Joan Collins (Dublin South Central, Independent)
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I raise the issue of delays in processing applications and reimbursing payments under the cross-Border directive. I will provide two examples. I know of one person who applied last December. He was advised that he had a knee problem and would have to get an operation. He got a scan done here in the South of Ireland. When he went up to the North he was told that it did not look like a knee operation was necessary. A full body scan was carried out and it was found that three vertebrae had fused; it was not his knee but his back. He had to apply for a change of code because different procedures are paid under different codes. It took from 23 July until 9 September for that application for a change of code to go through. It finally went through just before the consultant emailed him for his pre-operation consultation. The operation was carried out only last week. He has been waiting for reimbursement since June, when he was in hospital in the North. He rang up and was told that he could not be given a date for reimbursement. This scheme was brought in on the basis that people would be reimbursed within 30 days. People are getting credit union loans. This particular gentleman has been out of work for so long while waiting for his operation that he is on the pension rate of pay. He could not afford to pay the €15,000. His brother took out a loan of €15,000 from the credit union to pay it.

He is paying back €150 per week and still awaiting reimbursement. In another case of mine a young man who had an operation in March is still waiting to be reimbursed.

There is no point in setting up a scheme if it cannot be relied on. If a patient is told that he or she will be reimbursed within 30 days but must wait for 90 or 100, it causes major financial problems. The HSE will have to get its act together. I acknowledge there are problems, including staffing problems. If there are no staff, they should be put in place. There is definitely something perverse about the public health service being run down, with 194,000 additional outpatients since 2015, representing an increase of 50%. The report on this issue came out last week. There are 18-month waiting periods for operations. Patients are being forced into this. Taxpayers' money is being pumped into private hospitals in France, Germany, Spain, Britain, the North and here. There are Spanish public patients transferred to Ireland to private hospitals under the cross-border directive. I read an article that stated €2.5 million was paid in 2016 to private hospitals and €12.3 million last year. In the meantime, we are not even filling vacancies. Consultants have gone through the interview process. The figure for Galway is 11 and for Donegal, 100. There is a deliberate EU policy of running down public services and forcing taxpayers to line the pockets of private hospitals.

I would like the Minister of State to outline that there is something happening, that the extra staff are being put in place and that the Government is committed to reimbursement within 30 days in order that when patients obtain loans, they can make a commitment to pay them back in that timeframe and not be left high and dry, as is happening.

Catherine Byrne (Dublin South Central, Fine Gael)
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On behalf of the Minister, Deputy Harris, I thank the Deputy for raising this issue.

The directive on patients' rights in cross-border healthcare, commonly called the cross-border directive, provides rules for the reimbursement to patients of the cost of receiving treatment abroad where the patient would be entitled to such treatment in his or her home member state. The directive seeks to ensure a clear and transparent framework for the provision of cross-border healthcare within the European Union, for those occasions where the care patients seek is provided in another member state, rather than in their home country. The HSE is responsible for the operation of the cross-border directive and has a dedicated office resourced for this purpose. The office acts as the national contact point, as set out in governing European legislation, and processes applications for treatment received for the purposes of the operation of the directive.

As part of its functions as the national contact point, the cross-border directive office gives prior authorisation to patients availing of the directive where their treatment involves an overnight stay. I am informed by the HSE that applications for prior authorisation are generally processed within 15 to 20 working days. The vast majority of applications for prior authorisation currently in hand will be processed within that timeframe, with the remainder likely to be processed within 25 working days.

The cross-border directive was transposed into Irish legislation in June 2014. Since its transposition, awareness of the provisions of the directive has grown steadily. The number of claims for reimbursement being processed by the cross-border directive office has grown from 150 in the first full year, 2015, to 3,886 at the end of 2018. A total of 3,041 claims for reimbursement were received this year up until the end of August. The significant growth in use of the scheme and the associated increase in the number of applications being submitted have given rise to an increasing workload and a build-up of applications. The HSE has advised that the cross-border directive office is operating with a three-month backlog in the processing of claims.

Recognising this issue, officials from the Department met representatives of the HSE in July to discuss the issue of reimbursement delays affecting patients who had availed of treatment under the directive. The HSE has subsequently been requested to examine the current resourcing of the cross-border directive office and identify any necessary action needed to mitigate waiting times arising from current demand under the scheme. The Minister is aware that some measures have been put in place in the short term, for example, overtime and the deployment of trained staff to address the significant backlog in processing applications. Officials from the Department will continue to engage with the HSE to ensure appropriate action is taken to provide longer term solutions.

This matter was raised this morning during Leaders' Questions. The Minister for Communications, Climate Action and Environment, Deputy Bruton, made a commitment to the Deputy who raised it to bring it to the attention of the Minister for Health. I will do so also. If Deputy Joan Collins furnishes me with the email pertaining to the individuals in question, we might be able to process it.

Joan Collins (Dublin South Central, Independent)
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I do not know how to respond. The Minister of State's reply indicates that the Minister has known about this issue since July, yet, at the end of September and heading into October, patients are still waiting for over 90 days to be reimbursed money they borrowed. They do not have the money to pay €15,000 for a back operation. That is the cost in the hospital in the North. The individual in question is on a pension rate of pay and his family are supporting him by paying back the credit union loan. Reimbursement was expected within 30 days, but it could now be Christmas before that occurs. The individual is still waiting to be reimbursed for expenditure incurred in June when he had a consultation with the consultant.

A total of 3,886 people are being forced to use the cross-border directive because they cannot have an operation in the South. They may be waiting for over 18 months, two years or two and a half years. It is perverse. The European Union set up the cross-border directive to try to bring people abroad for treatment, involving a stay of one night or more, for which we pay as taxpayers. Spanish taxpayers are paying for public patients receiving private care in England. This issue has to be dealt with immediately. It has been known about since July. Overtime has been provided. The Government has to commit to reimbursement within 30 days for those who borrowed money. That is a very basic point. Extra staff can be brought in quickly and should have been by now. I cannot understand how it has not happened, given that the Department has known about this issue since July and spoken to the section concerned. I would like to see a commitment from the Minister in that regard. It is not good enough to run down the health service and tell people to borrow money they cannot afford if it is not paid back within the timeframe committed to by the HSE and under the cross-border directive.

Catherine Byrne (Dublin South Central, Fine Gael)
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Nobody is forced to use the cross-border treatment scheme. It is an option for patients if they wish to avail of it.

Joan Collins (Dublin South Central, Independent)
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If they do not opt for it, they must wait for two and a half years here.

Catherine Byrne (Dublin South Central, Fine Gael)
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The Minister, Deputy Harris, is fully aware of the matter and has spoken to the HSE about it. Overtime has been increased and trained staff have been deployed to deal with the backlog. There is a backlog because the scheme has been such a success.

Joan Collins (Dublin South Central, Independent)
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It has been a failure because public patients cannot have operations here.

Catherine Byrne (Dublin South Central, Fine Gael)
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I will continue to outline to the Minister the need to reimburse those who have to borrow to have an operation abroad. Having to wait for 90 days falls short of what is desired. Patients should be reimbursed within 30 days. I will continue to follow up on the matter with the Minister on behalf of all those who raised it in the Dáil this morning and afternoon. I cannot make a commitment to sort out the matter of reimbursement within 30 days, but I commit to making it my business, straight after this debate, to speak to the Minister about it. I shall ask him to consider urgently the need to reimburse patients who have taken out loans, some of which are quite substantial, to pay for treatment abroad. Provision should be made to reimburse patients as soon as possible, certainly within 90 days.

I note the frustration that has been expressed by Deputy Joan Collins and by others in the Chamber this morning. I assure them that when I speak to the Minister, Deputy Harris, about this matter, I will be as strong and powerful as I can. I agree that people are having to wait a long time to be reimbursed. Deputy Joan Collins has rightly pointed out that some of those who have borrowed to have procedures done cannot afford to wait any longer for these payments to be made. There is an urgent need to address these issues, which I will raise with the Minister, Deputy Harris. The Minister, Deputy Bruton, said he would do likewise when he replied this morning to some of the other Deputies who raised concerns about this matter.