Micheál Martin (Cork South Central, Fianna Fail)
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Letters from the chief executive officers of four of the largest hospitals in the State, St. James’s, Tallaght, the Mater and Our Lady’s in Crumlin, to the director general of the Health Service Executive, HSE, and revealed in last evening’s “Prime Time” programme illustrate how untenable the Government’s budgetary strategy is for the health service. Clearly, the letters indicate that the centre cannot simply hold if the Government proceeds with cuts of up to €666 million to the health budget. In a nutshell, they have stated the quality of services and patient safety are being compromised and will be irreparably compromised if the cuts go ahead. This is about access to services and patient safety. All the demands being put on the health service and hospitals, they claim, in contrast with the budget, are leading to undeliverable objectives and imperatives. Alarmingly, they also point out there are now delays in cancer services for patients. In essence, the progress achieved in the past decade in cancer care is being dismantled. This view was added to by Owen Smith, consultant paediatric haematologist at Crumlin, this morning on “Morning Ireland” when he confirmed that children and teenagers with cancer were having treatments delayed when timely interventions with their types of cancer were critical. He made it clear that survival and outcomes were being adversely affected as a result. The hospitals' chief executive officers have stated the implementation of the Taoiseach’s budget proposals will lead to “a serious dysfunctional and damaging outcome.”

For months, we have been raising the issue of discretionary medical cards, but the Taoiseach puts his head in the sand with denial after denial, week after week. Does he accept that services in our acute hospitals and patient safety are being compromised as result of budgetary policy? Will he accept that the provision of cancer care is being dismantled? Is he determined to proceed with the scale of the budget cuts in health that he has announced?

Enda Kenny (Mayo, Fine Gael)
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The health budget this year is €13.263 billion, with a capital fund of €357 million. The total savings identified this year are over €600 million. Everyone understands this will be a very challenging year for the health service. The Minister for Health, Deputy James Reilly, is operating with a budget of €3 billion less than in 2008 and 10,000 fewer staff. He is changing the structure of the costs of delivering health services, not the services. I reject Deputy Micheál Martin’s assertion that patient safety is not the Government’s priority. It is the absolute priority of the Government and the Minister.

I note the letter from the four hospital chief executives which was delivered yesterday. Clearly, the obligation and legal responsibility following the budget being delivered, as the Deputy will be aware, is for the HSE to prepare its service plan based on the budgetary figures. Owing to all of the challenges faced, the Minister has given extra time to the HSE to prepare the service plan which will be presented to the Minister on 15 November.

I note the end of the chief executive officers’ letter states: "We would urge that the implications of continuing in this vein be recognised and that constructive engagement with the hospitals in the budgetary formulation process be pursued." This will happen during the preparation and determination of the HSE service plan. I listened this morning to Mr. John McCormack of the Irish Cancer Society on “Morning Ireland” who indicated that he was not aware of the delays referred to in the same broadcast by a medical doctor. Cancer services are available for people on a regular basis to offer assistance and support.

Between January and August, the number of patients waiting on trolleys was down by 30% compared with the number in 2011. Consultants now see and discharge patients on a 24-7 basis which saves the State hundreds of millions of euro. That was an issue that was not tackled in the past. The biggest reorganisation of hospitals in the history of the State was announced in May. The HSE took a new approach to determining hospital budgets. For the first time ever, budget allocations were related to projected spend rather than historic budgets rolling forward from previous years. As a consequence, the Mater Hospital received an increase of 5.7% in its funding for 2013, while Tallaght hospital received a 2.8% increase. There was a reduction in funding for St. James’s Hospital and a slight reduction for Crumlin hospital. This year the budget figures for hospitals show a 3% increase. Hospital managers are expected to manage their funding on the figures they have received.

Micheál Martin (Cork South Central, Fianna Fail)
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The Taoiseach’s reply follows a well worn pattern at this stage - denial after denial. The chief executive officers in question are conservative and would be the last to come out with a letter like this to the HSE. It is carefully written, but when it is decoded, they are saying they cannot take any further cut to hospital budgets and stand over patient safety in the current budgetary climate. Dr. Owen Smith is not an ordinary medical doctor and if I were the Taoiseach, I would not second-guess him. He has been the principal leader and pioneer in the treatment of childhood and teenage cancers. He knows what he is talking about. He has said there are delays in the treatment of young people and children, while outcomes are being compromised.

Seán Barrett (Dún Laoghaire, Ceann Comhairle)
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A question, please.

Micheál Martin (Cork South Central, Fianna Fail)
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Can we have less of the denial? No one can pinpoint the proposed cuts in the health service at this stage because the Minister for Public Expenditure and Reform handed them to the Minister for Health with a take it or leave it ultimatum. Meanwhile, the HSE claims the cuts will amount to €1 billion when they are finished, not €666 million. The Taoiseach is getting many warnings. The system is telling him it can take no more, certainly not cuts of this scale. If they go ahead, patients’ lives will be lost as a result. The Taoiseach had better get that into his head, intervene, change tack and policy.

Bernard Durkan (Kildare North, Fine Gael)
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What does the Deputy suggest we do then?

Finian McGrath (Dublin North Central, Independent)
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That is the real issue.

Seán Barrett (Dún Laoghaire, Ceann Comhairle)
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I have called the Taoiseach in case Members did not hear me.

Enda Kenny (Mayo, Fine Gael)
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The path we have set out here is to change the structure of how health services are delivered in this country and cut the costs of delivering those services, but not the quality of the services. I reject Deputy Martin's snide assertion that patient safety is not a priority of the Minister for Health or this Government.

Micheál Martin (Cork South Central, Fianna Fail)
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I never said that. It is an issue.

Enda Kenny (Mayo, Fine Gael)
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If Deputy Martin is in the business of second-guessing, he should mind what he says.

Micheál Martin (Cork South Central, Fianna Fail)
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I have the letter here.

Enda Kenny (Mayo, Fine Gael)
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He went from a health expenditure of €3.6 billion to over €15 billion. We had all the answers when Deputy Martin was on this side of the House. We were going to have world-class services and the elimination of all these problems.

Michael Healy-Rae (Kerry South, Independent)
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Fine Gael had all the answers.

Enda Kenny (Mayo, Fine Gael)
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It might be of interest to those screeching behind Deputy Martin that when he was Minister for Health he spent €13.8 million on management consultancy and had to be bailed out to the tune of €664 million.

Seán Ó Fearghaíl (Kildare South, Fianna Fail)
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The Taoiseach should answer the question.

Barry Cowen (Laois-Offaly, Fianna Fail)
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The Taoiseach should answer a question.

Enda Kenny (Mayo, Fine Gael)
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The mess Deputy Martin left behind must be changed. I do not second-guess the eminent consultant who spoke on the radio this morning.

Micheál Martin (Cork South Central, Fianna Fail)
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The Taoiseach just did. He is still doing it.

Enda Kenny (Mayo, Fine Gael)
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I was merely speaking about Mr. McCormack, who delivers cancer support services to patients who need them. The budget for hospitals this year was increased by 3%. The Mater and Tallaght hospitals both received increases to rebalance their budgets.

Micheál Martin (Cork South Central, Fianna Fail)
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The Government had to bail out hospitals last year.

Enda Kenny (Mayo, Fine Gael)
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It is not the same old story. It is a case of cutting the costs of services but not the services themselves, and I reject the Deputy's assertion.

Micheál Martin (Cork South Central, Fianna Fail)
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The Taoiseach may keep on saying that, but nobody outside is listening.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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I reject the Taoiseach's assertion that this is about cutting costs but not services. It is very clear from the letter from the four hospital CEOs that their experience is that it is not simply prudent, cost-cutting savings that are being made but that services are being undermined. This morning cancer patients and their families woke to the news that they are next in line to be hit by health budget cuts. It is very clear that the crisis in the health system is getting worse. The CEOs of four of the State's largest hospitals tell us that cancer services will be affected and those patients will suffer. Most astonishingly, the Minister for Health refuses to comment. His get-out was that this letter was sent to the HSE. It is abundantly clear that the Minister, Deputy Reilly, is part of the problem. He is continuing with the same failed approach of the last Government and Deputy Martin in his time.

Micheál Martin (Cork South Central, Fianna Fail)
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My cancer policy worked.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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It is time for the Minister, Deputy Reilly, to go. He should resign. These four hospitals - the Mater, St. James's, Tallaght and Crumlin children's hospital - provide vital services. Their CEOs say the Government's cuts and demands for fewer staff and shorter waiting lists are unsustainable and undeliverable and that this approach is damaging the foundations of the health system. When four eminent CEOs from large hospitals state very publicly and clearly their lack of confidence in the Taoiseach's Minister for Health and his agenda for cuts, what is the Taoiseach's response? Does he have confidence in the Minister? Does he believe up to €1 billion can be cut from next year's health budget without hurting patients or compromising their safety? Is he willing to let cancer patients suffer because of the incompetence of his Minister and his austerity agenda?

Enda Kenny (Mayo, Fine Gael)
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Sometimes when Deputy McDonald gives her eloquent speeches she seems to forget what legal responsibilities are. That sometimes seems to be a tendency in her party. The legal responsibility after the budget is passed is for the HSE to prepare a service plan based on the figures in the budget for the Department of Health and present it to the Minister for Health. The Minister is not looking for an out. This letter was addressed to the director general of the HSE and was delivered yesterday.

Timmy Dooley (Clare, Fianna Fail)
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I thought the Government had abolished the HSE.

Micheál Martin (Cork South Central, Fianna Fail)
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It has not happened.

Enda Kenny (Mayo, Fine Gael)
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The HSE prepares that plan. The letter is from four CEOs and sets out their position. This year's budget is for a 3% increase for hospitals. Both Tallaght hospital and the Mater hospital received increases as a result of the rebalancing of budgets this year and not based on historic spends that, as the Deputy knows, were always boosted up in the last months to make a case for the following year. These were based on projected expenditure. The answer to Deputy McDonald's question about whether I have confidence in the Minister is "Yes."

On her second question about cancer, the CEO of Crumlin hospital has confirmed there are no extraordinary delays for children in accessing cancer services. He said there may be a delay of one or two days in some particular cases rather than immediate access to chemotherapy. As I said to Deputy Martin, the first part of the last paragraph, which sets out the chief executives' position, seeks constructive engagement with hospitals in the budgetary formulation process. That will happen in the preparation of the HSE plan to be presented to the Minister for Health on 15 November.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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I should not be too surprised at the Taoiseach's expression of confidence in the Minister, because it is clear that he lives in some kind of warped bubble regarding these matters.

Bernard Durkan (Kildare North, Fine Gael)
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Deputy McDonald should be careful.

Ray Butler (Meath West, Fine Gael)
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Does she have confidence in her own leader? Where is he?

Mary Lou McDonald (Dublin Central, Sinn Fein)
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The Government's backbenchers do not like hearing this, but they will hear it. The CEOs of these four hospitals have described the Government's proposed cuts of up to €1 billion as short-sighted and random. It is very clear from reports from Crumlin children's hospital that children with cancer are experiencing delays to chemotherapy. That is now on the public record. It is astonishing that the Taoiseach would cite an increase in hospital funding as some kind of get-out, as though that makes the matter go away.

Patrick O'Donovan (Limerick, Fine Gael)
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The Deputy has many matters that have not gone away.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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The letter clearly states that there is a crisis in the hospitals and that further cuts will lay low many of those services. The implication for those who rely on our health services is yet more anxiety and concern.

The Taoiseach attempts to lecture me about legal responsibilities with regard to the preparation of the HSE service plan. That is a joke coming from the Taoiseach. Has he any sense of his responsibility to the citizens of this State, to sick people, to patients who rely on these hospitals and to others for the services to which they are entitled? The Taoiseach cannot stand over further cuts to the health system. He should re-read the letter from the four CEOs and listen to their message of no confidence in his Minister for Health and his Government's policy.

Enda Kenny (Mayo, Fine Gael)
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I have a sense of responsibility to the people we serve. We serve the people. This is not a joke, but a very serious matter. This letter from the four CEOs is a serious letter and is written from their perspective. The budget for health this year is over €13 billion, with a capital programme of over €350 million. We had a situation for a number of years in which the extraordinary rises in health spending brought the budget above €15 billion but did not deliver the services needed by the patients to whom Deputy McDonald referred, and to whom I have a responsibility, or the standards they deserved. That was never going to change unless the structure of health services delivery was changed. This is not an easy job. The Minister for Health, Deputy Reilly, has probably the most difficult task of any Minister in this Government, given the complexity of the situation.

The legal requirement of the HSE is to produce the service plan, based on the budgetary figures as adopted by the House.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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What is the requirement of Deputy Kenny, as Taoiseach? Is it to stand by his man?

Enda Kenny (Mayo, Fine Gael)
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The budget for this year was for a 3% increase in hospital allocations. Hospital managers are expected to manage affairs in the hospitals for which they have responsibility, based on those figures. I fully expect that the request of the four chief executives for constructive engagement with hospitals in the determination of the HSE plan to be presented to the Minister will be granted. That is a fair request. If they were to write their letters any other way, one would say everything was to their satisfaction.

The chief executive of Crumlin Hospital has confirmed that there are no extraordinary delays for children accessing cancer services. I fully support the progress that has been made in delivering cancer services for patients who suffer from this ailment, one that has affected every family in the country in the past number of years. I have personal evidence of this, from within family and outside of it. Many people have said to me that the structure brought about, in terms of cancer services and specialist units, is the way to go and that people would never go back to a situation where services were provided here, there and everywhere without a focus on the issues presented.

Micheál Martin (Cork South Central, Fianna Fail)
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Is that a belated acknowledgement of the progress we made?

Enda Kenny (Mayo, Fine Gael)
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It is an important letter and believe me it is not being treated as a joke. The Deputy might treat it as a joke, but it is not. It is a serious business.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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It is the Taoiseach who is the joker.

Enda Kenny (Mayo, Fine Gael)
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It is also a serious business to change the structure of the way health services are delivered to people, so as to cut the cost of delivering those services, but not the services themselves. That is the area on which the Minister, Deputy Reilly, is focused. The focus is on patient safety and care and ensuring people have access to medical attention and care of the highest order when they need it.

I hope constructive engagement takes place with these chief executives and with the other six hospitals where cancer services are provided in the preparation of the health service executive plan.

Clare Daly (Dublin North, Socialist Party)
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It is not just in the health area that the Government and Ministers are running into difficulties. Has the Taoiseach given the Minister for Transport, Tourism and Sport an option on a job share, where he can balance his ministerial responsibilities with a role as a mouthpiece for the management of semi-State companies in their battles against the workforce? It seems that not content with his unfettered access to the airwaves last weekend, where he could berate and bully Dublin Bus workers and warn them that if they have the audacity or neck to vote for a fifth time against attempts to reduce their pay and conditions, those conditions and pay would be butchered anyway, with the full backing of the Government.

Yesterday the Minister, Deputy Varadkar, came into this House during Topical Issues and it was like an audience with Christoph Mueller himself. Against a backdrop of an unprecedented move by the Aer Lingus CEO to ignore the industrial relations machinery of the State, Deputy Varadkar told us that it had nothing to do with him and our 25% shareholding was irrelevant. Then he told us that the increased traffic into Shannon Airport was a good thing, and nobody would disagree with that. However, he then boldly stated that IMPACT's objections to the new arrangement would make the Shannon cabin crew base commercially unsustainable for the company and it would have little choice but to close that base. That is utter nonsense. Four competitive US airlines operate the aircraft on that route out of Dublin and all of them operate it with a cabin crew complement of six staff. None of them has a problem with commercial unsustainability. A cabin crew of six is the industrial norm.

Let us be clear. The real agenda here is to stand on and erode working conditions built up over generations and to facilitate a race to the bottom. The staff were prepared to consider a staffing arrangement of four or five, but were told it would be four or the base would be shut down. Shutting the base down involves the loss of 87 Aer Lingus jobs, some of which have been held for decades. This is a declaration of war. Is this a deliberate strategy? To take on one group of workers may be deemed a misfortune, but to take on two looks like a deliberate policy of union busting. Given the Taoiseach has unleashed Christoph Mueller in Aer Lingus and is now sending him into An Post, is the Government engaged in a deliberate policy to eliminate secure, permanent, pensionable employment and to undermine the industrial relations machinery of the State? If it is not, will the Taoiseach order his hound dogs into the Labour Court to deal with these issues in the traditional way?

Enda Kenny (Mayo, Fine Gael)
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The Deputy has had a good flight there.

Mattie McGrath (Tipperary South, Independent)
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Aer Lingus or Ryanair?

Michael Healy-Rae (Kerry South, Independent)
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The Government will have a crash landing yet.

Enda Kenny (Mayo, Fine Gael)
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The Deputy has gone from the Minister, Deputy Varadkar, to Dublin Bus, Aer Lingus, Shannon and cabin crew staff. I am not in the position of ordering any hound dogs anywhere. I understand the ballot is taking place in respect of Dublin Bus. I hope the strategy is accepted and that there is a clear result from the ballot. People in Dublin need Dublin Bus to provide its valuable service. The majority of the workforce in Dublin Bus have accepted the recommendations. I hope that when the ballot result is known, the service will continue as it is an important service, particularly towards the end of the year.

With regard to Aer Lingus and the decision regarding the number of cabin crew required to service aircraft Aer Lingus intends to fly across the Atlantic, there is still an opportunity for discussion between the union and the company. I hope those discussions will take place and a solution will be found.

Clare Daly (Dublin North, Socialist Party)
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The Taoiseach's response was brief and he was very keen to trivialise some of the issues. The problem for the Taoiseach is that it is not about going around the globe - ranging from the Minister, Deputy Varadkar, to Dublin Bus, Shannon and An Post is not about being long-winded - but about a system and approach being adopted by the Government to systematically undermine decent wages and conditions in the semi-State companies. There is no other explanation for it.

It was not the workers who ended the talks. The workers were engaged in discussion with management, but management pulled the plug in a draconian way - in a company in which the State owns a 25% shareholding. That did not just happen in regard to the cabin crew. The Taoiseach is aware there is a pensions crisis in Aer Lingus. The same chief executive has sent into the Labour Court a negotiating team that does not have a mandate and which is refusing to deal with that crisis. At stake here are serious issues for workers. Will the Taoiseach order his chief executives in the semi-State companies to engage in the industrial relations machinery in the State? For once, could he stand behind the workers who built those companies, rather than behind the management who are trying to erode their terms and conditions of employment?

Deputies:

Hear, hear.

Enda Kenny (Mayo, Fine Gael)
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The machinery for negotiation here is well known. Workers, unions, company directors and chief executives are entitled to engage regarding the affairs of any of these semi-State companies. Members are aware of the contribution the semi-State companies have made over the years and of the dividends being paid by a number of them that were not paid previously. They are aware of the changes that have been made and the changed work practices that have been brought about. There is an opportunity for union and workers to engage with management in respect of Aer Lingus. The period for engagement is short, but the opportunity should be taken.

I did not hear the Deputy mention An Post in her first contribution. That company is not the responsibility of the Minister, Deputy Varadkar. I hope that the new ballot in Dublin Bus, which provides an important service for this city, will result in the proposals being accepted and that Dublin Bus and its workers, who do such an important job, get on with the business of providing a valid service for the people of this city.