallaght. It has the biggest catchment area of the five major Dublin hospitals and caters for a population of 500,000 people. If one hospital in Africa had to cater for that many people, we would probably take up a collection for it. Last year, accident and emergency attendance at Tallaght Hospital was 93,000 people, in comparison with 60,000 at its nearest rival, Beaumont Hospital. Tallaght Hospital had just short of 250,000 outpatient attendances as opposed to the Mater, which was the next highest at 202,000. However, Tallaght Hospital has the lowest number of consultants and is significantly below the average number of beds for the top five Dublin hospitals.

What is the reward for the hospital which sees the most patients, with the least number of doctors? Not under the watch of Fianna Fáil, but under the watch of the Minister for Health, the reward this year has been a slashing of the Tallaght Hospital budget, down to €175 million. That is almost €30 million less than the next lowest amount for one of these hospitals. The Minister told us yesterday that this was all right, because the number of people on trolleys in Tallaght Hospital is okay and the hospital is operating within its budget. He is wrong on both counts. Tallaght Hospital is not within budget, but is operating on an overrun of over €10 million so far. There are not fewer people on trolleys there either. Let us debunk this myth now. What has changed is the method of calculation. HIQA has told the hospital only to count people on trolleys within the confines of the emergency department. How has this been sorted out? It has not been sorted out by the addition of beds or by dealing with people. It has been sorted by pushing trolleys out of the emergency department and putting them in wards where people are still sitting on trolleys and chairs but are no longer counted in the statistics. This is nauseating.

The Minister said that he is also dealing with the issue of primary health care and that we cannot just focus on hospitals. That is right. We need to address the issue of primary health care urgently. However, the Minister is not doing that. He talks about doing it, but he is not doing it. Again, Tallaght is a good example. There, the lack of GP coverage is a key problem which feeds into the crisis in the hospital. With a population of 71,000 there are only 24 GPs in the area, one per 3,000 people. Yet, the HSE and the Minister have a facility outside the gates of Tallaght Hospital. This is Chambers House and it was supposed to be a primary care unit. Some €3.5 million was put into that house, but the Minister told the Tallaght Hospital action group in June that it will not now be the primary care unit because it is unsuitable and the doctors would not go into it. Instead, it will be used for other community purposes. To add to this debacle, over €2 million has been spent on the old TB hospital at Crooksling to provide a convalescent facility, but the Minister is not facilitating this to release beds in Tallaght Hospital and is shutting it down.

We are going backwards and at the rate the Minister is going, we will not stop until we are almost back to the poor laws and the workhouses. I do not say this lightly, but what is in front of us is the elimination of public hospital cover and care, due to the creeping privatisation which is actively facilitated by Fine Gael without a whiff of abstentionism from the Labour Party. The Minister's universal health insurance scheme is a back door drive towards privatisation. It means privatisation and profits for the big companies and a lesser service for ordinary people. The solution for which we have constantly argued is a properly funded single tier public health service, along the lines of the NHS before it was butchered and progressively dismantled, where health care is a right and not a privilege for the few.

Joan Collins (Dublin South Central, People Before Profit Alliance)
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On 15 February this year the Minister gave an interview in which he said that health service managers who do not achieve targets for reducing waiting lists and trolley numbers would be fired under the Fine Gael Government. On 15 February, the figure from the INMO trolley watch was 461. The figure for today is 429. I presume no-one has been fired. I have not heard of any firing from the media. The Minister also stated that anybody who did not meet the target given to them would be shown the door, but that has not happened. These were strong words from the Minister, but should they not apply to him now? The special delivery unit has been set up, but what targets have been set for it? Have those targets been achieved? Has anybody been fired and will anybody be fired if those targets are not achieved.

Yesterday I met a campaign group from Skibereen which was highlighting the fact that an ambulance was about to be withdrawn from its area and the people there would be left depending on two ambulances based in Clonakilty and Castletownbere. It takes a minimum of 30 minutes to drive from those areas to Skibbereen. If the other two ambulances are involved in an accident while bringing someone to a hospital or are called out elsewhere, there is no ambulance immediately available for this area. If anyone needs an ambulance in the area due to a stroke, heart attack or pregnancy, these people's lives will be put at risk. One of the campaign members said that Skibbereen had one of the highest recorded burials for a town of its size during the Famine and he felt that Skibbereen could have the distinction of having the highest number of deaths due to cutbacks in the 21st century. The Fine Gael manifesto stated: "Fine Gael will review the fire brigade and ambulance service with a view to achieving greater efficiency and economy". That example shows that it will achieve greater efficiency and economies that have nothing to do with the human needs of the community.

I see extraordinary complacency in the Government amendment to the motion. This is a Government amendment carrying the full backing of the Labour Party. In September of this year, there was a very interesting article in the health supplement of The Irish Times by Dr. Jacky Jones. She pointed out that it is estimated that health services determine 10% of wealth status and the other 90% is due to factors such as education, social status, employment and income. Mortality rates for Irish adults almost halved between 1979 and 2005. This means that Ireland went from having the highest mortality rate among 19 western countries to ranking seventh and achieved this while, despite the comments of our Fine Gael colleagues, spending the least on our health services. This follows not because of a big improvement in health services but because of a reduction in the percentage of people without a second level education. Between 1979 and 2005, this fell from 64% to 15%, while unemployment fell from 14% in 1983 to 4% in 2005. The situation has reversed dramatically with 500,000 people on the dole and tens of thousands of people under huge stress because of the mortgage crisis, cuts in wages, the universal social charge and unnecessarily long waiting times for medical cards. These are things people need to survive in the economy at the moment. Dr. Jacky Jones pointed out that health services treat the ill-health caused by inequality and poverty.

If we accept this premise, which I do, our health service will now come under enormous strain and increased demands because of the economic collapse and the austerity programme following the IMF-ECB-EU bailout. The evidence for this includes the annual health index report for 2010, which found that visits to GPs have fallen from 75% to 71% since 2008. The survey found that the decline in use of medical services was most pronounced among the lower income groups. Those with the least access to health care, those without private health insurance and medical cards, cannot afford the fee of between €45 and €60 for a GP visit. Some 87% of GPs said that in the past two years visits from patients had decreased due to financial problems. These people will be most affected by the economic crisis and austerity and they will also be the most affected by health cuts. Our shambolic two-tier health service cannot take the cuts being imposed on it. By international standards, we have a low-level of acute beds, with 2.7 beds per 1,000 population where the OECD average is 3.8. A study by PA Consulting Group estimated that, based on our high current utilisation levels, some 8,000 more beds will be needed by 2020. The only alternative is a major increase in resources for community care, including free access to GP services and the provision of well-staffed public health centres. This will also mean confronting vested interests in the medical profession, and private health care and insurance companies.

Some Deputies say that one can throw as much money at the health service as one wants without solving the problem. The problem is the inequality in society. The Minister has been in office for eight months and has caused more problems for the health service in bowing to the EU-IMF-ECB bailout and implementing further austerity measures over the next three years. These will be crippling for our economy, our people and our services.

Mick Wallace (Wexford, Independent)
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I will start on a positive note by commending the Government on going ahead with funding for accident and emergency and maternity units in Wexford, which were much needed. For some strange reason, Wexford has been poorly treated for a long time. It has one of the highest literacy rates in the country yet it is one of the few counties without a third level education institution. At present, Wexford has one of the highest rates of unemployment, with more than 20,000 people unemployed. Even in the good days in 2007, 50% of the Wexford people who were working worked outside the county. It is welcome that Wexford is getting the much-needed hospital unit.

What is less positive is that in Wexford yesterday, 24 beds were closed and 15 patients were on trolleys due to the manager having the sole job of meeting a certain budget It is hard to blame her because her job seems to be to cut patient care in order to meet the budget.. Given the amazing statistic that the population of Wexford increased by 10% in the past five years, going from 131,000 to 145,000, one can imagine the extra pressure on the hospital. This is most noticeable in the maternity unit. At present, there are 14 wholetime midwives working 37.5 hours per week. The moratorium on recruitment and the fact that the maternity unit is part of the general hospital means the hospital cannot hire midwives, irrespective of demand. This year, the hospital has seven fewer midwives because of the moratorium and it is about to lose another three before Christmas. One wonders how they make this work and, from what I understand, it happens because of the goodwill of the midwives, which involves working through lunchtime, working late hours and receiving no overtime rate for this work. I am not sure how long this will last and, given that the situation will become worse if the moratorium is left in place, I fear for what will happen.

It is accepted that there is a direct correlation between financial problems and mental health. The Minister of State, Deputy Lynch, was present at the launch of a recent report by the Mental Health Commission entitled The Human Cost. This provides an overview of the evidence on economic adversity and mental health, as well as recommendations for action. Speaking at the launch of the report, the Chairman of the Mental Health Commission, Dr. Edmond O'Dea, said that the recession affects everyone, that for those with pre-existing mental health problems, issues such as debt and unemployment are likely to make things worse and that "in addition to the effect on people with pre-existing mental health problems, people with no previous history of mental health difficulties can be affected." Some of these individuals may have little previous experience of coping with hardship or financial insecurity.

From 2008 to 2009, there was a 24% increase in suicide. Suicide is a major problem in Wexford and today in my village, a man a few years younger than me took his life. The Minister of State is aware that the mental health institution in Wexford, St. Senan's, was closed earlier in the year. Some 75% of the patients go to Waterford and 25% go to Newcastle, County Wicklow. The facility in Newcastle, used by those in the north of County Wexford, is an excellent, state-of-the-art facility. However, the facility at Waterford is not fit for purpose. The 2010 report of the Inspector of Mental Health Services included the following observation: "The department of psychiatry was situated in the lower ground floor of Waterford Regional Hospital. It was divided into acute and subacute areas. The former was locked on the day of inspection. There were two involuntarily detained patients. While there was a garden area, residents did not have access to this. This impinged particularly on the residents in the acute area who were not free to leave the unit. A smell of cigarette smoke pervaded the building which was particularly noticeable in the acute area. A porch to this area served as a smoking room. Staff informed the Inspectorate that extractor fans were unable to clear the air adequately."

The Minister informed me in this House in May that a new crisis house would be opened in Wexford to replace St. Senan's Hospital which would ensure we would not be too dependent on services in Waterford. The new unit which is about to open at St. John's Hospital in Enniscorthy is being sold as an acute admissions service, but it is essentially a rehabilitation facility for patients coming from Waterford and Newcastle. That is not good enough.

Last week there were reports that mental health services in Wexford were likely to face further cuts in the near future. Following the closure of St. Senan's Hospital, community services in Gorey, Wexford and Enniscorthy were upgraded to be available seven days a week to cope with demand. However, we are now told there is a possibility this service will be reduced to five days owing to cutbacks. The Mental Health Commission has highlighted the connection between primary care services and mental health services and that the majority of common mental health problems are treated at primary care level. Further reductions in primary care provision will make the job of front-line workers extremely difficult.

A 2011 report by the World Health Organization on the impact of economic crises on mental health observed: "It is well known that mental health problems are related to deprivation, poverty, inequality and other social and economic determinants of health. Economic crises are therefore times of high risk to the mental well-being of the population and of the people affected and their families."

The economic crisis that began in 2007 has led to significant declines in economic activity, a rise in unemployment, a depressed housing market and an increasing number living in poverty. It continues to pose major challenges in health service delivery in the south-east region.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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I commend the motion to the House and intend to focus on the situation at Roscommon County Hospital. The promises made to us at election time were broken. People were lied to. That is somewhat normal, but it is nevertheless unacceptable. The Taoiseach, then Leader of the Opposition, made an inspirational speech outside Gleeson's Townhouse in Roscommon in which he assured us that under a Fine Gael Government, there would be no removal of accident and emergency services.

We also received assurances before the election from the current Minister for Health. He said: "I would like to confirm that Fine Gael undertake, in accordance with the Fine Gael policy on local hospitals, to retain the emergency, surgical, medical and other health services at Roscommon hospital which are present on the formation of the Thirty-First Dáil, and upgrade such services where feasible. I trust this clarifies the matter."

It did clarify the matter, but, unfortunately, the Minister did not follow through on his commitment. Fine Gael was rewarded for its promises to the electorate with two seats out of three in my constituency. It is clear that complement would be smaller if the truth had been told at the time. As a result of these promises, we have a person in Dáil Éireann under false pretences. Strangely enough, before the election, that same person goaded me through the media and told people that an Independent Member would have no power in the Dáil. Whatever power I have, let us consider the power this Member has brought upon us.

We are faced with the potential loss of 700 jobs at MBNA in Carrick-on-Shannon, the imminent closure of the courthouse in the Deputy's town of Boyle, the criminalisation of turf-cutting constituents and - the Deputy's greatest claim to fame - the closure of the accident and emergency service at Roscommon County Hospital. In order to soften our cough, we have in return received funding to upgrade the heating systems in swimming pools in the constituency. The swimming pool in my town made the headlines in the local papers last week, even though its heating system had already been replaced in recent years. The facts did not matter because it was a good news story.

It was bad enough that Fine Gael had gone back on its promise. What is worse is that the party tried to sell its actions to us as being for our own good. Supporters of the retention of the accident and emergency service warned there would not be enough space at University College Hospital, Galway. We were told this would not be a problem, yet less than a month ago the Health Service Executive warned people not to attend the accident and emergency unit there. This advice was contradicted in the House, where we were told that patients should only present if their condition was very serious. Most of those presenting at accident and emergency departments are not doctors. Are they to decide for themselves whether their condition is serious? The overcrowding that was not supposed to occur has, in one day last week, resulted in 52 patients being on trolleys at University College Hospital, Galway.

We were also told that mortality statistics at Roscommon were far worse than those in Galway. To be precise, the Minister stated in the House that outcomes for coronary patients were four times better in Galway than in Roscommon. When these figures were contested by the Hospital Action Committee which would have a representative in this House if the truth had been told, the Minister said the figures would be investigated and the results published. We have yet to hear the result of that inquiry. One can only assume the reason for the delay is that the Hospital Action Committee was proved correct.

Another red herring is that the Health Information and Quality Authority, HIQA, sought the closure of the accident and emergency department at Roscommon County Hospital. The Minister stated the reason for the termination of services was concern for patient safety, as identified by HIQA in its reports on Ennis and Mallow hospitals. However, HIQA has stated clearly it did not recommend the termination of accident and emergency services anywhere. Nor did it specify smaller hospitals or visit any hospitals other than those in Ennis and Mallow in order to assess safety issues. It was the HSE which closed our accident and emergency unit, with the blessing of the Minister.

We were also told that a souped up ambulance service would be provided, with advanced paramedics who would do just as good a job as accident and emergency staff. What we got was one additional ambulance and one additional advanced paramedic. This was the sum total of the resources provided. How can anybody argue that it is adequate? Less than one month ago, only a few miles from my home, a young man had an accident in which he punctured his stomach. The ambulance was called and the new paramedics arrived. They could not even insert a drip. It was only because the young man's mother was a nurse that his life was saved. Who would have taken responsibility if he had died?

We were told this was not about money but about patient safety; however, it is now clear that patient safety has been compromised. All that people were seeking was the retention of accident and emergency services at Roscommon. We simply wanted the port in a storm we had had for decades. Now, in order to create another smokescreen, the Government is telling us about all the great services it is putting in place instead. While these services are welcome, they in no way make up for what was lost. The key word is "emergency", which indicates that one has limited time. With limited time, one requires services to be close by, yet the services which have replaced the accident and emergency unit are accessed by appointment.

We are fortunate in Roscommon to have such an organisation as the Hospital Action Committee. Its members never give up and are now pushing for the provision of a helicopter ambulance service. It is not perfect, but at least it would be something. The committee has set up a charitable company in order to progress its idea. I hope that on this occasion the Government will listen to the people. Lives are being put at risk unnecessarily. None of the promises made to us has been upheld. We were told the new arrangements would be safer for patients, but that has not happened. We warned the Government that the hospitals suggested as alternatives would be overcrowded. We were right. The Government should listen to us when we demand that accident and emergency services at Roscommon County Hospital be restored.

Mattie McGrath (Tipperary South, Independent)
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I am pleased to support the motion and compliment my colleagues in the Technical Group on bringing it forward. The Minister for Health, Deputy James Reilly, promised much as an Opposition spokesman. He travelled around the country, including to Clonmel hospital in my constituency, promising that everything would be fine. I sat with the Minister of State, Deputy Kathleen Lynch, on various committees in the last Dáil. I cannot believe the transformation in her. We had a difficult time in meeting her to discuss the situation at St. Michael's Hospital in Clonmel. Deputy Mick Wallace referred to St. Senan's Hospital in Wexford which the Minister of State promised would work out fine because patients would be accommodated in Waterford. She promised on that occasion that she would take us by bus to see the facility in Waterford. She promised she would take us to see facilities in the west. They were empty promises because that was two months ago. She told us something else which I will not describe but the Minister of State knows what I am talking about. She is trying to close a perfect facility in Clonmel. She pinched the patients.

Kathleen Lynch (Cork North Central, Labour)
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I am not trying to close it; I am closing it.

Mattie McGrath (Tipperary South, Independent)
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That could be deemed to be harassment or victimisation. She told us the door was locked. We heard stories tonight of doors being locked and they should not be locked. The Minister of State proclaimed manna from heaven. The consultants in Clonmel and the staff in St. Michael's have been treated appallingly by gangsters in the Health Service Executive. I call them cowboys who have no respect for anybody or anything other than furthering their career. I cannot understand how the Minister can come into this Chamber and go to meetings and stand over their actions. I am talking about people like Mr. Healy-----

Michael Kitt (Galway East, Fianna Fail)
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The Deputy should not name people outside the House.

Mattie McGrath (Tipperary South, Independent)
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-----and not my colleague from south Tipperary.

Kathleen Lynch (Cork North Central, Labour)
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He does not have the right of reply. Deputy McGrath should not do that.

Mattie McGrath (Tipperary South, Independent)
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He has the right to bully us and tell us one day when we questioned him about the reconfiguration announced by the Minister, Deputy Reilly-----

Kathleen Lynch (Cork North Central, Labour)
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The Deputy should not do that. He is here long enough.

Mattie McGrath (Tipperary South, Independent)
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He would not accept our words because they are in charge.

The Minister, Deputy Reilly, promised many people that when he was in the Minister's office we would not get any more letters from the HSE saying, "Sorry, this is not a matter for the Minister, it is for the HSE", but slowly the letters are arriving. Nothing has changed. I am appalled at the Minister, Deputy Reilly, because he was a medical practitioner and an eminent consultant and he should have known better than to promise that there would be no more people on trolleys and that everything would be proper. The Minister will have deaths on her conscience, and she knows that better than me, and what she is doing in Clonmel and throughout the country is outrageous.

We have seen this happen over the years from Monaghan to Sligo to Drogheda, and it is happening now in the mid-west. Nenagh hospital lost its services. The Minister told the psychiatric patients in Clonmel that they can go to Limerick and now they find they will have to go to Ennis. I heard one of the Minister of State's colleagues say here recently that there were no services in Ennis for themselves let alone to allow them take new people in from Tipperary. It is an outrageous scam and a scandal. The Minister sold a pup to the public.

I am appalled by the change of attitude on the part of the Minister of State. I am appalled because we blocked these doors one night to try to get a meeting with her. She begrudgingly had a meeting with us afterwards but she just trotted out the line of the officials, which was outrageous. The way they treated the staff in Clonmel is outrageous. They did not have any consultation or show respect or appreciation of staff. They told a senior eminent psychologist in my presence and that of my former colleague and the then Minister of State, Deputy John Moloney, that the place was a zoo. How dare they do that? Some of them were only a fine day in Clonmel. They came from a failed system in England and walked into jobs here. The same applies to most of the people in the Health Information and Quality Authority. We employ them and send them around the country to do the dirty work for senior Department officials. I am appalled by them because they have no respect for the staff or the people.

I am appalled also by the Minister, Deputy Reilly, but especially by the Minister of State, Deputy Lynch, because of the tirades we had to listen to in committee when she was a Deputy. She attacked the Ministers and was a champion of all the people who were depressed and downtrodden but the poacher has become the gamekeeper. She is presiding over the outrageous behaviour by HSE officials who are not fit to be employed and who are betraying democracy in this country, and they are doing so on fat salaries. They will not listen to elected representatives or anybody else.

The Minister of State, Deputy Lynch, should hang her head in shame and bring us on that tour to St. Senan's and to the west as she promised but like all the promises before the election and the snow that disappeared off the ditch last January, she thinks that we are fools and that we will go away, but, like Roscommon, those of us in Clonmel will not go away. The fight is not over. We will continue. The Minister of State can go back and pinch the patients, or pinch Deputy Healy and myself, but she will not make fools of us.

Kathleen Lynch (Cork North Central, Labour)
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Deputy McGrath should know better than to name people here knowing they have no right of reply while he has absolute privilege. Would the people who are quick to do that be as quick to do it outside this House?

Mattie McGrath (Tipperary South, Independent)
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Of course I would.

Kathleen Lynch (Cork North Central, Labour)
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I doubt that very much.

Michael Kitt (Galway East, Fianna Fail)
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I have already said that, and I do not want anyone outside this House named.

Kathleen Lynch (Cork North Central, Labour)
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The Leas-Cheann Comhairle should have stopped him.

Michael Kitt (Galway East, Fianna Fail)
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I said that to him.

Mattie McGrath (Tipperary South, Independent)
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Send another letter to the consultant telling him he cannot get involved in-----

Michael Kitt (Galway East, Fianna Fail)
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Please, Deputy. No more interruptions.

Kathleen Lynch (Cork North Central, Labour)
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The Deputy needs to behave himself.

Mattie McGrath (Tipperary South, Independent)
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That is rich coming from the Minister of State.

Kathleen Lynch (Cork North Central, Labour)
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He is no longer in the position he used to hold. He should behave himself and have some manners.

Mattie McGrath (Tipperary South, Independent)
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I never pinched the patients. I might visit them but I would never do that to them.

Michael Kitt (Galway East, Fianna Fail)
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Please, Deputy.

Kathleen Lynch (Cork North Central, Labour)
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Have some manners.

Mattie McGrath (Tipperary South, Independent)
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The Minister should have some manners too, with respect.

Kathleen Lynch (Cork North Central, Labour)
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That is what this has boiled down to.

In terms of A Vision for Change, which was published in 2006 by the previous Government and which everyone here welcomed with open arms-----

Mattie McGrath (Tipperary South, Independent)
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We have no problem with that.

Kathleen Lynch (Cork North Central, Labour)
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That is the problem. It was a good document and it is about-----

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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We were not here.

Kathleen Lynch (Cork North Central, Labour)
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Those of us who were here welcomed it with open arms. It is a good plan for the future of our mental health services.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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If it is, it should be fully implemented.

Michael Kitt (Galway East, Fianna Fail)
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Order, please.

Mattie McGrath (Tipperary South, Independent)
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And not cherry-picked.

Kathleen Lynch (Cork North Central, Labour)
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The days of the big institution are gone. The days of being able to lock people away are gone.

Mattie McGrath (Tipperary South, Independent)
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We all accept that.

Kathleen Lynch (Cork North Central, Labour)
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We need to deliver a proper mental health service in the community.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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In accordance with A Vision for Change.

Kathleen Lynch (Cork North Central, Labour)
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Acute units should be used sparingly and for very short periods of time-----

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Absolutely, so why does the Minister want to close the one in Clonmel?

Kathleen Lynch (Cork North Central, Labour)
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-----but it appears to me that those who came in here and welcomed A Vision for Change are typical of-----

Mattie McGrath (Tipperary South, Independent)
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No, all of it.

Kathleen Lynch (Cork North Central, Labour)
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I can hear Deputy McGrath saying that. He said he had no problem with A Vision for Change provided there is no change in my back yard.

Mattie McGrath (Tipperary South, Independent)
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It should not be cherry-picked by officials.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Implement it fully and we will support it.

Michael Kitt (Galway East, Fianna Fail)
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Order, please.

Kathleen Lynch (Cork North Central, Labour)
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Everyone's back yard is being changed.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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No. You will not address that.

Michael Kitt (Galway East, Fianna Fail)
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Deputy, please. The Minister has the floor.

Mattie McGrath (Tipperary South, Independent)
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What is going on in Clonmel is outrageous.

Kathleen Lynch (Cork North Central, Labour)
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The days of locking people away in institutions are gone-----

Mattie McGrath (Tipperary South, Independent)
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We accept that.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Absolutely.

Kathleen Lynch (Cork North Central, Labour)
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-----and we have to accept that.

Mattie McGrath (Tipperary South, Independent)
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By closing St. Michael's and St. Luke's.

Kathleen Lynch (Cork North Central, Labour)
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We have to accept also that we can no longer dictate to people just because they have problems with their emotional well-being-----

Mattie McGrath (Tipperary South, Independent)
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The Minister cannot pinch them either.

Kathleen Lynch (Cork North Central, Labour)
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-----and we intend to deliver a better service in a different environment. That is what will happen.

Mattie McGrath (Tipperary South, Independent)
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To hell or to Connacht.

Kathleen Lynch (Cork North Central, Labour)
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As for the little tour Deputy McGrath wants to go on, no problem.

Mattie McGrath (Tipperary South, Independent)
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When?

Kathleen Lynch (Cork North Central, Labour)
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I did meet him, and he should not give the impression that I did not. I have met several groups since but Deputy McGrath was not present.

Mattie McGrath (Tipperary South, Independent)
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Thanks for the invitation.

Kathleen Lynch (Cork North Central, Labour)
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I welcome the opportunity to conclude this debate. There can be few more important issues that this House has to discuss than the reorganisation of our health care. I will start with the two greatest influences on that change this Government is introducing for the benefit of patients and not for any vested interests. First, we have a system that is no longer able to deliver the level of service our citizens need, nor does it represent value for money. No one here would dispute that for a long time our health system, and I heard everyone present say it, has needed to change the way it provides its services to patients. The Government has a clear view on what needs to be done and is setting about doing it.

Second, the financial situation in which we find ourselves exercises and will continue to exercise considerable restraints on the options available to us. However, that will not stop the Government making the changes necessary for better and safer care.

In that context we must remodel our health service, and in particular our acute and emergency provision. It is extraordinary, therefore, that there should be demands to return to a system which has become clinically indefensible and continued provision of which, as my colleague, the Minister for Health, noted last night, is threatening to become untenable, unsustainable and irresponsible. The notion that we should continue on with that system or return to the old system defies logic.

The clinical evidence is clear. We cannot safely continue into the future providing complex care across a large number of facilities at very low volumes. We cannot safely provide complex emergency care in every hospital. Equally, we cannot continue to use our large hospitals for treatments which can and should be provided as close to our patients' communities as possible. We cannot continue to use major emergency resources for injuries and illnesses which can be dealt with in other settings.

The financial evidence is just as clear. We must see a better return in terms of patients outcome for our health spending. We must use new ways of measuring outputs and outcomes from our acute services. This process of using information better to manage our system is already well under way with the advent of the special delivery unit, SDU. The number of beds we have is not an output nor an outcome. The number of staff we have is not an output. What matters is the number of patients treated and despite the reduction in funding, and I am glad to see Deputy McGrath has left the Chamber-----

Mattie McGrath (Tipperary South, Independent)
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Ta mé anseo.

Michael Kitt (Galway East, Fianna Fail)
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The Deputy cannot speak unless he is in the chair.

Kathleen Lynch (Cork North Central, Labour)
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-----that our current loss of sovereignty has forced on us, activity in areas such as day cases continues to increase this year. We must, within the constraints we are under, do everything possible to get more treatment for more patients from the health budget. However, to maintain this process and, more importantly, to deliver safer care we need new approaches, new ways of doing things and new plans implemented. In this respect, we must implement A Vision for Change.

Mattie McGrath (Tipperary South, Independent)
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Fully deliver on it.

Kathleen Lynch (Cork North Central, Labour)
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This Government is delivering on these objectives in a planned and strategic manner, and will continue to do so. Difficult political decisions recognise the clinical realities that will produce better outcomes for patients. These include the reform of emergency departments; the changes in work practices and structures that are already producing a modern, highly trained, more efficient pre-hospital emergency service; the targeted reduction in waiting times through the special delivery unit, SDU, led initiatives and money follows the patient funding, which many Deputies were asking about tonight; the consolidation of complex treatments in large hospitals to concentrate resources and skills to the benefit of patients; the strengthening of local systems to allow better access to day surgery, diagnostics and routine treatments in our patients' communities which will flow from the smaller hospital framework under development at the Government's request; the creation, as seen in Cork, of specialist elective facilities so the delivery of this treatment is not disrupted by the inevitable priority of emergency cases; and, above all, the provision of fair and equal access where our citizens need it through the creation of a system of universal health insurance.

Thomas Pringle (Donegal South West, Independent)
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I wish to share time with Deputy Boyd Barrett and Deputy Higgins.

Michael Kitt (Galway East, Fianna Fail)
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Is that agreed? Agreed.

Thomas Pringle (Donegal South West, Independent)
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I welcome the opportunity to speak on this motion and I commend my United Left Alliance colleagues for bringing it forward. It is vitally important to put our health and hospital services at the forefront and to have them discussed in the House.

I will speak about a hospital that is consistently the most efficient in the country, Letterkenny General Hospital. Since 2009, Letterkenny General Hospital's budget has been cut by €20 million, from €115 million to €95 million. This year the hospital will have a substantial deficit and next year the indications are that there will be a further 7% cut in its budget, which will bring it down to €90 million. This is the most efficient hospital in the country. Since 2009, the staff have been reduced by 113 because of the senseless embargo on recruitment imposed on the hospital. Nevertheless, the hospital continues to provide care for patients, although under unbearable circumstances.

The minimum amount needed to keep this hospital the most efficient in the country is approximately €104 million each year. A total of 93% of the activity in Letterkenny General Hospital is non-elective, emergency services. Approximately 120,000 patients pass through the hospital every year, yet the hospital will experience a 7% cut again next year in its budget - so much for money following the patient. The most efficient hospital in the country will be savaged by further cuts. Money following the patient is rubbish. It does not and will not happen.

At what point will our health services become dangerous with not enough staff to keep them going? It appears there is no point this Government will not go to in ensuring that cuts are imposed on hospitals that are working well and providing services for the county in which they are located. Letterkenny General Hospital is probably the exception to those mentioned in the motion in that it has not experienced massive closures in the accident and emergency department or withdrawal of other services. It is maintaining its services but it is constantly hammered by repeated budget cuts. Money does not follow the patient in this health service, and it will not happen as long as the diktat of the IMF-EU troika and the Fine Gael and Labour Party Government continues to hold sway.

The recruitment embargo has resulted in a reduction of nine members of staff in the X-ray department in Letterkenny General Hospital. The HSE closed the community X-ray facilities around the county and brought the staff into the hospital to keep the service going. This hospital shows all the other hospitals that regardless of what one does, one will be hammered by cuts.

The HSE must ensure that services in Letterkenny are protected by providing €104 million per year. It must show that money follows the patient. A hospital that is carrying out 93% of non-elective activity needs €104 million to maintain its services. I ask the Government to show in 2012 that money follows the patient and ensure that Letterkenny General Hospital's budget is not cut again in the future.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Yesterday the Minister took offence at the fact that we used words such as "massacre" to describe the cuts in the health service and "war zone" to describe the situation in our accident and emergency departments. He accused us of hyperbole. What else can one call removing 2,300 beds from the hospital service, and 5,000 over a longer period, aside from a massacre of bed numbers? What else can one call taking 1,000 nurses from the health system in two years, along with 5,000 other health staff, most of them front-line staff? What else can one call, aside from a nightmare, the fact that 429 people are on trolleys today? That is a war zone for patients and staff alike. What else can one call €1 billion being taken from the budget but a slashing and a massacre of the health budget?

Although the Minister is a doctor and I am not, one need not be an expert to understand that a health service is made up of ambulances, beds, nurses, doctors, hospitals, machinery and, dare I say, money. If one cuts those, one does not get a better health service but a worse one. If one slashes those things in the manner we have seen over the last number of years and if one intends to continue with an IMF-EU programme that insists on further cuts to those budgets and staff numbers, things will not get better, regardless of what words one uses to describe it. Reconfiguration, reform and all the other slogans mean nothing. The nightmare gets worse and the numbers on trolleys increase.

The evidence is clear from Roscommon. What the people of Roscommon feared has happened. The situation has got worse for them and it has got worse in Galway, where the overflow has gone. That is what will happen if Bantry, Youghal, Mallow or Victoria South Infirmary are downgraded to the remaining hospitals in Cork. In my constituency, Loughlinstown hospital has 21,000 accident and emergency cases per year. If it overflows into St. Vincent's Hospital, where there are 20 or 30 people on trolleys every day and where the hospital had to go off call for several days last week, will the situation get better or worse? One need not be an expert to work that out. Our motion is asking the Minister not to make things worse.

The link between the downgrading and the cuts and the real agenda of privatisation in the health service is clear in my constituency. Loughlinstown hospital is to be downgraded and the overflow is to go to St. Vincent's Hospital, which cannot cope. However, the Beacon Hospital, a private hospital, has opened in Sandyford and the Blackrock Clinic is advertising on the radio, urging people to come to the clinic. That is not movement towards a single tier system, but the stealth privatisation of the system. The public system is run down, people become fearful and anxious about a system that cannot cope so they are forced to go to the private health care providers. That is what money following the patient means. Money following the patient means the patient walks out of the public health system that cannot cope and into a private hospital out of fear. Money should go before the patient, so the bed, doctor, nurse, machinery, ambulance and resources are in place. That is where the money should go; that is the relationship between the two.

I do not have time to discuss the Dutch model other than to point out that a majority of Dutch people think health services have got worse since the introduction of universal health insurance.

James Reilly (Dublin North, Fine Gael)
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That is not true.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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The average household is paying between €4,500 and €5,500 of its income per year for this wonderful health system the Minister cites. Half of the Dutch hospitals are bankrupt. Half a million people in the Netherlands do not have any insurance cover at all. It is not better. It is stealth privatisation, and we reject it. We want a national health service.

Joe Higgins (Dublin West, Socialist Party)
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I have carefully studied the Minister's amendment to the United Left Alliance motion on our health services and what I conclude immediately is that language in the mouths of the Government ceases to have the meaning that words and sentences should have and apparently means the opposite. The Minister calls on the Dáil to support the Government's policy of developing the role of smaller hospitals to their full potential rather than closing or downgrading them. We do not have time to go around the whole country but let us go to one or two areas of the country, for example, the north east, where he said he would protect and develop small hospitals, after the serious downgrading of Monaghan General, Louth County, Navan Hospital-----

James Reilly (Dublin North, Fine Gael)
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The Deputy did not listen last night. He was not here. He left.

Joe Higgins (Dublin West, Socialist Party)
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I have the Minister's speech here and read every word of it.

James Reilly (Dublin North, Fine Gael)
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Did your read about all the new facilities in Louth County Hospital?

Michael Kitt (Galway East, Fianna Fail)
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Through the Chair, please.

Joe Higgins (Dublin West, Socialist Party)
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Yes, every word of it. The reality on the ground is that the serious downgrading has resulted in hospitals like Drogeda and Cavan having serious overcrowding and serious queues. Similarly in the mid-west, the downgrading of hospitals in Ennis and Nenagh has put such enormous pressure on Limerick Regional Hospital that the staff have had to give up their pay to go on strike to insist on the safety of their patients. That is the reality, not the misstatement in the Minister's amendment.

The Minister also said he wants us to note that the number of inpatient beds is no longer the best indicator of capacity to meet patients' needs. Last year the Minister was singing a different tune and saying quite clearly that the thousands of beds that had been taken out of the system over many years were directly responsible for the disaster in accident and emergency departments. Any doctor or nurse, any day of the week, will say that is the case. The reason they are there in such large numbers oftentimes, is that the beds are not in place for them to be moved into. The Minister is flying in the face of reality.

The Minister's amendment further notes that the majority of patients treated in hospitals are now day cases or out patients. What does the Minister do with day cases and out patients? In Connolly Hospital, Blanchardstown, the surgical day ward has closed 24 beds this week and next week, and the week after it will have only eight beds, down from 24. Instead of 40 cases being treated every day only ten to 13 cases will be treated. We are being treated with contempt by the Government in its amendment to our motion.

That two Ministers are sitting here prepared to stand over what is unreality is incredible. The reality is that the Labour and Fine Gael parties carry on where Fianna Fáil left off and they have no respect for the truth and no respect for the staff on the ground. The Defend Blanchardstown Hospital Campaign, which has been launched by staff and community, will challenge the Minister in the period ahead on all these issues, telling the truth about the situation and demanding a reversal of these cuts while next week €700 million will be sent to one group of unsecured bondholders in Anglo Irish Bank. It is incredible but it is a political choice. It is an economic choice that the Government is making and all our people are suffering.

Emmet Stagg (Kildare North, Labour)
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On a point of order.

Michael Kitt (Galway East, Fianna Fail)
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I ask the Deputy to conclude, the debate is over.

Joe Higgins (Dublin West, Socialist Party)
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Not only do we need more resources but we need a change in the management. The staff, nurses, doctors, household staff, must be brought to the heart of the management of the hospitals and the health service. That is how we will get massive change. They are the people who are suffering from the bad decisions being made though a desperate lack of resources.

Michael Kitt (Galway East, Fianna Fail)
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I thank the Deputy.

Joe Higgins (Dublin West, Socialist Party)
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I ask that the motion be accepted and that the unreality of an amended codology by the Minister be utterly rejected.

James Reilly (Dublin North, Fine Gael)
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And replaced by socialist fantasies.