Simon Harris (Wicklow, Fine Gael)
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I move the following Estimate:

Vote 38 - Health (Revised).

That a sum not exceeding €13,649,033,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 2016, for the salaries and expenses of the Office of the Minister for Health and certain other services administered by that Office, including grants to the Health Service Executive and miscellaneous grants.

I welcome the opportunity to address the House on the Revised Estimate for 2016 for my Department - Vote 38. It comes in the context of the Government’s determination to put the fruits of economic success to work for the people by improving the services that really matter and make a difference to their lives. I am privileged to have become Minister for Health at a time when we are in a period of reinvestment in the health service which gives me the opportunity to address some immediate issues facing patients, as well as meeting programme for Government commitments on which I want to deliver in my first 100 days in office. They include a winter initiative to manage overcrowding in emergency departments, an integral part of which is the provision of increased resources for home care services.

It is also of particular importance that the Revised Estimate places the health service on a sustainable financial footing. I welcome the statement by the director general of the Health Service Executive that the additional funding has stabilised the finances for 2016 and allows a realistic target to be achieved, with the emphasis he placed on the need for effective financial management. Additional funding of €300 million was provided in budget 2016 and this, with the Supplementary Estimate of €600 million remaining in the health sector base moving into 2016, resulted in an increase of €900 million on the 2015 budget, albeit that some of this had to be used to address once-off measures from the previous year. While the funding secured in the budget was welcome, it was becoming increasingly clear that the HSE was facing financial challenges in 2016, including the national service plan, as approved. The late approval of the 2016 Estimates has allowed the Government an opportunity to reconsider the health Estimate in the light of the emerging financial pressures and the economic position in which the country finds itself.

I am very pleased to announce that the Government is asking the Oireachtas to allocatea further €500 million in Exchequer funding for the health sector in 2016. This brings the gross current budget for the health sector in 2016 to €13.695 billion. This is equivalent to an increase of €1.4 billion compared to the original 2015 allocation of €12.295 billion and €736 million more than the final revised allocation for 2015. In percentage terms, this represents a 6% increase on the final revised budget for 2015 and an 11% increase on the original voted budget for 2015. This very welcome additional funding will stabilise the health sector financially and allow the HSE to set realistic and achievable targets for service areas, while still requiring it and service providers to demonstrate effective management control. It is an indication of the Government's commitment to reinvestment in the health service.

While I am confident that we are in a far more stable financial position than we have been for some time, 2016 and beyond still contain real challenges. We have an increased and aging population in this country, an increase in chronic conditions and new and expensive medicines and treatments. Our progress in diagnosis and screening for cancers and chronic illness means more people require treatments. Health services throughout the world are struggling with rising costs and Ireland is no exception. We must recognise the additional resource demands that come as a result of these new pressures.

I acknowledge these pressures and I am particularly pleased that the Dáil recently passed a motion to set up the Committee on the Future of Healthcare to develop a single long-term vision for health care and the direction of health policy in Ireland. I firmly believe that the Irish health service will benefit greatly from a single unifying vision that we can all get behind and that can help to drive reform and development of the system over the next decade. In particular, it is important that we work towards achieving universal health care. The motion establishing the committee notes the importance of achieving a single-tier health service in which access to services is based on need. The committee is due to provide a report to the Oireachtas within six months of its initial meeting. As Minister, I wish to assure the House that I will provide full support to assist this committee as necessary and as it requires. I am grateful to my colleagues, the Minister for Finance, Deputy Noonan, and the Minister for Public Expenditure and Reform, Deputy Donohoe, for their support and understanding in dealing with the challenges faced by the health sector.

The level of health services to be provided within the available funding is as set out in the HSE 2016 national service plan along with some additional programme for Government commitments, which I will outline later. The service issues which will be addressed under the Revised Estimate, as outlined in the service plan, include funding to reduce delayed discharges and emergency department overcrowding through providing additional funding for community beds and long-term residential care. It also provides for continuing the investment to improve the standard of care in residential services for persons with a disability through providing enhanced staffing levels and improving the quality and standard of their surroundings.

In the primary care arena the full-year effect of the under six and over 70 free general practitioner care is provided for, along with the extension of GP care without fees for all children under 12 years of age in the latter part of this year. The further roll-out of BreastCheck, enhanced provision of speech and language therapy, developments to our maternity services in line with the maternity strategy and further additional funding for mental health, which will be outlined by my colleague, the Minister of State, Deputy McEntee, were also provided for in the Estimate.

In the budget and this Revised Estimate the additional funding required to maintain existing levels of service in the acute sector is provided. Funding is also provided for ongoing strategic developments in areas such as paediatric scoliosis, strokes, the living donor programme and organ donor services, acute coronary care, bilateral cochlear implants and cancer services.

Earlier this year the Government launched the first national maternity strategy, a significant milestone in terms of the development of national maternity policy. Additional funding has been provided for maternity service developments in 2016, all of which will be allocated in line with the strategy.

The programme for Government emphasises the need for sustained commitment to improving waiting times for patients, with a particular focus on those patients waiting longest. It commits to €15 million funding for the national treatment purchase fund for an initiative targeted at those waiting longest from a continuing investment of €50 million per year to reduce waiting lists. The Department is currently engaging with the NTPF and the HSE in planning a dedicated 2016 waiting list initiative focused on endoscopy. The NTPF clearly has an important role to play and next week I will be meeting those responsible to discuss further waiting list initiatives.

Delayed discharges and waiting lists for acute services can arise when sufficient supports are not available for our older citizens in the community. Our population is ageing rapidly, with advances in health care leading to a dramatic rise in our older population. There is now a stronger emphasis on home care and other community services that provide a greater range of options to avoid admission to acute hospitals, support early discharge, and, where appropriate, to rehabilitate and re-able patients after periods of particular difficulty.

The HSE provides a range of community-based services aimed at ensuring older people receive safe, timely and appropriate care and treatment at the lowest level of complexity and as close to home as possible. However, demand for these services is rising as more people are supported in their homes rather than in hospitals or nursing homes, and I am delighted that the Government has been able to respond to this demand by providing an additional €40 million for home care in 2016 in this Revised Estimate.

For the future, A Programme for a Partnership Government commits to increasing funding for home care packages and home help year on year.

Of the additional €40 million we are announcing today, €20 million will be allocated to ensure that the 10.4 million home help hours, 15,450 home care packages, 130 intensive home care packages and 313 transitional care beds provided in 2015 are maintained; €10 million will ensure that the rate of service allocation can be maintained during the summer months; and €10 million has been ring-fenced for home care as part of the new winter initiative. There will, however, always be a cohort of older people who require a quality long-term residential care option. This must continue to be available to anyone who needs it.

The Government, together with the statutory and non-statutory agencies which provide services to people with disabilities, have been working towards empowering people with disabilities to live independent lives, provide them with greater independence in accessing the services they choose and enhancing their ability to tailor the supports they require to meet their needs and plan their lives. This year funding of €1.59 billion in total is being provided for health and personal social services for wide and complex range of services and supports for people with disabilities, including the additional €31 million which was secured for disability services as part of this Revised Estimate today, details of which were outlined by the Minister of State, Deputy Finian McGrath, last week.

The additional funding will cover costs incurred from compliance with national residential standards, services provided to meet the changing needs of people with disabilities and, importantly, the provision of emergency residential places. Of this additional funding, €3 million is earmarked for new initiatives, including an additional provision for services to meet the need of school leavers with disabilities and the anticipated cost of a number of emergency residential placements arising this year.

There is an onus on us all to use this substantial resource more effectively and efficiently. Most importantly, we must ensure that we are achieving real and significant improvements in the lives of people with disabilities.

Enhancing primary care and integration of care between primary and secondary are priorities for the new Government. Significant progress has already been made. GP care without fees has been successfully introduced for children under the age of six and all people aged 70 years and over. This has resulted in approximately 800,000 people now being eligible for GP care without fees, without having to undergo a means test. The service for those aged under six includes age-based preventive checks focused on health and well-being and a cycle of care for children with asthma. Other service developments include: the introduction of a diabetes cycle of care for adult patients with type 2 diabetes; an enhanced support framework for rural GPs; and a revised list of special items of service under the contract to encourage the provision of more services in the primary care setting.

There will be further investment in primary care, an essential element of which must be a comprehensive new GP contract, including an extension of GP care without fees for all children aged 11 years and under, including the asthma cycle of care. Other measures proposed are expanded GP access to diagnostic services and allowing more GPs around the country to offer minor surgery procedures.

There are two areas in particular to which I would like to refer in the context of these Revised Estimates and they are home care services and mental health, areas under the control and remit of the Minister of State, Deputy McEntee. Members will be aware that in the context of the approval of the national service plan, it was agreed that €20 million in time-related savings would be utilised to support services. I am pleased to say that as a result of the increased provision for health, we can provide the required funding for home care without relying on these time-related savings and can therefore restore the full ring-fenced mental health budget.

The Minister of State, Deputy McEntee, and my Department will work with the HSE to ensure that our mental health services get the maximum benefit from this funding, including, where appropriate, its use to support the development and refurbishment of the necessary facilities to house our new staff and provide more therapeutic surroundings for our service users.

In addition to the services set out in the national service plan, I am also pleased to announce that there is also scope for us to provide for the implementation of programme for Government commitments for the first 100 days. In particular, the additional funding being debated in the Dáil today allows us to provide €40 million in funding for a winter initiative to help address overcrowding in emergency departments. This initiative is currently in the early planning stages by both the Department and HSE. I have met the ED task force and asked for its input and there will be a specific ED task force meeting on this initiative. It will seek to support actions which improve patient flow through acute hospitals, as well as enhancing primary care and social care services.

As an integral part of this initiative, I will increase resources for home care services. As a result, we are not only maintaining home care and transitional care services at 2015 levels but are increasing them. The programme for Government acknowledges the need to improve services to our older citizens. The provision of additional home care services and transitional care will assist more older people to leave our acute hospitals when they are clinically ready to do so and this will allow patients awaiting admission in our emergency departments to be admitted.

Both my Department and the HSE recognise that the need for ongoing strengthened accountability and good governance within the HSE and voluntary bodies remains of critical importance. The HSE has reviewed its accountability framework after its first year of operation in 2015 and is involved in the ongoing implementation of the recommendations of that review.

This is focused on strengthening the operation, effectiveness and application of the accountability framework throughout the organisation to date, and will identify further changes to improve the process.

The allocation to address the budget overrun in the HSE must and will be underpinned by improved governance and accountability. My officials and the HSE will be working on the development of new and strengthened measures in this regard over the next two weeks. Health service management will be accountable for performing within the budget set by these additional resources. The Government believes the greatest need for improved accountability and control is in the acute hospital sector. For this reason, the programme for Government contains a commitment to establishing a performance management unit, which will work with individual hospitals where there are difficulties to achieve improvements. The establishment of this unit will contribute to a stronger focus on operational control and accountability in acute hospitals. I also see an enhanced role for the Oireachtas and Oireachtas committees. Those who are responsible for spending taxpayers' money on vital public services must be accountable.

When we talk about the need for improved performance, it is important for us to acknowledge the progress that is being made and the work people are doing to deliver improvements. The Department of Health is publishing the second annual report of the national health care quality reporting system today. This report, which presents health information related to immunisation uptake, cancer screening and survival, and the management of chronic diseases including asthma, chronic obstructive pulmonary disease, diabetes, stroke and heart failure, shows that clear progress is being made. It also sets out areas where there is room for more improvement.

The Government is committed to the development of a modern and patient-centred health service. While there is undoubtedly a strong case for increased health funding in the years ahead, it is also important to acknowledge that at a time of growing demand, more funding alone will not resolve the difficulties our services face. There must also be a focus on building a more effective health and social care service. Our experience during the boom years of the Celtic tiger, when satisfactory returns did not always accrue from considerable increases in health spending, is a stark testament to that.

I would like to take the opportunity presented by this debate on the allocation of additional resources to the health service, with the consent of the Oireachtas, to pay tribute to the health care staff who have taken us through some very difficult years. While issues have undoubtedly arisen, there have always been positive elements in our health service that are too often overlooked in this House. It was due to the hard work, commitment and dedication of the staff of the health service that it survived the most challenging period in its history. While we still face challenges, there is every reason to be optimistic and to believe things are now more manageable. We have a chance to embark together on a journey towards a better place for patients and front-line staff.

I thank the Members for their consideration of this Revised Estimate. I ask the House to consent to the provision of these much-needed additional resources to our health service. We are now in a period of reinvestment in the Irish public health service. I look forward to working with all Members of the Oireachtas in this regard.

Billy Kelleher (Cork North Central, Fianna Fail)
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I would like to share time with Deputy Browne.

Bernard Durkan (Kildare North, Fine Gael)
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Is that agreed? Agreed.

Billy Kelleher (Cork North Central, Fianna Fail)
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We are here again - this time in June, rather than October - to discuss a Supplementary Estimate for the Department of Health and the HSE. We accepted in recent years that the accounting practices, the assessment of demand and the provision of the funding needed to meet that demand were under pressure because of the financial downturn. The budgeting system in the Department of Health and the HSE has been chaotic over the past five years. The only people who thought the health budgets that were being proposed were believable were the Ministers of the day and those who worked closely with them when they were presenting those budgets to the House. I suggest they were in denial. No one other than the Ministers and their senior officials in the Department of Health believed the budgets that were being presented. On several occasions, Mr. O'Brien of the HSE said publicly at Oireachtas committees that the budgets which had been provided were not sustainable for the delivery of the required services.

Those who talk about the new political dispensation have said there is a need to involve everybody in the compilation of a new health strategy. A committee is being established to consider the preparation of a ten-year plan. The Dáil and the existing health committee have a role in discussing the budgetary systems that are in place. I suggest the best thing to do would be to start with an honest debate about the type of health service we want, how much we are willing to pay for it and what we expect out of it. We have never had such a debate. People waltz around this place on a regular basis promising the creation of a free health care system. We could have a system that is free at the point of use, but there would be costs somewhere else. Who is going to access health care? Who is entitled to free health care? Who needs health care? These are fundamental issues that need to be discussed. Over the five-year term of the previous Government and indeed prior to that, this House consistently listened to spin and nonsense about sustainable health budgets and real investment in health services.

The bottom line is that we will be rationing health forever and a day. Any modern country in western Europe will always be rationing health. Somebody somewhere will be playing God with somebody's life when decisions are being made about where resources and funds should go and who should be prioritised. I will give a case in point. The Minister just said that free GP care for those under the age of six and over the age of 70 has been "successfully introduced". Of course that has been done. As a result of that scheme being "successfully" rolled out to people in those age groups, some of those between the ages of six and 70 are suffering. They cannot get the resources they desperately need because others have been prioritised. The successful roll-out of a scheme in one area can have profound implications for the lives of people in another cohort of the population or of society. When we talk about investment in health services, we must be clear that we are talking about prioritising one group over another group. We must acknowledge that in our public health system, accessibility is based on one's private health insurance or one's ability to pay, rather than one's clinical need.

Even though he supported the previous Government, the Minister, Deputy Harris, is in no way responsible for some of the policies that were pursued by that Government. The reality is that as soon as the then Government decided the same cost would be imposed on all private health insurance companies for public beds, it chose to prioritise the private patient over the public patient. Hospitals immediately saw this measure as something that could be used to raise revenue at a time when they were starved of resources and funding. Policies that were introduced during the previous Government's term prioritised the private patient over the public patient. It is still happening to this day. If two people are wheeled in, one of whom can pay and the other of whom cannot pay, of course the hospital will take the patient who can pay. We need to be very honest about what we want.

I wish the committee on the ten-year strategy well. Deputy Browne and I will be joined by one more Fianna Fáil Deputy on the committee. We will absolutely play our role. I want to make it clear that the committee faces a massive undertaking. This nation has spent 60 years trying to come up with a health strategy. We are still talking about coming up with a strategy. Fundamentally, I do not expect the committee to come up with a complete strategy for health care over the next ten years in just six months. We will need to have ideological debates on issues like how health care should be funded, who should be able to access health care, the role of private health care providers, the role of private health insurance and the obligations of the State. Such fundamental issues will need to be debated as we consider how to move towards a sustainable and affordable system of universality. Of course some people will have views on universality, which is a noble concept but comes at an inordinate cost and has significant implications.

We could throw an additional €3 billion or €4 billion into the health system this year. It is clear that the more one invests in health care, the better the outcomes should be. The funds being invested have to come from somewhere else, however. It is at that point that the competitiveness of the economy starts to be undermined. We are always trying to strike a balance and to ensure the decisions we make do not have profound implications somewhere else. Health care is always prioritised in that process. Over recent years, we have consistently pretended that we are always trying to look after the most vulnerable people in our society and ensure funding is directed at those who most need it. However, that has not been the case when numerous decisions have been made. Mental health service budgets have been raided on a continual basis. They have been pillaged year in, year out. At the same time, the Minister has come in here to say that medical cards or free GP cards have been successfully rolled out to people under the age of six. I do not believe this approach has been successful. It cannot be said to be successful if people who are suffering with mental health issues, or people who are waiting an inordinate length of time to access essential care, do not have all the resources they need available to them. One should not prioritise people for electoral purposes, but that is what the previous Government did. Nobody in this Dáil would argue that a healthy six year old has more entitlement to a free GP service than a nine year old child who is dying with leukaemia, but that is what has happened.

We have to be honest that, as a State, we are consistently rationing health care. We must prioritise the clinical needs of the individual over political expediency. We have been slow to admit it in recent times.

This particular Supplementary Estimate, which is €500 million, is essential and required because the budgetary proposition announced last October to fund health services was not sustainable. This was highlighted by the HSE's Mr. Tony O'Brien and accepted by most Members, except the former Minister who said it was the first realistic budget in several years. It was not a realistic budget, although there was an increase in the moneys required. However, all the needs assessments from the HSE's service plans identified the changing nature of medical provision due to demographic changes and that this was not a sustainable budget.

We have been talking about primary care since 1987 when the then Minister for Health, Dr. Rory O'Hanlon, spoke in this Chamber about the need to reconfigure our acute services and ensure primary care became the bulwark and the main mechanism for delivering health care. We are now in 2016 and still talking about it. We have done very little with primary care. We have opened buildings but have not opened people's minds to the concept of primary care being the major way of delivering health care. We need to actually turn our thoughts to how we deliver care. Home care packages, home helps, community nurse services and GP-led services have all been put under significant pressure in recent years. We wonder why a 92-year-old is lying on a trolley in hospital for three days when they should not have been there in the first place. They are not sick but elderly and dying. However, they are put in corridors and wards of our acute hospital services.

I hope the health strategy committee, first proposed by Deputy Shortall, can take the politics out of health. I hope it will allow us to be honest with ourselves as a society in what we value, what we prioritise and, more importantly, what we need to do to provide health care and how we are willing to pay for it. That will take a significant effort on everybody's part because of some strong ideological views people have on health care.

For the past several years, we have consistently pretended we are prioritising health care and the vulnerable when, in fact, the opposite is the case. This Supplementary Estimate is testimony of this again.

James Browne (Wexford, Fianna Fail)
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I welcome the allocation of additional funding for health care. However, it is only necessary as a result of the lack of credibility in the previous Estimates which had no real honesty.

My concern and focus is on mental health. I welcome the return of the €12 million funding to mental health services. I know it was hard fought for but the availability of it is only the first step. We must ensure this money is well spent and targeted. Going on past HSE figures, people have a trust issue as to whether this money will be spent. It is critical this money is distributed and is spent on mental health with further spending next year.

People with psychiatric illnesses do not have access to community-based interventions or support, ten years after the launch of A Vision for Change. The full implementation of the policy is part of the agreement between Fianna Fáil and Fine Gael to support a minority Government. We will be watching closely to ensure the money is spent to fully implement A Vision for Change. We must also review A Vision for Change and see where we are going over the next ten years in mental health service provision to ensure it is kept as a priority. We need 24/7 access to mental health services, particularly in our community and primary care centres for recovery-led mental health care. As well as 24/7 community health care teams, we need a proper plan for the attraction and retention of mental health staff. Last week, psychiatric nurses threatened to go on strike not just about pay but the conditions under which they must work. They are short-staffed and under pressure, seeing those looking for help cannot get the supports they need. We need a clear plan for keeping nurses and psychiatrists, including career pathways for them.

Emergency departments are not appropriate places for people suffering acute mental health episodes. They need to get support in the community. If one is suffering from a serious mental health situation, going to an emergency department is stressful enough. Many of these departments do not have psychiatric nurses and those that do, have them only from nine to five, Monday to Friday. We know psychiatric episodes are worse at night times and at weekends when people are alone or have taken alcohol and so forth, which may exacerbate the situation.

If one goes to the emergency department in Wexford hospital after 5 o'clock, one will be seen by a triage nurse after four or five hours. This nurse will have basic training in mental health and he or she will do his or her best. The triage nurse will telephone a psychiatrist at Waterford hospital who will make an assessment over the phone. If the psychiatrist deems further assessment necessary, the patient will be told to make his or her way to the Waterford emergency department, where one could wait another four or five hours. We know there is a significant level of walkouts from our emergency departments, particularly from people suffering from psychiatric episodes. It is understandable. If they are under stress, the last place they need to be sitting for five hours is in an emergency department. If a patient is deemed not to be a priority by Waterford hospital, he or she will be told to make their way home. This is not acceptable. We need to ensure there are supports in place for people with psychiatric issues.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I wish to share time with Deputy David Cullinane.

Bernard Durkan (Kildare North, Fine Gael)
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Is that agreed? Agreed.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Despite all of the marketing language of the budget for the health services, against the backdrop of the Supplementary Estimates for the past several years, there are serious problems not only for this year but for the years ahead. The position for acute hospital groups into the future is particularly challenging. The plans for hospital trusts in the programme for Government raise serious concerns. What we see there is not a blueprint for a public health system but a private health business. The programme for Government concerns us as a charter for privatisation of our health services, putting them further out of the reach of the people who need them the most. It is undeniable our public health system continues to suffer acute and chronic underfunding.

The annual deficits run up across the system every year, alongside lengthening waiting lists and numbers of patients on trolleys. These are a testament to the failure of successive governments to allocate adequate funds. Not only that, but it is a testament to how we have failed to develop a long-term vision for our health services.

I very much welcome the newly constituted committee. I want to record once again my appreciation to Deputy Róisín Shortall for proposing it. We will, of course, participate in this committee. We will be constructive and solutions-focused, as we always are. The fact is that we must become better stewards of our health spending. This is not about pursuing efficiencies in order to facilitate cuts to the overall health budget. Rather, it is about ensuring we deliver the best care possible from the funds available.

While I will touch on some of the specifics of the Estimates and the ministerial announcements made in the past week, I would like to take this opportunity to touch briefly on two areas where I believe there must be greater emphasis in terms of health spending. The first is reducing reliance on agency staff and the second is reining in the pharmaceutical bill. In the first instance, we all know that a moratorium on recruitment across all areas of the public sector was introduced in March 2009. Many Deputies may not be aware that the moratorium in the health service was, in fact, brought in years previously, in 2007, and it created a health system propped up by agency staff. We need to ensure that the HSE reduces reliance on expensive agency staff and makes permanent posts more attractive for qualified applicants.

The current approach is clearly costing us dearly, not alone financially. In financial terms, however, in the period from January to May, over €68 million was spent on agency staff, which amounts to 2,378 whole-time equivalents. If progress is being made on this, what progress has been made to date in the conversion of agency staff posts to permanent positions? How many posts have been converted in the last six, 12 and 18 months? What are the approximate savings to the Exchequer through converting these positions? The Minister has already agreed with me that agency staff do not represent good value for money, although we cannot deny they do very valuable work. We need to see exactly what the Minister is doing about this.

The second issue is one that has been topical in recent weeks and one which I believe will become more prevalent in the future. The undeniable fact is that the Irish taxpayer is still paying too much for on-patent medicines by international standards and, importantly, our system still uses far too much of them. On-patent drugs account for 78% of the State’s public health drug budget. It is clear the State health service has a limited and finite budget, and this will always be the case. Therefore, it is important that issues of cost effectiveness and value for money are considered.

Sinn Féin does not accept that these two policy objectives are mutually exclusive. We have proposed a range of measures in our "Better 4 Health" policy document that would address the serial impasses in regard to access to new medicines. The Minister, the Department of Health, the HSE and the pharmaceutical industry all have clear responsibilities in this regard. Indeed, the European Commission, on page 74 of the Commission working document that is part of the country-specific recommendations process, noted:

For medicines no longer patent-protected but which fall outside the system of interchangeable groups, no price benchmarking exercise has been performed. As before, the authorities seem reluctant to activate their pricing powers gained under the Health (Pricing and Supply of Medical Goods) Act.

The Government, the EU and the international community should not allow pharmaceutical companies to hold citizens or states to ransom. This is, in effect, what they are doing and what they will continue to do until such time as the structure for funding the research, development and commercialisation of new medicines is redirected towards the public good and the interests of citizens, and away from big global corporations. The Government needs to play a prominent role in calling for this much-needed change at EU level. Bulk buying, risk sharing, State funding of research and development and compulsory licensing are all possible options that must be considered. I would like to know if further engagements are intended with the Irish Pharmaceutical Healthcare Association in regard to proprietary drugs, and with the Association of Pharmaceutical Manufacturers in Ireland in regard to generic drugs. What further engagements does the Minister intend to have? Is he seeking to achieve new and increased savings through agreement with both of these bodies? On a very important point, has he identified targets in this area?

Before I come to the Estimates, I want to ask on one important detail in regard to the health Estimates. Has the Minister put money aside for compensating Amanda Mellet and any future women who will need compensation until the eighth amendment is removed? The UN found that our laws violated Ms Mellet's entitlement to freedom from cruel, inhuman or degrading treatment. The UN further found that Ireland, which is a State Party to the International Covenant on Civil and Political Rights, is obliged to provide Ms Mellet with an effective remedy, including adequate compensation and the psychological treatment she may need. We received the Estimates yesterday morning, and I apologise if I have missed it, but given the equivocation of this Government in dealing with this issue, which means it is almost certain that other women will be placed in the very unfortunate and tragic, but very avoidable, position in which we placed Ms Mellet, I have to ask whether the Minister has put money aside. The bills and the need for compensation will rack up until something is done in this regard. More women will be subject to cruel, inhuman and degrading treatment for which they will be entitled to compensation. It is a shame that we are here talking about compensation when we should be talking about real remedies. We should be talking about taking care of these women, not compensating them. Even on the issue of compensation, I see nothing in the Estimates to give me, as a woman, or Ms Mellet, as someone who has been through this, any comfort that money has been put aside to deal with these awful circumstances. This is an issue that will not go away. The Minister can dismiss it, kick it into a citizen's assembly and deny it, but it will not go away. It is very real and it needs to be addressed.

With regard to the Estimates, particularly the ministerial announcements this past week, I welcome that the €12 million plundered from the mental health budget earlier this year will be restored. I would take issue with references being made to this as restoration, which was said in some of the Minister's press releases, or as additional funding. This is not additional funding but funding that was callously removed from this area and that is now being replenished after a public outcry.

I read the Estimates in the short time allowed to us before this debate and I am not impressed. I fail to see any meaningful investment and it is clear to me that the publication of the Estimates spells bad news for those who are on waiting lists - those who will spend tonight on a trolley, those who will continue to wait for vital services, those families who will be diagnosed with a fatal foetal abnormality and those who are depending on this Government to respond to their very real needs.

David Cullinane (Waterford, Sinn Fein)
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In 2011, in addressing the previous Minister for Health, Senator James Reilly, I told him he could be a reforming, radical Minister for Health. I then said the same to the Minister, Deputy Varadkar. Unfortunately, both failed in their jobs - both failed to reform the health system and both failed to bring us any closer to a single-tier, fair universal health care system. The Minister, Deputy Harris, now has the opportunity to do that. I hope he will not be the third health Minister of this Government who will fail in that duty.

The Minister and the Government present this as new money.

The so-called extra €500 million for health is typical of Government spin. Not even Fianna Fáil in its darkest days, and it was very good at spin, would have had the brass neck to come in and present this as new money when everybody knows it is not. The Government knows it cannot introduce a supplementary budget because of rules which Fine Gael and Fianna Fáil supported. What we have here is a supplementary budget by another name. This €500 million is not extra money but funds necessary to stop parts of the system from literally shutting down. This is why the money is being allocated. Why can the Government not provide adequate funding to our health system at budget time rather than having these continuous underspends every year? We point this out and provide for increased funding for health in our alternative budgets but they are knocked back and criticised by the Government, which then comes in here months after the budget to seek more money because Sinn Féin was right when we said enough money was not put into health in the first place.

The Government purposely underfunds health and then announces emergency funding as some kind of bonus. It is some sort of gift that extra money will be spent. This is cynical. It is cynicism of the worst kind. There is a need for real reform of our health service. The Minister and the Government paint a very rosy picture of our health service when it suits, and they give the sense the Government is improving our health services and that it is making a difference. Let us see if it is true. Let us deal with a number of facts. I received from the HSE a response to a parliamentary question tabled to the Minister on the number of patients at University Hospital Waterford who were languishing on hospital trolleys for the first nine weeks of this year in comparison to the number of patients languishing on hospital trolleys in the same period in 2015. The figure for the first nine weeks of 2015 was 281. The figure for this year was 710, which means almost three times as many patients were left lying in hospital trolleys at University Hospital Waterford. This was just with regard to the accident and emergency department. This was according to the reply to a parliamentary question and Minister shaking his head does not alter facts. Facts are facts.

Simon Harris (Wicklow, Fine Gael)
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Distortion of facts.

David Cullinane (Waterford, Sinn Fein)
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This is as a result of many problems in many areas of the hospital in Waterford with regard to orthopaedics, ophthalmology and ear nose and throat. There are real pressure points in all of these areas. All of these bottlenecks merge in the accident and emergency department and create the crisis we have. We have record numbers of people awaiting treatment and not only in Waterford. This morning, the Minister was in the Chamber when Deputy Mattie McGrath raised on Leaders' Questions the issue of what is happening in the acute hospital in Tipperary. The Minister recognised and accepted there are capacity issues. There are capacity issues in acute hospitals throughout the State. The Minister needs to get real about the extent of the crisis and deal with it.

I wish to discuss public sector pay and what might happen in respect of the public pay commission which the Government will establish. The Minister needs to prioritise post-2011 new entrants. We cannot continue with a two-tier pay structure. I believe in the principle of equal pay for equal work. If the Government agrees with this, it must deal with this as a priority in health and throughout the public service generally. I appeal to the Minister to push this as a priority for the Department when these opportunities arise.

Alan Kelly (Tipperary, Labour)
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I wish the Minister and the Minister of State, Deputy McEntee, well in what is a very difficult area. This is their first engagement of many and I congratulate them on their appointments. Their combined age is probably younger than some of their predecessors singular.

Simon Harris (Wicklow, Fine Gael)
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That is true.

Alan Kelly (Tipperary, Labour)
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With regard to the Estimates, most of us who observe these things knew this day would come and the €500 million is obviously necessary now. This has been going on for decades under Fianna Fáil and other Governments. It is like a figure is picked from the sky for the health budget and it is constantly supplemented, as everyone knows. We cannot continue like this. Collectively, I hope all of us who deal with the issue of health care will come to a process by which we can support proper budgeting.

I note from the briefing document, for which I thank the Minister although unfortunately I received it only this morning, the Department states it is working towards the development of programme budgeting and changing the structure of the health Vote. It is incredible that in this day and age the process by which the vote is announced and the way in which it is segmented and structured does not work. We need to change this. The document states it will take time to do this but I find this strange. Why it cannot be changed quickly is, perhaps, something Deputy Harty will want to examine as part of the committee's work.

Later this year the Minister will seek more money. We all know this. That €500 million will do it will simply not happen. I will lay this bet with the Minister right now, and I guarantee him he will be looking for more money. It is a simple fact.

I welcome the comments the Minister made earlier about the prioritisation from a budgetary point of view of the management of the acute hospital network. It is the right way to go. With regard to the mid west and south east, to be frank, I could never accuse those managing non-acute areas of not managing their budgets well. They manage them particularly well. I am not convinced I could state this confidently about the acute side. This is not through the fault of management in these areas. Different circumstances exist, which we might get onto later, and I appreciate this.

I am very much taken by the committee, which I believe is a good idea, but I agree with Deputy Kelleher that we will have to be realistic. What will we achieve in six months? It will not be utopian. We will not be able to achieve everything. There are ideological differences in the House, which is why we are here, on health care and health care management, which we will not solve in six months. I ask that we identify what we will try to achieve as regards some form of pathway to a consistency of approach in health care. Somebody will replace the Minister eventually and that person will deal with the same issues. I hope we will have laid the foundations through the committee to create some form of pathway for managing a better health service, particularly with regard to how we manage funding the health care system.

It is necessary for all of us, particularly those who are spokespersons for various areas of health and the Minister, to make it above politics. I know this is a cliché but we must adopt a different approach not only because of the political nature of the House but in general we will have to do it differently to achieve results.

I have a number of questions about some of the specific provisions the Minister has brought forward. Many of these questions remain unanswered and I hope the Minister will be able to answer them. I do not expect he will be able to answer all of them today but he might do so in writing to me afterwards.

Will the Minister give us a breakdown of how the much vaunted accident and emergency department winter initiative will work? Where will the funding be allocated, in what measure and how will it be appropriated? It needs to be appropriated in various ways. I would like to see a breakdown of how it will work. I know the Minister was left in a position where the funding was not there but it cannot be just a case of throwing the money out there. It must be used in a quality way.

I lament the fact the post of Minister of State with responsibility for primary care was got rid of. According to the Irish Medical Times, which I presume is correct, the Minister stated he would personally take control of the primary care portfolio.

I am glad to hear that. He might explain how he will do that. During the term of the previous Government we rolled out 90 primary care centres and commenced the construction of 73 more, and they will go some way towards the provision of facilities for people into the future. How many will be funded over the duration of this Government? What are the Minister's projections in that regard? What is the target for primary health care provision and centres? How will he measure that? Is there a figure that he will stand over for the optimum number of primary care centres that we need across the board and the various jurisdictions?

Regarding free general practitioner care, I welcome what the Minister has said about moving on from care for under sixes towards later this year increasing that to under 12s, but when will that be delivered? When and at what time of the year will he commence doing this? How does he see it being rolled out? Has he abandoned the plan to extend GP care from over 65s to over 70s or is that something that he intends to do?

I wish the new Minister of State for Mental Health very well. In fairness, she has a hard act to follow. The previous Minister was a very good one. A Vision for Change, while a fine document and something that was broadly supported, is in an implementation phase that must continue rapidly. Will that happen? Does the Minister believe he has the resources to do that? It is not something that can be done piecemeal, stopped halfway through or not implemented to the level that was planned.

I welcome the funding allocation for home care packages. This is a bugbear of mine about which I have spoken to the Minister previously. I believe the allocation will only allow matters to stand still. I have made my own inquiries about this and believe the allocation only fills a gap that was previously filled by taking funding from other sides of the budget, particularly in mental health. The allocation will only ensure that existing home care packages will be funded. It will not allow for any more home care packages. It might allow for a few extra hours for a few people in various areas but I do not believe it will have a huge impact on the totality of people. The Minister's figure is €10.4 million. That is up from €10.3 million, I think. I would like to see how that figure will work. Ultimately, we must consider what home care packages cost, at approximately €639 per week, compared to €12,000 or €15,000 for a nursing home or multiple thousands for somebody in a hospital on an acute bed. It makes common financial sense and health sense that we fund this area appropriately because it helps with pathways to the management of people, it prevents bed-blocking and financially and from the point of view of health it is the best way. The Minister will hear as a common commentary from me in my time as spokesperson on health that I am a huge advocate for this. There are multiple wins in this regard, and I ask the Minister to prioritise home care packages and home help hours. I know of people who are simply sitting in hospitals and cannot be discharged, will not be discharged or are refusing to be discharged because the home help hours are not provided to deal with them.

Does the Minister have a timeline for the beginning and conclusion of negotiations on the new GP contract, which is obviously essential for the rolling out of GP care and enhanced primary care services? Has he met with GP representatives? If not, will he do so and when will he do so? They are asking to meet, as the Minister knows. A number of us in this House have a real concern about GPs in rural areas. There are serious issues in this regard and it is something that I would like the Minister to prioritise.

Has the Minister undertaken a cost-benefit analysis of the reactivation of the National Treatment Purchase Fund? It is prioritised in the programme for Government.

How will the accident and emergency and the emergency department, ED, task force, which I welcome, be managed? This is a priority. If one considers the situation in Limerick, Beaumont, Galway and many other hospitals, what we need regarding this task force is to see how pathways will be put in place for the management of people who are going through ED units. There needs to be new thinking around this, and it is a critical area. Will there be sufficient funding, given what the task force will have to come out with, to ensure that happens? Not all of this is bricks and mortar or funding for staff, by the way. It is about managing processes, pathways and people who come into ED units in the first place. How can we ensure the primary issue we should be ensuring, namely, that first, patients get a good service but second, that some of them who are going into EDs are treated somewhere else because they should not be there in the first place? I think we are all aware of this.

I have a number of specific questions which I want to rattle through and on which the Minister may come back to me. There is a cut in the budget in the drugs initiative and he is saying that that is a transfer to the community. Can we get figures for and transparency on that? There was a big hullabaloo when about 17,000 Ministers visited the north inner city in Dublin a few days ago, yet the communities will probably want to see an explanation for this.

The allocation for medical cards on day one was not correct. Is the Minister happy that the allocation that he has now specified will work? There has been a huge increase in legal fees, according to what we are hearing. Why is that?

I welcome what the Minister has said about scoliosis. This is something I have personally advocated for and I would appreciate if he would inform me of the details of what he is doing about this because it is something that has needed to be addressed for a long time.

I wish to raise two final issues. One of them does not relate to the Minister for Health directly but relates to the Minister for Finance, and I hope the Minister for Health will speak to him. We have a serious issue in this country regarding graduate doctors.

Simon Harris (Wicklow, Fine Gael)
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Yes.

Alan Kelly (Tipperary, Labour)
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It cannot continue. If it does, I do not know where we will end up. There must be some provision in this regard. The average cost for somebody who is training to be a doctor is about €16,000 to €18,000. If one multiplies that by five years, one can see what the cost is for them. The issue is also a societal one because it is my belief that if mammy and daddy or somebody else does not sponsor these people or if they come from a certain social background, they simply will no longer be able to become doctors because it is too expensive. What can we do, maybe through the Finance Act or the budget, to facilitate and help these people and, as part of that, to ensure that they stay in this country for a period of time, if not forever? Can we put them on a pathway that would ensure that they want to and will stay in this country? One of the Minister's colleagues made a proposal previously - I will not be exhaustive, but this was one of them - regarding doing something about the interest on the loans that they take out to educate themselves. I ask the Minister to consider that and talk to his colleague. I would support that.

Finally, as the Minister is aware, this morning there is a HIQA report about South Tipperary General Hospital which is quite damning. It is incredible. I have never heard the like of it before and I ask the Minister to visit the hospital with me or with others.

Simon Harris (Wicklow, Fine Gael)
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I will.

Alan Kelly (Tipperary, Labour)
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I am concluding, in case the Chair jumps in again. There was one such famous incident. The issue is that the hospital is in such a state that it really needs direct intervention. I have never in my life heard of representatives from HIQA going into a hospital and things being so bad that they suspended their visit and contacted the CEO of the hospital group in order to have issues addressed. They did not want to continue their visit because it was such a serious issue. Can we therefore please have some process for managing and dealing with this quickly? The Minister will not have all the solutions immediately, but the matter does need a specific intervention because people being left outside in reception areas and on trolleys with no access to critical equipment, oxygen etc. in this day and age is simply unacceptable.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I congratulate the Minister on his new post. I hope he will not be called Chopper Harris, after a famous footballer, for his cuts and so forth.

Alan Kelly (Tipperary, Labour)
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Chelsea.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Yes. The crisis in the health service is universally accepted as a fact, and with good reason. Waiting lists and trolley queues are not a seasonal aberration but a permanent fixture. The state of mental health service staffing, after ten years of A Vision for Change, is a national scandal. It is extraordinary that the Government’s acceptance of this crisis is still in doubt. The publication of the Revised Estimates for health shows that the Government, which has presided over the health crisis over the past five years, seems to be still stuck in denial.

During the past five years, the Fine Gael mantra was “more for less”. First James Reilly and then Deputy Leo Varadkar expected us to believe the cutbacks in health funding would do no harm. A child could have predicted this. Patient support groups and staff representatives told the Government about the devastating effects of austerity cuts on patient care. All of this advice fell on deaf ears. Less service for less funding would have been bad enough. However, Fine Gael wanted to introduce the market and the private, for-profit sector, which is its answer for everything, and we got even less service for more money. As a result of the additional €5 billion spent on health insurance and out-of-pocket expenses, Ireland has ended up with health spending that is above the EU average and quality that is below the EU average. We get less for more, not more for less.

Fine Gael and Fianna Fáil have misled the country about our health service and they continue to do so. All through its time in government, Fine Gael lectured the left on costing, insisting that the figures for alternative health proposals did not add up. Meanwhile, it never costed its flagship health policy of universal health insurance, UHI. Fine Gael introduced this UHI policy of private, for-profit health insurance in 2009 as FairCare. It announced it as policy in the Fine Gael 2011 election manifesto and the programme for Government. However, when it finally outlined the policy in a White Paper three years later, in 2014, it still had not costed it and could not say how much the health insurance would cost or what it would cover. I doubt Fine Gael has learnt a lesson from this.

The approximately €500 million increase in the health budget announced in the Revised Estimates is almost entirely consumed by the current real spending in health. This is not an overrun as the Government claims. In 2008, eight years ago, the health budget was the same, €13.6 billion, as it is today after the so-called additional money. Inflation in the same period was cumulatively more than 30% and the population is increasing in number and in age. This means there is less spending on health care than ever before. The smoke and mirrors of health funding continues. While the overall budget increases by just 6% year-on-year, the Minister has increased spending on consultancy fees in his Department by a whopping 96%.

Given the level of public concern and outcry about the neglect of mental health services, the Minister’s failure to address mental health is amazing. Staffing of mental health is only three quarters what it should be and only half the recommended level for children’s mental health services. Despite this, while the overall budget has increased by 6% the mental health budget has increased by only 2%. In the Revised Estimates, the €35 million noted as not yet allocated for new developments in mental health is described as additional funding. However, even when it is added in, the total is no more than the general increase in the health budget. The level of funding in mental health is only half what it should be, based on international comparisons, resulting in a deficit of €800 million.

While the announcement of developments in primary care, speech and language and psychology services is welcome and overdue, it is dismaying that no specific funding or staffing targets are addressed. While Fine Gael recently said it is committed to developing a one-tier, publicly funded health service, confidence is not inspired by the failure to be honest about deficits in capacity, staff, hospital beds and primary care centres. Continued talk of superficial fixes through buying and selling care in the National Treatment Purchase Fund and the setting up of hospital trusts can only lead public representatives, such as us, to conclude that Fine Gael, supported by Fianna Fáil, is still up to its old tricks. It is time for the Minister to stop running and spinning the numbers and address the staffing and funding crisis in the health service.

Mick Barry (Cork North Central, Anti-Austerity Alliance)
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Although I could probably speak on 20 different issues under this heading, given the time available I will speak on only one issue in more detail, namely, the rates for nurses in general and for young nurses in particular. Even from a young age, I have always found it telling how many capitalist societies force nurses, who save lives, to live on relatively low wages while paying handsome salaries to members of the elite, who play, to put it mildly, a far less valuable role in society. For example, a student nurse in his or her fourth year working in a hospital, with onerous duties and responsibilities receives €9.48 per hour, which is 33 cent above the minimum wage. The starting pay for a fully qualified staff nurse is less than €23,000 per year and yet the salary pay cap for bank executives is €500,000 per annum. Gerry Gannon, one of Anglo Irish Bank's Maple Ten, receives a salary of €170,000 per year from NAMA. A failed developer is paid eight times more than a young nurse and a bank executive can be paid more than 20 times the salary of a young nurse. This is a sure sign of a society which has its values screwed up.

Late last year, the Union of Students in Ireland, USI, published the results of a survey of 600 student nurses which showed 93% of nurses had considered emigrating. More than 2,000 young Irish nurses have left the country and gone to work in Australia alone. Meanwhile, there are more than 600 vacancies for psychiatric nurses. Why are young nurses leaving and why can these positions not be filled? Let us take a few reports from the front. Claire Treacy, the industrial relations officer for the Irish Nurses and Midwives Organisation, INMO, speaking in late 2014 on the situation pertaining in Galway University Hospital, said:

On average there are nine nurses on duty and they can be caring for 70 or 80 patients. There were nine nurses to 120 patients one day. These nurses are burned out and stressed. The hospital has been offering counselling and well-being sessions over the last few months but it is not enough. It is not one bad day at work, like other people have; every day is a bad day.

Tony Fitzpatrick, the INMO representative in the north east of the country, said of the situation in Our Lady of Lourdes Hospital:

Everything is stressful. They [young nurses] go home crying. Several have told me on the drive home in the car they have tears running down their faces, that they cannot sleep at night thinking about the patients, still thinking about their colleagues at work. They know it has been impossible for them, on that day, to deliver quality care for patients.

Young nurses are leaving the country because the job is so utterly stressful. It is a downward cycle when that happens. The key to breaking that cycle is an improvement in nurses' pay. If it is increased, nurses who have gone to Australia, the UK and elsewhere will be attracted home. Increasing the number of posts will result in more nurses on wards and will lead to a situation where there will be sufficient nurses on them. The work will become less stressful and, as the word spreads, more people will be attracted home. This will then become a virtuous cycle compared to what has gone before.

In recent weeks, Luas workers achieved a pay increase of 18.3% and I congratulate them on having done so. Why not give an 18.3% pay increase to nurses, not over a period of four years but as a bold stroke over one year? The Minister and the Government will no doubt say the country cannot afford it. However, the country cannot afford a scenario where money is spent educating and training young nurses before forcing these incredible national assets to emigrate and resulting in us losing the benefit of that investment? This is skilful economics as well as a humane approach to the issue. The hidden pay traps in place for nurses need to be removed in addition to giving them a pay increase. The nurses' hand-over involves one nurse coming off duty while another is coming on. He or she has to be informed of the position regarding the patients on the ward, which can take half an hour. Nurses do not get paid for that in many cases. On wards where there should be three nurses, there are two because of cutbacks. What happens when they need a lunch break? They cannot go to the canteen or off campus. They have to eat their lunch in a room beside the ward but they are not paid for that. What about the position of the many nurses who, de facto, do the work of ward managers but who have not been promoted to the relevant positions? In other words, they are ward nurses in practice but not in the context of title or salary and they have to take a hit as a result. What about the many opportunities for training and, flowing from that, promotion that have been denied to them during the austerity years? These issues need to be tackled and resolved.

I refer back to the example of Luas workers. I urge the Government and the House to implement these policies. I believe they make sense but I have no confidence in a Fine Gael-led minority Government implementing such policies. The issue, therefore, needs to be driven by workers and the unions that represent them. They could do a lot worse than consider the example of the Luas workers who set out their case and made a militant stand for pay increases. If nurses make a similar stand for an increase, the vast majority of ordinary people in this nation will be fully behind them.

Catherine Connolly (Galway West, Independent)
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I welcome the opportunity to contribute to the debate. I deplore the fact that we did not receive a briefing document earlier. I understand from a telephone message I received that the document was only made available in the past hour. That is not a way to deal with this. The Minister is shaking his head but I will not use my time on this other than to record that we did not receive a briefing document as should have been the case. We should also have received a copy of the Estimates before yesterday.

I would like to raise a number of issues. I welcome the Revised Estimate but it is a drop in the ocean for a health system that is creaking at the seams because of previous decisions. The word "ideology" has been used in the debate. I am no ideologue; I am a practical woman when it comes to services. I believe in a public health service funded by taxation and the vast majority of people want that. It makes sense even on an economic level and I will outline a number of examples form the documents that have been circulated. I would like the Minister to stop referring to elderly people as a burden. Perhaps he might be doing it indirectly but the language in his documents states that elderly people place an increased demand on the health service because of an ageing population. I would like to balance this comment with a few figures. Only 4% of our elderly are in nursing homes and a further 5% receive home care services. The other 90% of elderly people live independent lives. It was established that the elderly make a substantial contribution in terms of spending and taxation to society in England following a costing that was done there recently. We should get away from looking on the elderly as a burden and consider the talent and the money they contribute.

Reference is made to stroke on page 24 of the briefing document. I welcome the positive statement on the improvement in services for stroke victims. However, Professor Harbison, the clinical director in respect of stroke at St. James's Hospital, has made figures available through a newspaper article and they are worth examining. They outline what the failure to implement the national stroke strategy is costing the State. He pointed out that an amount that is less than the amount proposed to be spent on two new drugs over five years has been spent on the strategy. Strokes costs the economy €500 million annually but at least 50% of them are preventable. This year alone, 8,000 people will suffer a stroke, yet six of our acute hospitals do not have the most basic requirement, namely, a special ward or unit for the treatment of stroke. Professor Harbison stated, "Despite the successes, we still have huge deficiencies in stroke care in Ireland", with only 40% of the stroke unit beds required. Currently, only half of stroke patients are treated in special units. That is a clear example of where money could be saved and then put into education and prevention and proper treatment in order that stroke victims would spend less time in hospital. They would spend less time taking up beds if money was invested in order to provide appropriate care in the home.

A total of 140,000 children live in consistent poverty. We have a major housing crisis and, yesterday, I outlined literacy figures. All those factors contribute to an unhealthy society and lead to people having to avail of health services, which would not be necessary if basic homes were provided for our people and if problems relating to illiteracy and alcohol were addressed.

In the briefing document, one page is given over to mental health services. The document does not refer to the cost to the economy of the failure to treat patients who are mentally ill. I use these figures deliberately because this is a debate on the Estimates. A Vision for Change was a revolutionary document published in 2006. I am reluctant to quote one figure it contains - the figure is incredible - because it must be a mistake.

Extrapolating from the Northern Ireland figures, it is said that the cost to the economy for the failure to treat mental illness is more than €11 billion per year. I use that figure very carefully but if the cost to the economy is anywhere near that, do we not have a serious problem due to our failure to treat mental illness appropriately? There is no mention in the Revised Estimates of a review of the mental health strategy, A Vision for Change. No timespan is given for that. The period of time that plan covered expired in January of this year and it is now June. I do not see a reference to where that review is at. During that ten-year period, there was an inbuilt mechanism for monitoring progress and the independent monitoring group, along with the Mental Health Commission, repeatedly pointed out that the implementation of the mental health strategy was both inconsistent and tardy. The then Government's response to that was not to have a third implementation body, so it sat for two three-year periods and was then disbanded. The mental health vision set out has not been monitored and we have actually gone backwards.

During the many very sensitive debates in this Chamber on mental health, suicide was mentioned, as were all of the problems that we have. I sat here in utter frustration simply because all those problems were identified in 2006. The suicide levels ten years ago were very acute. A strategy was clearly set out but none of it was implemented. As was said previously, when we hear the whirring blades of the helicopter in Galway, it means something completely different to us now as week after week somebody is taken from the water. The problems were identified as were the solutions to them. However, the solutions were not implemented.

With regard to hospital beds, I have watched the underpinning of the public health system since I was first elected, particularly since I was elected to a health forum in 2006. Certainly Fianna Fáil and the Progressive Democrats were responsible for that and certainly Fine Gael and the Labour Party followed suit. I hope this Government will change the direction and commit to a public health system funded from taxation. The Government cannot keep giving money to the National Treatment Purchase Fund, a special delivery unit and agency staff.

I would like to ask the Minister specifically about our obligation under the EU directive whereby if one can succeed in borrowing money from the credit union or any other credit establishment, one can go abroad for treatment. Where is that factored into the Revised Estimates? When we see all the money that is being allocated to agency staff, the special delivery unit and the National Treatment Purchase Fund and all the money going out of the country, would it not occur to the Minister or his staff to propose we put it into the public system and thereby increase the bed capacity, as we have a lack of intensive care beds and many doctors have gone out on a limb. Doctors have put their names repeatedly to letters to The Irish Timesand other newspapers begging for the bed capacity to be increased and for a very long time, we have had to listen to the mantra that we need fewer beds.

We have been told we cannot employ staff. Having had a depletion of our public health system and an embargo on recruitment, we now cannot find staff.We have not changed our recruitment system in trying to find staff. If we have spare money in the recruitment budget, could it go to Console, the Samaritans or to the other organisations that are literally saving people from the water? I listened with dismay to an interview where the director of mental health said she could not possibly spend that €35 million before the end of the year. I welcome the U-turn but should the Minister have any difficulties in the future in spending funds in the budget, will he come back to us? We will certainly tell him where it could be spent, and Console would be one of those organisations.

I will conclude on a final parochial note. We require a new hospital in Galway. I raised this matter with the Minister and he gave me a bureaucratic answer to the effect that there were no plans at the moment, and that is despite the fact the clinical director of the hospital in Galway said everything they are doing is a fire-fighting exercise and that the lack of capacity and the inadequacy of the hospital is the number risk factor.

Séamus Healy (Tipperary, Workers and Unemployed Action Group)
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I thank Deputy Connolly for sharing her time with me. I want to specifically address the situation at South Tipperary General Hospital and I appeal to the Minister to give it the urgent and immediate support that it needs. I invite him to visit it to see the excellent work that is going on there. I have raised this issue repeatedly since this Thirty-second Dáil was convened a short period ago. I speak as somebody who knows the hospital intimately. I was the hospital administrator for 21 years. I have been a patient there, my family members have been patients there and I am in the hospital on a regular basis. Only yesterday, I was there as a director of the Friends of South Tipperary General Hospital, which is planning fund-raising efforts to support the hospital.

Today's HIQA report confirms what we have known for some time. South Tipperary General Hospital is a very progressive and successful hospital. It is working well in excess of capacity but it is under-resourced, underfunded and understaffed. To use a colloquialism, the hospital is bursting at its seams. Staff are working above and beyond the call of duty on a daily basis and, indeed, on hourly basis. The hospital is working at about 120% capacity on a daily basis and the medical department, which has 79 beds, is working at somewhere in the region of 150% capacity. That is when 85% capacity would be accepted as full occupancy. Inpatient and outpatient attendances have increase beyond all expectations. There are huge difficulties in the accident and emergency department. The trolley count at the hospital increases all the time. The trolley count for 2011 was 750 but the trolley count now is well in excess of 3,000 and over the last period, on no fewer than five occasions, the hospital has had the highest number of patients on trolleys. I have met patients and have seen patients who were accommodated in the foyer of the hospital near the vending machines, the lifts and the cafe and it was shocking. I have to accept what HIQA has said on that issue but it arises because of underfunding and under-resourcing of the hospital.

South Tipperary General Hospital, effectively, is a regional hospital but it is operating on a completely underfunded and under-resourced basis. The background to that is that about 25% of the budget, approximately €12 million, has been taken out of the budget on an annual basis over the past number of years and we have lost well over 100 staff during that period. We need urgent and immediate action to ensure a quality hospital service for the people of Tipperary. A number of steps need to be taken, both in the short term and in the long term. We need the immediate opening of step-down beds, beds we were promised three years ago. Our Lady's Hospital, Cashel, which is located fewer than 15 miles down the road from this hospital, is a modern hospital, properly refurbished following millions of euro having been spent on it, but its door is locked. That hospital should be opened and beds in it should be made available to support South Tipperary General Hospital. We need additional nursing and support staff at the hospital and we need full-time community intervention teams. We need to put back into the system the help hours that were taken out it during the past number of years. Two million home help hours were taken out of the system during that period, and that is unacceptable. A scanning unit is currently under construction. The first floor of that unit is a shell. We need the Minister and the Department to fund turning that shell into a modern ward with additional beds for the hospital. In the long-term, we need the commencement of the development of phase two the hospital, the modernisation of the old hospital area and the putting in place of proper hospital structure to deliver health services and hospital services for 2016. I hope the Minister will take up my invitation to visit the hospital in the very near future.