Dáil debates

Thursday, 22 June 2017

Committee on the Future of Healthcare Report: Motion


5:50 pm

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I move:

That Dáil Éireann shall consider the Report of the Committee on the Future of Healthcare, entitled ‘Sláintecare Report’, copies of which were laid before Dáil Éireann on 30th May, 2017.

In last year’s general election, health care was the No. 1 issue of concern for the public. This was hardly surprising when one considers the huge level of unmet need, with over 600,000 people on waiting lists for hospital services, hundreds of thousands on waiting lists for community services such as speech and language therapy and physiotherapy, and great difficulties for many in accessing mental health services, home care and disability services. There is no doubt that the political system has failed the people in one of the most basic and essential public services, namely, health care.

Unlike most other developed countries, we in Ireland have never sought to identify the most appropriate model of health care for the Irish people. A very disjointed, inefficient and inequitable system has evolved over the years which fails to adequately meet the needs of the people. Ireland is an outlier in terms of our two-tier health system. In no other European country are so many people denied access to services or forced into private health insurance. On the one hand, almost 40% have eligibility for free health care. This is eligibility rather than entitlement and is merely theoretical as many of the services either do not exist or are hopelessly inadequate. On the other hand, some 45% of the population feel they have no choice but to take out expensive private health insurance that rises every year, yet the level of cover provided fails to meet the cost of many essential services.

All service users are faced with significant out-of-pocket expenses that have risen significantly in recent years, often to a catastrophic level at which many are denied access to care. In the Irish context, the inverse care law clearly applies. Those most in need of care are least likely to receive it. This point was very strongly emphasised and graphically displayed to the committee by a group of GPs working in disadvantaged areas known as "Doctors at the Deep End".

Our health service is very much dominated by vested interests. Going back as far as the mother and child scheme of the 1950s, proper public health services have been blocked by those who see health care as a commodity from which to gain profits. The reality is that the weaker the public system, the more the private system benefits. The reverse also applies. The better the public health system, the less opportunity there is for profiteering. As a result, too often attempts to reform our dysfunctional system have been stymied by those who care little about equity and put private interests ahead of the public interest. When we hear public commentary on the health service, including some of the negative responses to this report, it is always wise to ask cui bono- who benefits? Are these people more concerned with their own commercial interests rather than the public good? At a political level and often at official level, vested interests have held too much sway. Too often, the ministerial approach has been to juggle these vested interests and thereby maintain the status quo. This has happened at the expense of the patient.

The interregnum last year provided an opportunity for the Dáil to take a new approach. Some 89 members signed up to a Dáil motion calling for an all-party consensus. Shortly afterwards, the Minister and Government came on board and the result was a unanimous decision of the Dáil to establish the Committee on the Future of Healthcare. The Dáil motion set the terms of reference for the committee. These had three key aims. They were to seek political consensus on a ten-year strategy for the health service, to plan for the introduction of a universal single-tier health service based on need rather than ability to pay and to re-orientate the health service away from our hospital-centric model so the vast bulk of care is provided at primary and social care level. Fundamental to these objectives was an acceptance that we need to stop making a political football out of health and reach a consensus on how our health service should be designed and structured in order to put the needs of patients first.

From the outset, we decided that our approach would have a number of elements. We were determined that our work would be evidence-based. We said it was a priority to listen to service users and staff. We took expert advice, most notably from the Centre for Health Policy and Management at Trinity College Dublin, which worked very closely with us and guided us in developing our report. We learned from best practice in other countries and took advice from people like Allyson Pollock and Dr. Josep Figueras of the OECD. We held expert-led workshops and agreed on a set of values and eight principles which would underpin our work. They are creating a modern, responsive and integrated public health system comparable to other European countries through building long-term public and political confidence in the delivery and implementation of this plan; all care planned and provided so that the patient is paramount ensuring appropriate care pathways and seamless transition backed up by full patient record and information; timely access to all health and social care according to medical need; care provided free at point of delivery based entirely on clinical need; patients accessing care at most appropriate and cost-effective service level with a strong emphasis on prevention and public health; a health service workforce that is appropriate, accountable, flexible, well-resourced, supported and valued; only spending public money in the public interest or for the public good ensuring value for money, integration, oversight, accountability and correct incentives; and the centrality of accountability, effective organisational alignment and good governance to the organisation and functioning of the health system.

The areas which we prioritised became the key chapters of our report. They are population health profile, entitlements and access, integrated care, funding and implementation. We have called our proposals Sláintecare. The key elements are a new general health card, cárta sláinte, entitling everyone to a broad range of treatments and medicines at low cost or for free, which will reduce out-of-pocket expenses for all; waiting time guarantees of 12 weeks for an inpatient procedure, ten weeks for an outpatient appointment and ten days for a diagnostic test, all of which are to be underpinned by legislation; delivery of at least 70% of peoples' health care services locally in their community, including chronic illness management, diagnostic services and minor injury care; more investment in preventative public health and the promotion of healthy lifestyles, mental well-being and early detection and management of chronic illness; and the phased elimination of private care from public hospitals. Everyone will be entitled to access public care in public hospitals. Those who have private health insurance will still be able to purchase care from private health care providers but there will be no subsidisation of that. Other key elements of the plan include significant up-front and ongoing year-on-year investment rising to €2.8 billion over a ten-year period and a transitional fund of €3 billion to support investment across the health system in areas such as infrastructure, e-health and expansion of training capacity and the settling up of a Sláinte implementation office under the auspices of An Taoiseach to develop a detailed implementation plan for the reform programme.

On the question of funding, we very much recognise that Ireland already spends a lot on health relative to other countries but it is clear that the manner in which that money is being spent means we get very poor value for money and unsatisfactory health outcomes. Our approach has been to recommend spending in order to save where there will be significant saving for individuals and families in terms of out-of-pocket expenses, where the need for private health insurance will decrease, where we move to a much lower cost model of care and where this is facilitated by a full e-health programme.

We urge the Government to endorse the detailed and costed approach set out by the committee in Sláintecare. This is not a menu of options from which to pick and choose. It is a comprehensive strategy whose elements are inter-related and interdependent.

As a result, I am concerned about the mixed messages coming from the Government in respect of its response. While the Minister is sounding positive, the Government Press Office seems to be briefing negatively. A report in The Irish Timeson Monday went as far as to say that the Minister has signalled his intention to implement the future of health care report only partially and that he will tell the Dáil that he welcomes those elements which are consistent with Government policy. I also know that there was similar negative briefing of journalists after Tuesday's Cabinet meeting. I sincerely hope this is not what the Minister is going to say and I hope it does not represent his views because to do so would be to fly in the face of the hard-won political consensus on which Sláintecare is built.

I take this opportunity to thank all members of the committee for their engagement in this process over the past 11 months. It was demanding and time consuming and involved a lot of meetings and much reading between meetings. We were all challenged to find workable solutions. I believe all members approached the task with an earnest desire to fulfill the remit which they had been given by the Dáil and to draft a strategy to ensure that their constituents and all people in Ireland would be provided with a modern, equitable and efficient public health care system.

I also thank the secretariat here in the Oireachtas, which provided important support and backup and worked to challenging and tight deadlines. The committee was particularly fortunate in being able to engage the expertise of the team from the Trinity College Dublin centre for health policy and management, under the leadership of Dr. Stephen Thomas. Its wide-ranging expertise and guidance was invaluable to the work of the committee. I also thank the Minister for Health, the Department of Health and the HSE for their support during the process, and for the data and responses which they were able to provide for the many queries which we raised.

The Sláintecare plan will deliver for Ireland the sort of fair, affordable and effective public health system that we desperately need and deserve, and which most of our European neighbours enjoy. This is the first time there has ever been cross-party consensus on how to deliver a modern universal health care system that meets the needs of all people based on their medical needs, not on their economic status. Sláintecare is a realistic and achievable plan. It is about investing now in those key elements of the health care system in order to bring about better results and to save on funding later. It has been costed by health experts and has strong support among many patient groups and medical practitioners.

What we now need is a Government commitment to implement this plan in its entirety. We cannot continue with our broken health system where patients are dying on waiting lists, where many people's lives are limited by the lack of availability of much-needed services, and where families are impoverished because they have had to bear the costs of services that should be available free of charge in a modern, fully-developed country.

This is an historic opportunity to introduce a high-quality public health service for everyone in Ireland. We will not be forgiven if we allow this opportunity to pass.

6:10 pm

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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I thank Deputy Shortall for her contribution to this debate. She has once again spoken with passion and determination in pursuit of better health services for the citizens of our country, and I would also like to state that her contribution as Chair of this committee has been enormous, and I acknowledge that today.

I also commend all members of the committee, from all political parties and none, for the time and effort they have dedicated to this process. There are many people, both in this House and outside, who remain sceptical about the political make-up of the current Dáil and about what we can achieve together. The way this committee went about its business, and the near unanimity in support for its report, provides a solid rebuttal to those critics. Members engaged in an open, respectful and positive approach to discussions, and understood the prize of achieving a consensus position for patients and for all citizens. It behoves us all to continue in this spirit, and to do our utmost to act on the vision and the strategic direction set out by the committee in the Sláintecare report.

I will not dwell for long on the challenges facing our health system. They have been recounted here and elsewhere with increasing frustration in recent years. We have a fractured system, an outdated model of care that is unfit for purpose, chronic access issues, and growing sustainability concerns as we face into a period of significant population ageing. These problems have persisted for some years now, and have unfortunately led to a real lack of public confidence in elements of our health service, particularly relating to the issue of access. That is not to say that there are not positives. Health outcomes continue to improve, and services are continuously adapting to provide more effective care. Every day, people in this country experience excellent care at the hands of extremely dedicated and qualified health care professionals.

Over the last year, I have had the opportunity to visit health care facilities right across this country. I know the difficult working conditions that people face. I have seen first-hand the commitment and professionalism of staff and management that underpin our services, and most importantly, I understand the genuine hope and ambition that still exists across the system, despite the bad days, to deliver health services that we can all be proud of. The committee's report demonstrates that this hope and ambition is shared in Leinster House.

I have no doubt that the publication of the Sláintecare report will come to mark a critical milestone in the history of our health service, and can provide us with the solid framework and guidance for health services development over the next decade. It is clear in its resolve that considerable change and transformation are required. I fully agree with this. The former US President, Bill Clinton, said "The price of doing the same old thing is far higher than the price of change."

The report sets out a clear set of principles developed through political consensus. We should not overlook the importance of these eight fundamental principals outlined by Deputy Shortall. It is not possible to map out in advance all of the decisions that will be required over the next ten years. Some specific details may inevitably need to be revisited based on experience, as Deputy Shortall said about implementing any plan. However, the principles set out in the report provide a basis for getting the important calls right throughout the implementation process. They also provide clarity in challenging resistance based upon vested interest.

I also believe that the ten-year timeframe is a key strength of the report, which needs to be viewed in that prism. In some of the commentary I have heard on this report, people have talked about it as if it all needs to be implemented right this moment. It is a ten-year plan. We need to be realistic about the timelines required to plan and implement large-scale system change in services as important as health care. It may be possible to make ad hocchanges over shorter timeframes, but it is not realistic to introduce meaningful changes on a sustainable basis without proper planning, the building of support, clear accountability for implementation, and the monitoring and evaluation of outcomes.

The report strongly advocates for a new model of integrated care, centred on comprehensive primary and community care services. We all know that this must be the direction to travel. Our hospital system simply will not cope with the likely levels of demand in the coming years if we continue with our current model of care. More importantly, health outcomes and patient experience can be much improved by developing greater services in the community and by bringing about deeper and more seamless integration across the health and social care system, as set out in the Sláintecare report.

Proposals to develop capacity in both HSE primary care services and in contractor-provided services such as general practitioner and community pharmacy services, increased provision of diagnostic capacity, a greater role in the management of chronic conditions, and measures to support GP practice in rural and deprived urban areas, all dovetail well with actions set out in the programme for Government, and will be fundamental to supporting the desired shift to primary care.

A range of enablers and initiatives supporting integrated care are also given strong endorsement in the report, including the Healthy Ireland strategy, eHealth, integrated workforce planning, clinical governance, enhanced community nursing, integrated care programmes, and current strategies in the areas of maternity care and mental health. The support for these initiatives can add greater impetus to their successful delivery.

I will pick eHealth as an example. Just as in all sectors of society, the role of information technology in health cannot be overstated. We simply cannot achieve the responsive, integrated, effective system that we all desire without significant investment in information systems. We can all agree that we were coming from a particularly low base when the eHealth strategy was first put in place. This is a prime example of a challenge that, at the time, may have seemed too daunting to even contemplate with regard to systemic change. Now we can begin to see what can be achieved when a clear strategy is put in place and an effective implementation plan and roadmap is defined.

I will also single out the committee's conclusion that our health structures are in need of change. I spoke on this issue in my appearance before the committee. While I do not believe that structural change will be the panacea for improvement in our health services - far from it - I firmly believe that our current structure is not serving patients or staff in our health service in the best way.

I welcome the fundamentals set out by the committee that should underpin structural reorganisation, including the re-establishment of a HSE board, and the reconfiguration of the HSE to involve a leaner national agency, retaining national level functions complemented by a more devolved, responsive and integrated entity at regional level. I intend to move ahead with the establishment of a HSE board, and will publish the necessary legislation this year.

As we evolve our structures, our overriding ambition should be for policy, entitlements and standards to be set nationally, but for these to be delivered locally to the greatest extent possible. We need to bring decision-making closer to the point of care delivery, and provide a counterweight to the unnecessary over-centralisation which impedes service responsiveness.

6 o’clock

The report is also clear in its call for the establishment of a universal single-tier system where access to care is on the basis of need and not ability to pay. Let me be clear, that is a view I share and it is a view that my party has also endorsed in terms of both the terms of reference and the work of our members on the committee. Of course, this is in accordance with the terms of reference for the committee. To deliver on this aim, two fundamental policy changes are proposed by the committee: (1) the introduction of universal entitlement to healthcare services underpinned in legislation, and at no or at low cost; and (2) the removal of private activity from public hospitals. These are fundamental changes. There is currently an inherent unfairness in our system when it comes to accessing care. Ability to pay does have an influence today on access, and for many, accessing care comes at too high a price. This needs to be addressed.

The committee's report represents a very important step in the reform of our health services. It provides us with a vision and strategic direction that parties, and indeed Independents, across the House have signed up to.

However, it is only a first step. As recognised by the committee report, "mechanisms for implementation are as important as the report's recommendations". It is appropriate that we now allow time to reflect and deliberate on the findings of the committee and consider how best the vision and spirit of the report can be realised. I understand the desire of many to move quickly on the recommendations and to demonstrate real momentum and this is a desire that I share, but we need to balance this with the potential consequences of rushed or incomplete implementation plans. It is critical that we get this right. I agree with the need for a whole-of-Government approach and the role of the Department of the Taoiseach and the Taoiseach as outlined in the report, but I also need to balance that with the responsibilities that I have, as Minister for Health, and indeed that future holders of this office will have, in terms of our own duties to the House, to the Oireachtas, to the Cabinet and indeed under the Ministers and Secretaries Acts, but I believe we can tease that through, as I have already discussed with many members of the committee.

As Minister, it is my duty to consider the challenges we are likely to face in delivering the scale of reform envisaged in the report. At the outset, I would like to stress that I consider these as challenges with solutions, as opposed to immovable barriers, but they require consideration.

The first obvious challenge, and one that is recognised throughout the report in fairness to the report, is that of current capacity. To be blunt, out starting point is not good. Since taking up the position of Minister over a year ago, I have been clear that we need more capacity, both physical and staffing. This is a problem that is being experienced right across the health service and it is one that will not be remedied overnight.

A capacity review is under way which will report later in the year. It will give us a definitive assessment of capacity requirements across the system and will provide a platform for planning and delivering health services in the years ahead. There is also a concerted effort under way to recruit and retain staff. By the way, I believe this report, in having a ten year plan, helps in that aim to recruit and retain staff in the Irish health service. Recruitment and retention is not without its challenges but the development of a more attractive working environment will go hand in hand with the roll-out of system improvements.

However, we must be realistic about our current capacity situation when we are considering timeframes for delivering on the report's ambitions. It will take time to put in place infrastructure and a pipeline of trained healthcare professionals. Entitlement expansion and waiting list guarantees will be meaningless unless we match them with increased capacity - that is something on which we can all agree. It will be important to introduce sufficient increase in the supply of healthcare as we stimulate demand and utilisation through changes in entitlement or charging if we are to avoid exacerbating access issues for those most in need or reducing quality for everyone. We should also introduce changes in entitlement on a phased basis so that we can monitor and address the impact. We also need to be conscious of the ever evolving economic and fiscal environment and the range of demands across all public services for funding increases. It is a point we all agree on. Whilst the report provides costings, I doubt there is a political consensus on funding. I am sure that will be an issue that we will debate on many an occasion in this House.

In saying all that, I do not want to concentrate solutions overly on capacity increases. We are all agreed that additional capacity and extra funding cannot be the only answer. Fundamental changes in our model of care, as I mentioned earlier, must be a central plank of long-term reform plans. The report also points to fundamental policy changes in entitlements and in the mix of public and private activity within our hospital system and in GP services. We are all aware of the realities in delivering reform in these areas. This process will require more than will and leadership from within the political sphere. It demands leadership and flexibility across the health service and within the health professions, and I appeal to all health professionals in that regard. Changes in contracts will not be easily achieved and this cannot be at any price to the taxpayer. It would be naive to consider that there will not be resistance to change in these and other areas. The Chairman acknowledged that when she referenced vested interests.

Successive Governments have long advocated for a shift towards primary care. It is something upon which there has been genuine broad agreement for some time but we must ask ourselves why it has not been successfully delivered to date and what measures can be taken to realise and capitalise fully on the potential primary care has to offer. These will be important considerations for implementation. To achieve integrated care requires much more flexible, organisational and professional practices than has been the norm to date.

The report quite rightly addresses the learning from the reorganisation of our cancer services but the reform of hospital services in cancer and other areas based upon quality and sustainability considerations has not always won support locally or in the House. There is a duty on every Member of this House to acknowledge - I include my party in this - that when it has come to reforming health services and when it has come to making changes everyone is in favour of it until it is in his or her own constituency. The committee rightly references in the Sláintecare report the success in relation to cancer services but reform of hospital services involves all of us making decisions on the basis of quality clinical advice and sustainability, not on the basis of political point scoring. I hope we can build upon the political consensus achieved in this report when it comes to addressing these and other difficult issues in health over the next decade.

In pointing to these challenges, I do not intend to be defeatist - far from it. I firmly believe that the time is opportune to deliver the kind of change that we all know is needed and that is indicated and outlined in the Sláintecare report. We now have a cross-party report which enjoys widespread political, and I would suggest widespread societal, support. There is a desire evident at all levels, both within the political system and across the health service, to work together to deliver lasting improvements in our health services.

This is a desire shared by the Government. The Taoiseach was very clear in his speech to this Chamber last week that delivering real improvements in our health services is a key priority of this Government. He has tasked me with preparing a detailed response to the report, including proposed measures and timelines. It is my intention now to discharge my duties as Minister for Health in that regard following this Dáil debate. I hope to bring forward not just proposals as to how we might gear up for implementation taking account of existing statutory responsibilities, but also some immediate decisions that we might be able to proceed to implement to show momentum.

I have already had the opportunity to hear initial views from some Members of the Oireachtas and from various stakeholders, and I look forward to hearing contributions from across the House today. Following this, I hope to bring detailed analysis and proposals to Government.

I remain positive that we can make a real difference to the lives of individual patients and the health system as a whole and I have no doubt that this report will be an essential reference point for all Governments and parties in the fundamental reform of our health services over the next decade.

6:20 pm

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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Fianna Fáil was part of the cross-party Oireachtas Committee on the Future of Healthcare and believes it provides a pathway on how the health services should be delivered. However, it needs substantial investment and will also require a large number of reform measures to be delivered. There is an obvious need to build capacity in our health services to meet both current and future demands and Fianna Fáil is committed to working to achieving this.

We fully support building up our public health system, funded primarily by general taxation. We acknowledge that the proposals in the report are ambitious and exceptionally challenging. The committee recommends investment in the region of €2.8 billion over ten years and states that to implement system change, there is a need for additional once-off transitional funding estimated at €3 billion. It is quite a challenge in terms of both the required reforms and the funding necessary to ensure we have a health service that can deliver care to the people when they need it.

On background, in June 2016, the Dáil established the Committee on the Future of Healthcare with the goal of achieving cross-party, political agreement on the future direction of the health service, and devising a ten year plan for reform. Specifically, the committee was to devise cross-party agreement on a single long-term vision for health care and direction of health policy in Ireland.

The terms of reference explicitly recognised the severe pressures on the Irish health service, the unacceptable waiting times that arise for public patients and the poor outcomes relative to cost; the need for consensus at political level on the health service funding model based on population health needs; the need to establish a universal single tier service where patients are treated on the basis of health need rather than ability to pay; that to maintain health and well-being and build a better health service we need to examine some of the operating assumptions on which health policy and health services are based; that the best health outcomes and value for money can be achieved by re-orientating the model of care towards primary and community care where the majority of people's health needs can be met locally; and the Oireachtas intention to develop and adopt a ten year plan for our health services, based on political consensus, that can deliver these changes.

The report recognises that the Irish health service as it stands is not providing the population with fair or equitable medical care and that our health services do not have the bed capacity to provide timely, urgent and planned care. The report emphasises the need to move decisively towards equitable access to a high-quality universal single-tier system. The Chair of the committee, Deputy Róisín Shortall, referred to the eight fundamental principles on which the committee deliberated to reach broad consensus. I wish to put on record my appreciation to the Chair, all the members, the staff of the committee and to those from outside the Houses of the Oireachtas who made presentations and oral and written submissions. This process was critical in engaging with the stakeholders.

We went through a journey over the past year. While we might have believed we knew a great deal about health services and health care, we learned that it is complex. There is considerable interdependence on the various specialties and professions within health care. Certainly, the fact there will be major challenges was exposed in the context of the change that is required, including legislative change and structural change, as well as in the context of funding.

Reference has been made to whether the costings in this report were accurate. I wish to put on record that I believe the costings in the report are as accurate as they could be in the context of what we are undertaking over the next ten years.

There are certain issues we have to accept. The demographic is changing rapidly and fundamentally in front of our eyes. That is something that collectively, as a society, Parliament and Government, we have to take on board quickly. While this report highlights the challenges over the horizon, this is something we have to address collectively in the context of the cost of health care and in respect of the question of pension provision. Both areas will put extraordinary strain on resources. We have improving life expectancy. We have better health outcomes. We are living longer. The complexities that are provided in the context of treatment and services in health care are continually improving, but all this comes with additional costs.

All these issues have to be taken into account when we try to implement the report. We need to ensure that, while we strive to go for universality, we do not go for universality of average outcomes. Universality must not mean diminishing returns. We need universality and excellence at the same time. I am concerned that if we do not commit the resources to this health care report and its recommendations, we will diminish the standards available to people in trying to roll out universality. There is need to provide the resourcing along with the structural changes and the legislative underpinning of same to ensure that does not arise.

Let us consider the broad issues in terms of health care. The report highlights that we have an unusual system in the context of the interdependence and intertwining of public and private health care. The report makes a recommendation to the effect that there is need for us to unwind private health care from the public health system over a period of years. The report also acknowledges that this change will be complex and difficult. The Minister referred to contractual arrangements and loss of income to the public system. However, if we are to enhance capacity in the public system, then a good start would be to start to unwind from the public health system the demands that the private system is currently taking up.

Private patients, by and large, should be treated in private health care facilities, as one might expect. Public patients and people who wish to go publicly should have an entitlement to know that there will be a bed for them as well as provision of treatment in a timely and accessible fashion. Unfortunately, that is not the case.

Reference was made to the fact we are starting from a poor base in the context of the capacity we have in our public health system, not only in hospitals but throughout the primary and community care systems as well as capacity for supports in the home as well. There is no doubt this challenge, regardless of the other areas of this report and the associated recommendations, is going to put extraordinary strain and drain on our public finances to fund same.

The Chair of the committee referred to how we spend a large sum of money in the provision of health care in this country. There is no point in pretending otherwise. We are going to have to commit additional resourcing in the coming years for several reasons. This is because we are coming from a low base in the context of our infrastructural capacity and bed capacity. Another reason is because of the changes in our demographic profile and the challenges that will come from same as well. These two things have to be addressed quickly.

The Minister referenced the bed capacity review. I look forward to that report. I have said previously that it should be independent, and I hope it will be. The last thing we need is to start basing assumptions and assessments on reports that are not fully independent or verifiable in that context. This is a critical part of the implementation plan. If we deny the challenges that exist, we will simply try continually to force more people into a system that simply cannot and will not be able to provide health care.

Almost 50% of the population have private health care in some form or another at the moment. I have said as much numerous times in the House, and commentators outside the House have said it as well. There is no doubt that if this 50% did not have private health care, our public health system would simply implode. It would not be able to cater for the demand placed on it if there were no private health care facilities providing health care to people with private health insurance. The reason many people have private health insurance is not because they want a nice room on their own but because of the fear they will not be able to access timely diagnosis or intervention when they require it. Often, the motivation for taking out private health care is based on fear that the public health system simply cannot or would not be able to accommodate their medical needs in a timely fashion. That is undermining and sapping the confidence people have in the public health system.

I urge for the report and the implementation plans to be taken on board and seriously assessed. We should have continual and incremental assessment of where we are in terms of the implementation of the report and the resources required in the short, medium and longer term to ensure the report is implemented in full over a ten-year timeframe.

Reference has been made to consideration of the plan. Many commentators asked whether it can be delivered next week or next month. The report is clear on the timeframes. We have referred to decisions to be made in years one, two, three and four right out to the final horizon of the ten-year plan.

I hope the broad political consensus arrived at in the committee will spread further afield into this Chamber and into various Governments that will take up office in the years ahead to ensure this report is implemented and to ensure the public will get a public health system of which we can all be proud.

6:30 pm

Photo of Mick BarryMick Barry (Cork North Central, Solidarity)
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I served as a member of the Committee on the Future of Healthcare over the course of the past year. I thank the Chair of the committee and the secretariat for their work. I agree that the Trinity team are worthy of special mention. In particular, I thank all the groups and individuals who engaged with the committee either in writing or by attending meetings. There were many of them.

There were 14 members of the Committee on the Future of Healthcare. I did not sign the final report. Mine was the sole dissenting voice and, in the course of my remarks, I will explain why.

However, I want to start by making some points about the positive proposals included in the report. There are three proposals I wish to single out and mention. The first is the proposal that there would be free general practitioner care for all by 2023. The idea is not that, five or six years down the road, this would simply appear. The idea is that it would be built towards 250,000 people gaining access to free general practitioner care year on year, starting with those without medical cards who are on the lowest incomes.

I would like to see a shorter timeframe but I am not going to make a huge point about that here. That is a very positive proposal which we will be supporting strongly.

The proposal to legislate for maximum waiting times of 12 weeks for inpatient procedures, ten weeks for outpatient appointments and ten days for diagnostic tests is very progressive and many in society will be watching carefully to see that it is implemented. The proposal to remove private health care from public hospitals by the year 2024 is significant and important. While I would like to see it happen more quickly, the important issue for today is that it happens. We will be watching that one very carefully.

I share Deputy Shortall's concern at the comments attributed to the Minister, Deputy Harris, in the newspapers the other day about implementing those sections of the report that are consistent with Government policy. It strikes me that it is counter to the idea of establishing such a committee in the first place and has the potential to gut the report of many of its positive recommendations.

6:40 pm

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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Did the Deputy not hear what I have just said?

Photo of Mick BarryMick Barry (Cork North Central, Solidarity)
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Members of his party signed up to the report and if the Government does not implement it, groups campaigning on the issues in society will take the matter up and apply pressure.

I support the idea of an Irish national health service, the cornerstones of which would be public ownership of the hospitals and primary care centres, free at the point of use and funded from a steeply progressive tax system. I believe that the committee has missed a golden opportunity to advocate for such a system. What is the difference between this and the proposals before us? I do not have time to go into them all but will highlight a few key points. On the question of charging, the World Health Organization is unequivocal that the complete removal of all charging is the best way to deliver universal health care based on need rather than ability to pay. In its world health report 2010, Health systems financing: The path to universal coverage, it states that one of the reasons direct payment is unsuitable to the delivery and consumption of health care is that it inhibits access. This is especially true for poorer people who must often choose between paying for health and paying for other necessities such as food or rent.

It is true that the Sláintecare report advocates the abolition of some charges such as overnight hospital charges and general practitioner charges over a period of five to six years. However, it is not consistent and does not advocate for this across the board. It advocates maintaining the €100 charge for emergency departments for a full eight years and, crucially, recommends that drug payments currently set at €144 per month, so that the patient pays the first €144, be reduced to €100 but then maintained at that rate indefinitely. That is poor. Overall, the report allows for €437 million in charge reductions by the year 2028. In fact, that is actually less than 15% of the €3 billion spent by Irish people on out-of-pocket health expenses in the year 2014 alone.

The report also advocates achieving public health care goals through a very high reliance on for-profit market mechanisms. The proposed shift from acute hospital care to primary care in the communities is based around three pillars, namely, pharmacists - sole traders; general practitioners - also sole traders, although there is a proposal for salaried general practitioners which is not given sufficient emphasis, and new primary health care centres to be built by public-private partnerships on a for-profit basis. That is actually the most expensive way to build such centres. In 2001 there was a ratio of 80:20 between public and private nursing homes. Today that ratio has reversed completely to 20% public and 80% private, largely as a result of the tax incentives offered by right wing governments. The result is that nursing home care in the State is controlled by those who prioritise the maximisation of profit over the care of the elderly, and rely on a workforce which is in significant measure comprised of low-paid women workers and immigrant labour. Government policy is for 9,000 new nursing home places in the years ahead, 7,000 of which are to be privately provided and 2,000 publicly. The report does not challenge this. It expresses an aspiration for a certain change but refuses to back it up with concrete proposals. Some 9,000 publicly funded nursing home places would cost €360 million. No provision is made for that in the funding proposals. The same applies in respect of home help services.

We talk of integrated care, yet the Irish health system is divided up into silos. We have publicly owned HSE facilities, privately owned hospitals, section 38 facilities, many of which are church owned voluntary hospitals, and section 39 charitable facilities, with about 2,000 entities which in other countries would be covered by the health service. None of the non-HSE pillars could survive for any length of time without taxpayer and public support. This includes the private hospitals, which have benefitted from massive tax breaks and from colocation with the public hospitals that do the more difficult and less profitable work. The vast bulk of these entities should be taken into public ownership with compensation paid on the basis of proven need, so that all forces can be brought to the point of attack to benefit public health care.

That would involve, in part, the separation of church and State. The public is ready for that, as was shown by the controversy about the National Maternity Hospital. Those public hospitals should provide full IVF facilities, abortion facilities, and services for trans people such as gender reassignment and hormone therapy.

On the question of who pays, there is potential for enormous savings to households. In 2014, the average household in this State spent more than €5,000 in out-of-pocket expenses and private health insurance. There is potential for significant savings to the State by eliminating profiteering by the agencies that supply so many nurses to our hospitals and over-reliance on an insurance-based system with unnecessary administrative costs, competitive advertising and so on. Of course there would be a need for extra money and investment to implement a national health service of that kind. I can see no better way for the Apple €13 billion or €19 billion, whichever figure one chooses, could be spent.

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Thank you, Deputy.

Photo of Mick BarryMick Barry (Cork North Central, Solidarity)
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I will conclude on this sentence. Between 50% and 70% of multinational corporations are paying no corporation tax. There needs to be serious corporation tax and we need a steeply progressive tax system so that it is not ordinary working families and the middle class who pay, but those who can well afford to do so.

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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That was a very long sentence.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I will be sharing time with my colleague, Teachta Nolan. I thank the chair of the committee, Deputy Shortall, for driving the report. It cannot have been easy to achieve cross-party consensus on an issue as contentious as health. I would also like to acknowledge the work done by the secretariat - Ronan Murphy, Celeste O'Callaghan, Stephanie Bollard, Ronan McCabe, Denis McKenna, Claudia Zelli and Donal Smyth - and by the Trinity team for all the work and advice it gave us.

I am not sure they had an easy job but they made our job much easier with their assistance.

I am delighted this report has been published. I would have been even more delighted to hear a little more enthusiasm for it from the Minister. When he uses words such as "consider" and "reflect" in the context of the report that makes me think his approach may be to delay, postpone and have a think about its implementation.

It could be said that the Irish health service has been researched to death. We know what and where the problems are. We know we have a problem with capacity and yet we keep being told we must have a capacity review. The Minister does not need a capacity review to tell us there is a problem with capacity. He need only take a trip down to any of the accident and departments and have a chat with any person on a chair or a trolley and they will tell him, in no uncertain terms, that there is a capacity issue. He can see it for himself. The only way we will be able to address the capacity issue is by reopening the beds that were closed and by addressing the staffing shortages. To address those, as I have said on more than one occasion and the Minister will be aware of this, we need to create a workplace where our valued health professionals and health workers actually want to work. We need to say to them that we will create a decent workplace for them and that we want them to work in the Irish health service.

We in Sinn Féin want to see an Irish national health service where health care is available on the basis of need and not ability to pay. This report represents a very significant step in that direction. We in Sinn Féin are very pleased that we can see some, although not all, of our policies reflected in this report. It is a credit to members of the committee that we were able to put aside our political differences, in some instances, and consider good ideas, regardless of from where they came. Credit is due to the Chair of the committee in that regard.

When I was a young woman my father and I had a conversation about politics. I note the Ceann Comhairle is smiling. My father told me that everything we do is political. He said the water we drink is political and, indeed, it is in this country.

6:50 pm

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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We found that out.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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The air we breathe is political. I had thrown my eyes up to heaven because my father was talking about politics again and he said "Louise, everything is political". We cannot depoliticise health. We can say we want to but we cannot. The Minister described the position very well, and I do not want to put words into his mouth, but he said something along the lines that "if you want to go there, I would not start from here". We are not starting from a great place. The political choices of previous Governments are what has led us to be in this place. However, that said, we have an opportunity now to come together, put our shoulders to the wheel, set aside those political differences and get behind this report 100% rather than implementing it in a piecemeal manner, which is my concern.

I fully welcome the words of the Minister with regard to his support but I also noted a certain amount of equivocation, which is not what is needed. Rather we need a concerted effort to accept this report, and I say that coming from a party whose members believe this report could have gone an awful lot further. That said, we are prepared to do all within our power to ensure this report is implemented. There should not be a delay in its implementation or any waiting for the right time to do so. The health service is in a perpetual state of crisis. We read about it in the newspapers we hear about it in the media. Now is the time is be ambitious, to be bold, to take action and to get fully behind this report rather than try to implement it in a piecemeal manner.

Photo of Carol NolanCarol Nolan (Offaly, Sinn Fein)
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I am thankful for the opportunity to speak on this very important issue. Throughout the whole process of the development of this report, Sinn Féin has fought for an adequately resourced public health system that treats people on the basis of health need and not on their ability to pay. We fought to ensure that the future of the health care will be universal health care. I commend the hard work of my colleagues, Deputies Louise O'Reilly and Pat Buckley, who worked very hard on the committee to ensure that a number of progressive solutions were put forward in this report.

In particular, I welcome the fact that this report recognises the need to establish a universal single tier health service with treatment based on health need and not on ability to pay. I welcome the fact that it has been recognised that additional resources are required in order to reduce the waiting times and enhance community health facilities. I also welcome the fact that there is agreement to phase out private health care in public hospitals and introduce a carta sláinte, which would ensure access to all publicly funded health and social care services. These are just a few successes of this report. As my colleague said, Sinn Féin would like it to go much further.

Our policy proposals outlined in our plan for universal health care include the recruitment of an additional 6,600 front-line staff, the roll-out of free prescriptions and investment in our ambulance service. We would support older people through increases in home help hours, respite and providing additional nursing home beds. We would implement universal health care and deal with the trolley crisis. I am convinced that a Sinn Féin-led Government is the only one that will truly deliver the type of a health system that the citizens of this State so badly need, want and deserve.

However, we recognise that this report provides a good starting point in addressing the crisis in our health service. It is a crisis that the people of my constituency know only too well. The latest figures show that the outpatient waiting list in Tullamore hospital stands at 13,000 with over 2,500 people waiting more than 15 months for treatment. The full capacity protocol and emergency measure was activated in the hospital last year 230 times, and that was the third highest in the State. Meanwhile key posts remain vacant and front-line staff struggle to cope with the sheer scale of the crisis with which they are faced I take this opportunity to commend those front-line staff. It is unfair that they are being put in the position of having to deal with the crisis in which we have been landed. Only 57% of children and adult community mental health services recommended for the region under A Vision for Change have been put in place. The health service in Offaly just like the rest of this State is in an absolute shambles.

This report is only worthwhile and only worth the paper it is written on if it is implemented. It simply cannot be allowed to sit on a shelf and gather dust. I hope, rather than believe, that both Fianna Fáil and Fine Gael are serious about implementing the necessary recommendations of this report.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I would also like to echo my appreciation and thanks to the chairman of our committee, Deputy Róisín Shortall, who did an excellent job in keeping us all together and encouraging us throughout the 11 months the committee sat to draw up this report. I also thank the secretarial staff and those who helped us from Trinity College. They were essential in getting this report completed almost on time. We took a little longer than anticipated but, as the Minister will appreciate, it was a mammoth task.

We approached the report with pragmatic idealism. We understood this is a very complex and difficult task but we were idealistic in our outlook and we also realised the complexities of what needs to be done. We know the way things are but we want to see them how they should and could be. We have to see where this health service is at at the moment and why we need reform because the current system is not fit for purpose. It is fragmented, disjointed and incoherent. There are some areas of the health service that work very well and work to a high level of excellence but they also struggle like the other areas of the health service that are struggling for resources, capacity and staff.

It is quite obvious that our system is under severe stress when we see the ever increasing waiting lists for outpatient appointments, elective inpatient care and urgent inpatient care and waiting times in our accident and emergency departments.

An emergency department opened in Limerick hospital three weeks ago. It still has the same number of trolleys in the new department as it had in the old one. There was never any expectation that that would change. We need to look beyond a piecemeal solution to our health service. I understand that we cannot believe everything we read in the newspaper, but I was concerned to read that the Minister was looking at the elements of the report which complied with Government policy. I hope that is not the case because this report must be looked at in its entirety. As Deputy Shortall said, it is not a report from which one can pick and choose areas that comply with Government policy because Government policy is not working. If we were to comply with Government policy, we would get nowhere. The central part of this reform programme is integration. The report must be looked at and studied in its entirety, because one cannot integrate fragmented, piecemeal structures. Integration is a large chapter in this report and it is central to it, because unless the report is looked at and implemented in its entirety, then the integration component means nothing.

It is a roadmap and a blueprint. We are not saying it is a perfect report and it will have flaws. If each member had written the report on his or her own, he or she would have written a slightly different report, but it is a consensus report. It must be looked at in its entirety. When the health system is reformed in its entirety, sequenced and phased properly, and properly integrated, we will have a health service that is more efficient, much more effective and cost-effective. I agree that pouring money into our broken health system is not a good idea. This is a ten-year blueprint for our health service. It needs to be studied seriously by the Government. I hope the Minister will accept it, not necessarily every word of it, but the direction in which it is going, which is a universal, single-tier public health service delivered on medical priority need, not on the ability to pay. It is a short sentence but requires a complex reform programme by which it would be delivered. It must be looked at in that way.

Delaying reform is not an option. We are at a crossroads and we demand that this health reform begins. I am delighted the Minister has continued in his office because the lack of continuity in the health Ministry would have been disastrous for this report. He now has the opportunity to adopt reform during his tenure. Reform should be the word he looks to each morning when he wakes up, and he should ask himself how he can reform our health service. This is critical. It would be of great import if the Minister came out with the statement, "I intend to reform this health service, and I intend to start now." If the Minister made that statement, it would improve the morale of the staff within the health service and it would make people looking for health care positive that something was going to change. It would be important if the Minister could make a statement like that.

The Minister also needs to speak to front-line staff. I know he says he has visited almost every hospital in the country.

7:00 pm

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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Photo of Michael HartyMichael Harty (Clare, Independent)
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He should visit them in an unsanitised way. He should talk to front-line staff. Quite often, if there is a problem in a hospital, when one talks to the junior staff or the lady who works in the canteen, they can say what is happening in the hospital and, of course, higher management will have its own view. If one talks to people who experience things every day, one will get a far greater feel for our health service.

The CEO of the HSE, Tony O'Brien, has commented on the report. It is important to read it into the record. He says it is a once in a generation opportunity to reform our health service. He says our service is no longer fit for purpose and has outdated structures and practices. This report requires unprecedented co-operation, collaboration and integration, and "unprecedented" is the word. There must be a huge cultural change in how we look at our health services. There should be a political and a societal consensus that this needs to happen. That is very important, and an important part of this report is that there must be political buy-in at the highest level, at the level of the Taoiseach and at the level of the Minster for Health. It must be driven forward by very strong political buy-in. In concluding, Mr. O'Brien said there has to be a constructive debate, and I know that the Minister is going to start a constructive review of the report, but there must be a constructive debate on how this programme is implemented. It is a reform programme for the entire health service. The Minister must look at it as a whole programme rather than picking bits and pieces. It is the entire health service. It must be looked at globally. It is a single-tier, public service, delivered on priority need, not on the ability to pay.

One of its tenets is a shift from hospital-centred service to community and primary care-centred service. That is critically important. We have had a huge change in our demography and, as the Minister will understand, the hospital system cannot possibly cope with the amount of chronic illness that is developing as people get older and with the multiple co-morbidities that people develop in older age. We need generalists, GPs and public health nurses, and people on the front-line in the community to look after those people properly. Of course, we need specialised hospital services, but those should be allowed to work for complex cases and urgent cases that require hospitalisation. Our hospital services are overwhelmed by care which could be delivered in the community much more effectively with much better outcomes for patients. Community services are what people want. We need to shift away from everything being concentrated into hospitals and recognise that hospital care is under severe pressure, with a bed capacity issue. Why do we have trolley queues and an ever-lengthening waiting list? It is obvious. I know a bed review is under way but we must increase our hospital capacity.

Another major reform in this programme is to disentangle private care from public hospitals. Ireland is unique in Europe that our public system is dependent on private medicine to fund itself. Some €650 million comes into our public system annually from delivering private care in our public hospitals. That is a fundamental change which we must untangle. The delivery of private care in our public hospitals is an obstruction to reform. It provides perverse incentives for hospitals to maximise money from insurance companies and a perverse incentive to consultants to treat private patients and, in some cases, to prioritise them above public patients.

We need to reform our GP services. I have spoken to the Minister on this on many occasions. We need a new GP contract. General practice has been gutted by the financial emergency measures in the public interest, FEMPI. There was a 38% reduction in the money to run practices. That is not GP income. GPs are ageing. The average age of GPs in Europe is 57 years. In Ireland, 33% of GPs are over the age of 55 years. Unless these issues are addressed, one cannot transfer care from the hospital service to community service. We need a new GP contract. I have often told the Minister that the process of negotiating the GP contract is fundamentally flawed. He has entered into a series of negotiations with just one organisation. There are two organisations and it is fundamentally flawed if he continues in this way. If we are to transfer services from hospital to community, we need GPs, and unless there is an acceptable contract that cannot happen.

Photo of John McGuinnessJohn McGuinness (Carlow-Kilkenny, Fianna Fail)
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I congratulate the Minister on his reappointment. I also congratulate Deputy Shortall, who is passionate about the whole area of health, the committee and all those who contributed to its work, including those outside the House who made their professional services available. That this report has ended up being debated in the House is a first step in recognising that politics needs to be taken out of health. We need to have one single focus and support whoever is the Minister for Health in achieving the type of reform that is necessary. As such, a lot rests on the Minister's shoulders because he is the one receiving this report and he is the one who will have to action it. While others have said that the Minister should make a statement on his intent regarding the report, and that is true, the Minister will be judged by his actions. The sooner he can act and take a step in the direction of keeping this cross-political approach to the delivery of a better health system, so much the better.

Political agreement is hard to reach in this place. Going back to 1997 and the period when Mary Harney was the Minister for Health, it was clear then that if political agreement had been reached, and if some kind of political peace were established in the area of health, we might have made far greater progress with the money then being allocated to health. It is never too late to start, and we have something now. However, as good as the report is, many other reports - hundreds of them, I am sure - have been put in place by various Ministers for Health that have never been acted upon and never will be. I hope this report does not end up on the same shelf as all of those reports.

What should the Minister do to act on this report? The HSE is dysfunctional. It does not have the capacity or ability to fulfil any part of this report. The Department of Health washed its hands of health a long time ago and it creates that distance between the HSE and the Department of Health. The Minister is the one who must drive the reform and, therefore, is the one who must find the method to be put in place to manage this change. I remember previous health reform packages that were talked about publicly, and it was Eddie Molloy who said change managers within the HSE are required to drive change on the policy and direction to which the Minister refers. This is where previous policy failed badly. Therefore, there is a need for a cohort within the Department of Health or the HSE that will drive this necessary change, pick the quick wins we can have out of this report, implement them and show, by leadership, not only that we have a report covering the next ten years, but also that the Minister will have the managers of change in place to insist that all the pieces that are agreed upon and can be funded immediately happen. All of us in this House must agree on it, health professionals must agree on it and the trade union movement must contribute to changing the culture of resistance and bringing about the necessary change in co-operating with this House and the general health management to ensure we get the best deal for the patients we are all talking about.

I would start with that change management, and then I would take the simple things. I would look at the parliamentary questions put to the Minister for Health every day and at the number of them that deal with single patients and the desire to get services for them and to bring about better outcomes. There are hundreds of such questions every single day, but what do we get? The Minister answers the questions by stating, "If you do not hear from the HSE within 15 days, give us a shout." One does not hear from the HSE within 15 days and one may as well be shouting in the middle of Croke Park because nothing happens. As a result, people have lost faith in their politicians, in the ability to change the system and the ability to get the services when and where they are needed. The Minister must stop this. I would like to see him take full charge of the parliamentary questions system in this House. As real accountability is introduced, we will get outcomes to our parliamentary questions.

The Minister should tell the HSE to start by telling the truth at Committee of Public Accounts meetings and health hearings in this House. He should tell the HSE to acknowledge the wrongs early and stop the prolonged established legal practice within the HSE of fighting every single case, only to end up making an apology and giving out a heap of taxpayers' money. Billions of euro are being paid out on mistakes made within the HSE. I accept that mistakes will be made, but do we learn from those mistakes? Judging by the amount of money I see paid out from year to year, we do not. It is a colossal amount of money. How many people could be taken off trolleys if only that culture within the HSE were sorted? The HSE seems to think it is grand to do it because the taxpayer is paying for it. I ask the Minister to answer the parliamentary questions, deal honestly with committees and insist on taking responsibility for the HSE and change management.

Primary care is essential to all of this. It is the cornerstone on which our better health services will be built. Every single statement from Minister states that services will be conducted in the primary health care sector, but there is no money attached to that sector. General practitioners, GPs, are leaving this country in droves. One practice got in touch with me to tell me that a GP of 30 years said the health system is going down the tubes and GPs are having to face more work in an ever-depleting workforce. We are educating our GPs to export them. That is essentially what is happening. GPs are pressed to their limits to try to deliver the services they provide, not to mention the services we, as politicians, want to see the primary health care sector provide.

Psychiatric services are at crisis point. They do not have the professionals to deal with the issues with which they are being confronted. Only recently, the Union of Students in Ireland made a presentation to us on health services and access for their students who are under pressure. If one family wishes to access health services privately over a three-month period, cover with VHI costs €90,000. No one could afford it. As a result, the cost of cover by VHI and other private health care providers is going through the roof. There is no control and there is no transparency to it. There is a duplication of waiting lists.

Best practice in orthodontics and dentistry, for example, was highlighted. The two most prominent consultants in the country recommended change to all of this, but what happened? They were deemed to be the people out of step. They were the ones who were sanctioned in the Department and they are the ones who suffer to this day for wanting to provide a better service. They had a proven model that worked perfectly but it did not suit the HSE or the Department of Health and they ended up in poor health themselves. We have all been asked about Lyme disease and many other diseases, but nothing happens. Protests are held outside the gates, but nothing happens. Therefore, it falls to the Minister.

I wish to mention the case of the sarcoma specialist, which is just incredible. There were two applicants for the job. Seventeen people were on the interview board for two applicants, and the foremost person in the world who was in situdid not get the job. It is incredible. That is our health service. They do it their way just because they want to. The same goes for scoliosis. How many times has the Minister been asked about scoliosis? How many times has he been asked to change treatment for scoliosis? How many young people are suffering because of it? Between now and the change in this ten-year plan, the Minister needs to do something. He needs to make sure that those who are being paid huge money within the HSE to manage actually do so. People will say that if one gets into care, it is the best care one can get, yet there is an imbalance in who is employed by the HSE. There has been an imbalance in terms of the number of managers for years. The Minister must seek their co-operation to change that. In the context of this change, I ask that he implement some kind of management between now and the time he takes his first step in the process of this ten-year plan. I commend everyone associated with the report.

7:10 pm

Photo of Hildegarde NaughtonHildegarde Naughton (Galway West, Fine Gael)
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I wish to share time with Deputy Bernard Durkan.

I welcome this debate and the opportunity to discuss the report of the Committee on the Future of Healthcare, of which I was a member. I thank my fellow colleagues who sat on the committee as well as the committee secretariat, the Trinity team and, in particular, the Chairman, Deputy Róisín Shortall, who worked so diligently on the report.

There is nothing startling in this document. At its core, it emphasises a move away from the traditional hospital setting to a more community-based approach to the delivery of our health services. Inpatient hospitalisation is required for some medical conditions.

7 o’clock

However, community health care is appropriate for numerous conditions and it offers many benefits. Patients who do not need intensive medical care can receive care in their own homes from registered nurses, physical therapists, occupational therapists, social workers and allied professionals. Nurses perform tasks such as changing dressings, monitoring and administering medications, drawing blood samples for laboratory tests and educating patients and family members. Home health aides perform tasks such as assisting patients with personal hygiene, preparing meals and helping patients eat, checking vital signs and performing light housekeeping tasks, allowing patients to remain in their own homes with their families while receiving the help that they need.

If nothing else in this report was implemented, a properly resourced and efficient primary care structure throughout this country could transform our system for the better. It would mean elderly residents in nursing homes would not longer have to be admitted through accident and emergency departments to get intravenous antibiotics. It would mean elderly and ill people in our community having the most basic of treatments in, or close to, their homes. It would mean general practitioners having access to diagnostics and a range of services currently only provided in a hospital setting. If I could distil our report down into one sentence it would be: there are a large number of patients admitted to our acute hospitals who do not need to be there. Their needs can, and should be, met in the community. I thank the Minister, Deputy Harris, for his positive comments and his clear understanding of the report and the health care needs of the country.

The implementation of the report will require an injection of funds both in capital costs and ongoing expenditure into the future. The report requires significant expenditure annually and I look forward to the Department of Public Expenditure and Reform's costing of the proposals.

7:20 pm

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I thank Deputy Naughton for sharing time. This is an important report and I was happy to be a member of the committee. A tedious process had to be gone through but everybody agreed there was a serious need to overhaul the delivery, manner and methodology of our health services. Many experts gave opinions during the committee's hearings and I acknowledge their work and the work of the chairman, Deputy Shortall. She stayed with it and it would have been easy to give up and walk away. The views of the witnesses were hugely important because, in many cases, they presented the views of the people who had direct access to the requirement for the health services in one way or another. It is always important to take account of their views.

I agree with the report in general, while acknowledging it will be expensive to implement. However, it is important that the building blocks put in place to address this issue complement one other. We cannot afford to have an intervention that goes in a particular direction only to find that it does not work two or three years down the road meaning we have to go in another direction. That is how the health service has operated for several years. There are many deficiencies and I am a great believer in the notion that these can be identified mathematically in every area and remedied rather than using a broad-brush approach to secure as much funding as possible and throwing it at the system. That does not work. The report has highlighted the need to identify those deficiencies and to address them in a methodical and complementary way. The Minister may well have said initially that the report will be expensive to implement and we will not be able to do it all in one day. It will take a number of years but the critical issue is that whatever happens should remain in place for the duration and additional funding and operational changes should complement those interventions in a meaningful way.

It is about time we stopped kidding ourselves about where the deficiencies are and so on. They need to be identified. For example, we need to work out simply why there are waiting lists. This question was posed many times during the hearings. Various reasons were put forward, including nursing and consultant shortages and accommodation and capacity issues, as well as the ageing population, allegedly. At the same time, I note we have a relatively young population in comparison with other European countries. We have a much better youth profile than most of them. I do not buy into the notion that our ageing population is a serious issue coming down the tracks. While we have to address it, we do not have to do so to the extent that has been posited.

The committee discussed the dual system at length because it has dual costs and expenses. Ultimately, the public and private systems weaken each other and we would be better off with one or the other. The report recognises the purpose of the exercise is to provide a public health service that is accessible, dependable, modern, effective and efficient. If we do that, we will have done a great job. In addition, it must be recognised the current costs and the capital costs must go together. They are expensive and will require embellishment as time goes by. Deputy Kelleher mentioned the costs are as good as can be expected at this stage. No matter what one does, there will always be factors - events, as a famous man once said - which will affect the outcome.

The public will buy into something they believe is worth buying into. They will support something they believe will happen and to which they contribute through direct and indirect taxation. They will support it in the clear knowledge that by doing so, they will support their own interests. The private health system must be acknowledged and it does some good work. However, that cannot be done at the expense of the public system.

We must come to a juncture. It is somewhat like the housing issue in that we can spend as long as we like playing around with it on a day-by-day and year-by-year basis in a minuscule way but at the end of the day, we will all be dead before it will be addressed. It is important to identify the starting point and the initial shock that has to be experienced to clear the waiting lists and get the system moving. That is possible and that is provided for in the report, which is good. When we get to that stage, this report will have done a major service to the people of the country and the health services, in particular. By supporting the report and making it work, all political interests will have done a major service to society, to themselves and to the future development of the health services. We discussed the cost of medicines, hospital costs and so on but when people realise we are serious about we are doing, they will also make a contribution in every way through the different portfolios, which will be meaningful, effective and beneficial to all.

Photo of Pat BuckleyPat Buckley (Cork East, Sinn Fein)
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I wish to share time with Deputy Crowe. I welcome the opportunity to acknowledge the hard work and dedication of the committee members and to thank the Oireachtas Library and Research Service, the Trinity College team, the committee secretariat and all the witnesses, stakeholders and groups who gave evidence to the committee.

Of course, we must not forget the key driver in all of this, Deputy Róisín Shortall. It has been an amazing experience for a newly elected Deputy to be on such an intense committee. The Committee on the Future of Healthcare was unique. It was the first time we saw those of all political parties and of none coming together to set out a strategic plan and a vision so we can possibly have one of the best health services, and one which is not based on how much money anyone has in their pocket.

Several speakers mentioned accountability and responsibility. Deputy Shortall may have needed medical care at one stage as she was probably black and blue from listening to me mentioning accountability and responsibility, given it came up so many times. It is one of the things that has to be addressed within the whole system. It has always been one of my gripes and I want to put on record that it still is. Every time I hear an unnamed spokesperson for the HSE say that it cannot find someone who is responsible for something, it makes me certain that this area needs to be addressed.

With Sláintecare, we will have a single-tier health service which will be based on a person's need, not on the ability to pay. This is something Sinn Féin has been calling for a very long time. Like every plan, not everything in it is perfect but there are massive benefits. One of the important points is the removal of inpatient charges in public hospitals in the first year. Anything that improves out-of-pocket expenses for people is positive because these expenses are a fear. In the same way, it is due to fear that private health insurance is taken out by the majority of people who use it. I spoke to a gentleman in Midleton last week who, when we were discussing the overall health system, said he would pay €100 more a week if he was guaranteed a proper health service. That is a testament to the people out there. I admired the man for that - I wish I could afford €100 a week, but that is a different story. The dental treatment scheme, which provided a vital service but which was abolished a number of years ago, will be reinstated in the first year of the report. There are knock-on effects from that, for example, with regard to heart defects and so on. These are minor changes that make a huge difference to the system.

I could speak about many other reductions in charges. One Deputy said things could have been done better in regard to the reduction in prescription charges for medical card holders, but again it is a step in the right direction to reduce it from €2.50 to €1 by the third year. If we could get it all for free, we certainly would, but some things are not possible.

Another issue we touched on is the proposed expansion of primary care and the shift to community-based treatment, which is the bread and butter of the whole plan. I could talk about this for months but I am conscious I am sharing time with Deputy Crowe. Nonetheless, I want to touch on an issue which is very close to my heart. Strong proposals have been made in regard to mental health. Some €120 million would be required to finally deliver the promises in A Vision for Change and that would be accounted for over five years, and we can see the benefit of this.

This health care plan is nothing only benefit after benefit. I want to finish with a quote from Nye Bevan that is close to my heart. He said, "No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means". I want everybody to take that on board. This is what it is all about. This is for our children and grandchildren. Each and every one of us, across the political sphere, can be extremely proud of this achievement.

7:30 pm

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Like others, I commend the members of the committee. It is unprecedented what they have done here, with broad political support. Some speakers said we need to take politics out of it. I have a different view in that I think politics is what is going to drive it. I listened to my colleague talk about her father telling her that everything in life is about politics, and that is the direction he gave. Deputy McGuinness spoke about the former Minister, Mary Harney's time and suggested that if things had been done differently then, and different decisions had been made, the situation might be different now. I would argue that it was when Mary Harney was in charge that the privatisation route was taken and many of these policies were put in place.

Some Members spoke about the starting point. If there is a delay in regard to the Sláintecare report and the proposals within it that will kill the report. I listened to Deputy Durkan pointing to interventions that will not work and suggesting we have to take this very slowly. As with all these things, the first question that strikes me is what are interventions that will not work in regard to this report. That is the big question. If people want to delay it, what are the concerns they have with it?

Every day on my way here I pass by the hospice in Harold's Cross. I have known a number of people who have died in the hospice. There is something special about it - the care that is delivered by the staff, the empathy, the understanding, and so on. Only for good fortune, I could have ended up there myself. I have been in the hospital system and I am still in the hospital system, so I have seen where it has worked and where it has not worked. As a public representative, I am conscious of the many successful cases that go through the system, and we need to talk that up, given there is huge delivery for people every day. However, I am also conscious that we get those cases where the system has failed people. My colleague talked about mental health and it is on that area I want to concentrate in the speaking time I have left.

I was at a board meeting of a project in my area last week. Six people connected with that project had committed suicide. A woman on the board said that for one of the groups she was involved in, she was aware of nine individuals associated with the project who had committed suicide. That is in the Tallaght area. I am conscious that families are probably listening to this debate who are still hurting. The norm is that men take their own lives but, in these cases, it was mostly women. There is a huge problem there. It is about delivering care. In some cases, people go to accident and emergency or to their doctors, but the system is broken. Collectively, we all accept there is a crisis out there and that we need to do things differently. This is one area we need to concentrate on, and I know different approaches have been suggested.

We need 24-7 care. Although the Government is talking in terms of seven-day care, it is not between 9 a.m. and 5 p.m. that these things happen; it is normally at weekends and so on. Many of us have got that call. I have been in that situation where I got a call from a family to say, "My father is coming around to the house. Has he arrived?", but the father had committed suicide. I am touched by that. I want to do things differently. I want to work with people. That is what we are trying to do in this plan but we need to start doing things differently.

I would like to talk for longer about what is going on in my constituency. I was at a primary care launch where people were talking about the difficulty of going to the local hospital. We were talking in a hall in an area where 6,000 people lived with no doctor based in that area.

Again, this goes back to what we are doing right and what we are doing wrong.

I wanted to talk about disability, as the Minister of State, Deputy Finian McGrath, is here, and I wanted to talk about senior citizens, but I do not have time to do so. There will be time in future. I commend the committee on all the work it has done. We can fix the system. The message we need to send out to people is that while the system may fail some individuals, it is working well for the vast majority of people. However, we can do a lot better.

7:40 pm

Photo of Anne RabbitteAnne Rabbitte (Galway East, Fianna Fail)
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I compliment all the members of the committee. I was not on the committee, but it is an honour to have an opportunity to speak this evening. Deputy Shortall did a phenomenal job in pulling all of these different personalities together for the past 11 months, starting with four hours twice a week and moving up to 12 hours a week. I thank my colleagues, Deputies Kelleher, Brown and Brassil because it was a huge commitment. Members from all parties and none made this commitment for the past 11 months in the best interests of all the people whom we in these Houses represent and I thank them all very much.

I will continue in the same vein as Deputy Crowe. As Deputy McGuinness said earlier, there is a great opportunity here and the report provides the foundations and building blocks for the future. Everybody has contributed to it and everybody has hit on every aspect that comes through their own doors, be it personal or from constituents. There are certain wins for the Government in the report. We spoke about dental care and I looked at the costing. In the first year it would cost €17 million. However, it is off the pitch and we have moved on. The Government would show that it is really committed by hearing what is being said. Actions speak louder than words and this is what we are looking for. Regardless of whether we leave politics out of it, actions speak at the end of the day and this is how we know the Government is taking it very seriously.

The report is aspirational because what it recommends would be very expensive. When Deputy Shortall spoke, I thought she was costing us €1 billion a minute but, to be quite honest, it is a pathway to the future and the recovery of the health boards. I had an experience during the week, which I will share with the House later. We need to bring accountability and traceability into it. We need to remove certain layers of bureaucracy from the health service and bring it back to change managers, who have to be business managers. They have to be able to walk in and state what resources are there, what actions are being taken and what is being delivered, because it is the only way this will be done.

During the week, I was fortunate enough to get my hands on an intensive home care package. Such packages are like hen's teeth. It is the first time there has been one in Portumna, Woodford, Killimor, Mullagh or Eyrecourt, all of which comprise a large area in east Galway. The intensive home care package is for a person with dementia, and it means that person will leave hospital care with exactly what it says on the tin. The doctors had stated that on his release the gentleman would need 28 hours home care. Previous to this, he had been receiving ten hours. He was told the 28 hours could not be obtained because of the waiting list for intensive home care packages. I compliment Senator Colette Kelleher and Deputy Butler on their assistance. They helped me put the case together and they worked with the family. The person has obtained the 28 hours, and will receive speech and language therapy and nursing care hours. For his family members it means their father, who is in his early 60s, has been returned to his home. This is the wraparound service we speak about. I am sharing a success story because sometimes we speak about all the negativity in the health service. This is a situation which has worked very well.

This home care package is one of the 500 such packages but, to date, fewer than 300 have been allocated. Last year, we did not spend enough on them because only 110 of the number actually allocated were drawn down. We need to use what is allocated. Last year, 500 packages were allocated and 500 should have been used. There is a commitment to 500 this year and they need to be used. Dementia is a growing problem in the State. In 20 years' time, we will have 110,000 people with dementia. If we do not start building on home care packages year on year, which is recommended in the report, we will not address the problem. This is just one aspect.

I come from a rural community in east Galway and the most important things for me, as is the case for all communities, are primary care and GPs. GPs deliver 25 million hours a year in services and consultations. They are a breed that will die unless we do something to support them. We are exporting our GPs abroad. The GP contract is a fundamental part of what needs to be addressed in the report. We need to encourage more GPs into the service. Gone are the days when a GP would work 24 hours a day seven days a week, morning, noon and night. That service is not there any longer. GPs want a work-life balance and well-being for themselves and their families. They want the GP contract reviewed. When the GP contract is being reviewed we need to look at putting in place primary care centres in tandem. If we do not have primary care centres dotted throughout the entire country, our acute hospitals will be in crisis.

We need to start with where a problem originates. The report would deliver all of that to which I refer because it looks at every aspect, including where it starts, which is in the community. It starts with a person's first visit to the GP. We could halt it straight away by building up and providing the required wraparound service to communities. We can put in place wellness centres and diagnostics in our GP practices. We can then bring the role of pharmacies into communities. This is what we need to look at and this is the value of the report. It is a fantastic pathway and mapping system but, with no disrespect to anybody, it does not contain anything of which we were not previously aware. We have articulated - in a huge document - the requirements of what is needed but we have also shown examples of where we can have quick wins. We can also see what is needed when we look at communities and the geography of areas. In my community and, I am sure, in many others, it is GPs and primary care services that are needed.

Earlier, we spoke about mental health and CAMHS. At present, 5,200 children in Ireland are waiting for access to social care workers. That is unforgivable. Of those 5,200 children, 1,520 are level 3 and level 4. Level 3 and level 4 children are classed as being at risk. A child at level 4 will be monitored because he or she will have suicidal tendencies. This is where early intervention is needed and we need to recruit the requisite staff at a rate of knots. If we cannot recruit through the public sector, we need to look at what other services are out there. We need to look at organisations such as Sugru, a not-for-profit group which provides these services. It can provide counselling and a wraparound service to a family and a child. This is what we need to look at. It is not just about the individual as we also need to look at what support we can give to families. With regard to the 1,520 children at level 3 and level 4, we must consider advocacy groups such as EPIC and YAP, which have social workers. These are advocate groups that have social workers who can provide the service. The committee's report tells us what we need but it also tells us that we can look outside the box and start linking matters. Until such time as we start to join the dots, the system will not work.

I conclude by saying well done and thanking the committee for the opportunity. The report will be a talking point for years to come. However, I do not wish to see it remain on a shelf as happened with A Vision for Change. A Vision for Change was a fantastic document if it had been implemented. Regrettably, it never reached implementation stage. We picked parts from it. The Government must set a monitoring gauge as to what it will do on this report on an annual basis. It should clearly state to everybody, "we have taken this from the report and over the ten years your vision should be delivered".

7:50 pm

Photo of Joan CollinsJoan Collins (Dublin South Central, Independent)
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I thank the secretariat, the Trinity College team, the chairman, Deputy Shortall, and all my colleagues on the committee. There was an arduous 11 months of work on this report. I voted for the report in the committee despite the fact I believe it does not go far enough. Other Deputies think it goes too far. I will continue to support it and I will fight for its implementation in full. Like other Deputies, I do not wish to see the report left to gather dust because the political will to implement it does not exist. I do not wish to see it cherry-picked and turned into another set of so-called reforms of our health services. In fact, it would add to the existing mess of an unfit-for-purpose system if it were cherry-picked. This report comprises a set of moving cogs and if one part is put in place the other part must be set alongside it.

Our health service is a broken system. Other Deputies have mentioned various areas but I have had to represent people who are dealing with the urology department in St. James's Hospital. An 84 year old woman told me that she had been referred by her GP to the urology department and she received a letter saying that she would have her appointment in four years' time. She asked me if the department was waiting for her to die rather than serve her illness. I followed it up with a parliamentary question and discovered that there is only one consultant in the urology department. The other one left a year and a half ago. There are approximately 1,300 people waiting for outpatient appointments in that department in St. James's Hospital. That is an outrage. It shows the stark reality of what is happening in many hospitals throughout the country.

I support this report for one simple reason. Its main recommendation of a single-tier universal health service paid for by general taxation would, if implemented, represent a huge step forward in health care and in the provision of public services generally not only for patients but also for staff, doctors, nurses, GPs and community services. It is long past time that we dismantled the expensive and unfit-for-purpose jumble of private and public bodies, State bodies, charities, religious bodies and non-governmental organisations that we have inherited since the Victorians and established health care as a citizen's right, not an act of charity. This report is moving towards that. It is progressive in that way. I welcome the objective in the report to separate the public and private systems. This is a fundamental step towards a single-tier universal service.

A crucial part of the report is the implementation office and bringing in a person to drive the report's recommendations. If that does not happen, there will be a problem. The report requests that this be examined in July. It will be a first step to see the Minister for Health doing that. It will send a message to the health service that he is serious about the report. Then it will be necessary to go to the hospitals to explain what it is about and what we are trying to do, and to go to schools to explain to young people why we want them to go into training and to college so they can work in our hospitals and in our general practitioner and primary services.

However, a major failing of the report, and it was a bugbear for myself and other Deputies, is the issue of sections 38 and 39 bodies. Section 38 bodies are 100% funded by the State, so they should be in full public ownership and management. It is unacceptable that the new maternity hospital, to be built by the State at a cost of €300 million, whose 4,000 staff are paid for by taxpayers and which will be 100% funded by the State when it is up and running, would be under the ownership and management of a religious charity trust. This question has been raised in the Dáil by Deputy Shortall and others over the last week or so. The Minister must address it. It should be under the auspices of the public service and the HSE.

St. John of God is another section 38 institution. It provides services for disabled people and people with autism. We saw the horrendous situation where the chief executive officers in that institution were receiving money under the table and having their pensions propped up while services in the institution were affected by austerity. I have a copy of a letter from the mother of a child in St. John of God which she sent to the board of St. John of God when she heard and saw what had happened there. She says:

It is with great sadness and anger that we wish to inform you of our decision to withdraw our monthly donation to St John of God.

Our youngest son, Joseph, has been a pupil in Islandbridge for the past 3 years. Due to budget constraints, Joseph has never been seen by a therapist (speech or OT) since he joined the school. Joseph is 16 and his fine motor skills are such that he cannot hold a pen and write. He cannot read either. The teachers are doing everything they can to help Joseph develop and learn but the school lacks funds and access to therapists is operated on a priority basis. Joseph is not considered a priority and we would agree with this judgment. However, while we agree that Joseph may not need urgent access to therapists, we believe he needs help and could achieve much more if granted access to regular therapy.

The letter concludes:

We all make good and bad decisions. Most of us hope that the bad ones have limited implications for others. Most of us hope that the bad decisions will not break the trust, love and support we receive from those around us. Others have no such concerns.

The families whose children are attending St. John of God have been absolutely devastated by what has happened while the services they need so badly are not available.

Nursing homes and home helps are big issues as well, but we could not deal with everything in the report. These areas should be examined. We have been told that reviews in these areas are taking place. I hope we will be able to feed into that over the next period of time.

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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The Deputy can resume her contribution on the next occasion.

Debate adjourned.

The Dáil adjourned at at 7.40 p.m. until 2 p.m. on Tuesday, 27 June 2017.