Mary Butler (Waterford, Fianna Fail)
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I move: "That the Bill be now read a Second Time."

I am pleased to have this opportunity to address the House on Second Stage of the Health Insurance (Amendment) Bill 2021. This is an annual technical Bill comprising nine sections, all focused on the issue of health insurance. This legislation is needed in order to revise the parameters of the risk equalisation scheme, which is a financial mechanism that supports our community-rated health insurance market.

The amendments outlined in the Bill will ensure the ongoing sustainability of the private health insurance market and seek to keep health insurance policies at an affordable and equal price for all citizens, young or older, healthy or sick. I will begin by briefly outlining the purpose of risk equalisation before providing an overview of the process undertaken to set the 2022 rates and then outlining the specific provisions which will apply next year.

Currently, 46% of the population in Ireland holds private health insurance. This amounts to 2.3 million people and represents a total annual premium income of more than €2.5 billion. Health insurance in Ireland is provided according to four principles, namely, open enrolment, lifetime cover, minimum benefit and community rating. Our community-rated health insurance market means that the cost of health insurance is shared across all members of the market. In general, everyone, with certain exceptions, can buy the same policy at the same price. Insurers cannot take into account personal circumstances such as health status. Older and sicker people pay much less for health insurance than they would in a risk-rated market. Younger and healthier people who are less likely to access health care pay more than they would in a risk-rated market. As young people grow older, their health insurance needs may increase and they too will be supported by community rating. This principle is called intergenerational solidarity.

Community rating is supported by the risk equalisation scheme, which has been operational in Ireland since 2013. In essence, the scheme is a financial transfer mechanism whereby money flows from insurers with healthier members to insurers with sicker members in the form of credits. These credits are funded directly by stamp duty levies on all health insurance contracts when those contracts begin and these levies flow into the risk equalisation fund. Without the scheme, an insurer with older and sicker members would be forced to charge much higher premiums than its competitors to cover its claims costs. None of the stamp duties on health insurance contracts goes to the Exchequer; they are all used to fund risk equalisation credits. The risk equalisation fund is managed by the Health Insurance Authority, the independent regulator of the health insurance market.

The risk equalisation scheme requires state aid approval from the European Commission in order to function as part of the private health insurance market. The current scheme was approved in 2016 following negotiation with the Commission, with similar schemes approved and in operation in Ireland since 2003. To date, the scheme has been considered a state aid which is compatible with the internal market by the European Commission. The current scheme is approved to operate until 31 March 2022 and was extended from 31 December 2020 due to the impact of Covid-19. Negotiations are at an advanced stage with the European Commission for the new scheme and are expected to be finalised by the end of the year.

As Deputies will be aware, a health insurance Bill is needed each year to update the amount of credits paid to insurers under the scheme and the corresponding stamp duties required to fund them. In addition to these standard technical amendments, this year's Bill provides the legislative basis for the introduction of high-cost claims credits to the scheme. Furthermore, the Bill provides for an updated benchmark of reasonable profit and the introduction of a time limit for insurers claiming from the fund. I will set out the detail of these amendments shortly when outlining the specific provisions. These updates are based on the recommendation of the Health Insurance Authority. Each year, the authority carries out an evaluation of the market, focused on the claims costs that every insurer has paid over the year. This evaluation includes information on market conditions, which is particularly important in recent times as Covid-19 continues to have a large impact on the market. Based on that analysis, the authority recommends the level of credits that should apply for the next year. Significant work has also been carried out by the Health Insurance Authority in the past few years in relation to high-cost claims and how high-cost claims credits will be introduced to improve the effectiveness of the scheme. The authority has provided several reports to the Minister for Health on this new addition, including a final recommendation in June of this year following an open consultation which involved health insurers and members of the public.

I will now outline the specific sections of the Bill. Section 1 defines the principal Act as the Health Insurance Act 1994.

Section 2 amends section 6A of the principal Act to include high-cost claim credits in the definition of risk equalisation credits which the insurer is entitled to have paid on behalf of an insured person. This section also proposes to insert new definitions for high-cost claim, high-cost claim credit, high-cost claim quota share and high-cost claims threshold. High-cost claims credits will work by targeting claims costs over a threshold of €50,000 in a rolling 12-month period and compensating the insurer for 40% of the claims cost over this threshold. Currently, health insurers receive no subsidy for these claims. The hospital utilisation credit is the only credit paid related to the health status of customers and is paid when an insured person accesses hospital services. The high-cost claims credit will increase by 25% of the amount of the fund paid directly for health service usage. High-cost claims arise in the Irish health insurance market where an insured person is extremely ill and attends hospital for an extended period and are closely linked to chronic conditions such as cancer. Health insurers must pay claims costs where they are medically necessary and are covered by the insured person’s contract. This new type of credit intends to target subsidies towards the claims costs of sicker customers. This will support the objective of community rating.

Section 3 amends section 7E of the principal Act. It provides that the Minister may require the Health Insurance Authority to furnish a report relating to the high-cost claims credit parameters. The Health Insurance Authority will include the level of high-cost claims credits that should be paid out of the fund, and the basis on which they will be paid, in its annual report and recommendations to the Minister.

Section 4 amends section 7F of the principal Act to provide for a new benchmark of reasonable profit and for transitional arrangements for how it is to be applied for the three-year periods 2020-22, and 2021-23. The benchmark of reasonable profit is used to assess whether an insurer has been overcompensated by the risk equalisation scheme. This is currently set at 4.4% return on sales, gross of reinsurance and excluding investment income. This was agreed with the European Commission under state aid rules in 2015. This section amends the 4.4% return on sales to 6% on the same basis. This was based on the recommendation of a new benchmarking exercise among European and Irish insurers.

Section 5 amends section 11C of the principal Act to provide for a new effective date for revised age-related credits payable from the risk equalisation fund. This section also introduces a time limit on all risk equalisation credits that can be claimed from the risk equalisation fund. There is currently no time limit or cut-off period in the Act restricting how long a health insurer may have to make a claim to the fund. Introducing a cut-off for claims on the fund is expected to have benefits from a data management, administrative and financial reporting perspective for the Health Insurance Authority. There will be a transitional period where health insurers will have an opportunity to submit any claims, which are backdated before this new time limit is introduced.

Section 6 replaces table 2 in Schedule 4 to the principal Act. This table provides for age-related credits, which are payable for insured people over the age of 65. These new credits would be payable from 1 April 2022. This year, the Health Insurance Authority has recommended a marginal decrease in the age-related risk equalisation credits to facilitate the introduction of high-cost claims credits. Age-related credits provide a subsidy for insurers who provide cover for that cohort. These credits cover the expected extra claims costs for insured older people.

Section 7 amends the principal Act by the addition of Schedule 5 which provides the parameters for high cost claims. These are the high-cost claims threshold which will be set at €50,000 and the high-cost claims quota share, which will be set at 40%.

Section 8 amends section 125A of the Stamp Duties Consolidation Act 1999.

This will specify the stamp duty rates that will apply for 2022. As I outlined earlier, the scheme is Exchequer neutral. It is not funded by the State and the State does not derive any funds from it. The amount of stamp duty levy is calculated to offset the costs associated with the payment of risk equalisation credits. Any surpluses or deficits that arise under the scheme are rolled over and included in the recommendation for the following year.

Covid-19 has had a major impact on the private health insurance market in Ireland, as it has on the entire public and private health sectors. The pandemic has restricted utilisation of hospital services, which has impacted claims activity, thereby causing fewer risk equalisation credits to be paid out. That has caused a surplus to arise in the fund. This section provides for a reduction in the stamp duty levy applicable to health insurance contracts from 1 April 2022, which incorporates a surplus of €100 million that had gathered in the fund. The amount of stamp duty payable varies, depending on whether a contract is advanced or non-advanced. The difference between the two is how much private hospital coverage the contract offers, with non-advanced contracts providing for mostly public hospital cover. The stamp duty on advanced health insurance contracts will be €406, a decrease of €43 from 2021 rates. For non-advanced health insurance contracts, the stamp duty will be €122, which is a decrease of €35 from 2021 rates. It is hoped these reductions can benefit customers by way of a reduced premium charged by insurers next year.

Section 9 provides for the Short Title, commencement, collective citation and construction of the Bill. The provisions in the Bill relating to the introduction of high-cost claims credits and the amendment of the benchmark for reasonable profit are subject to approval by the European Commission under state aid rules. The commencement of these provisions will be done by ministerial order.

To summarise, this Bill allows us to maintain the community-rated health insurance market. Its provisions will increase the effectiveness of the risk equalisation scheme, which is a fundamental support to the market. I conclude by highlighting the Government's commitment to improving public health services under the Sláintecare programme. As access to these services improves, the proportion of people who hold health insurance may decrease over time. Importantly, the programme for Government commits to retaining access to private healthcare services for people in Ireland, thereby ensuring choice for those accessing healthcare. While such a high proportion of people hold health insurance across Ireland, it makes sense to maintain the community-rated health insurance market. I commend the Bill to the House.

David Cullinane (Waterford, Sinn Fein)
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I am sharing time with a number of colleagues. Sinn Féin will support this Bill, as we always do. It is an annual Bill to renew the risk equalisation mechanism that supports the community-rated health insurance market. The Bill revises the stamp duty levy on policies and the risk equalisation credits payable to insurers for 2022. It is a self-funded system. The Bill also provides this year for high-cost claims credits, which will provide an additional layer to smooth the costs of credit allocation by directly subsidising very high-cost outliers, subject to European Commission approval. Risk equalisation ensures costs are constant across the lifespan of the individual. It seeks to ensure, where possible, that age, gender and health status do not influence the cost of an insurance product. Recognising the reliance of many people on health insurance, we will support the Bill, as we have done in previous years.

I take this opportunity to reiterate our critique of the current insurance market and the two-tier healthcare system in this State. The Minister of State restated in her opening remarks the Government's commitment to the implementation of Sláintecare and the commitments contained within it. The people who resigned their positions and walked away from the implementation of the programme would disagree that the level of urgency and commitment that should have been given has, in fact, been given. I do not doubt at all that additional funding was made available in last year's healthcare budget, but it followed a decade of underinvestment. Moreover, as we know, most of that money was not spent and was rolled over to this year. Even still, many of the staff and beds that were promised were not delivered and potentially will not be delivered.

A total of 45% of people in this State rely on the health insurance market, not because they want to take out private insurance but because they feel they have no choice in the matter. How can we blame then when we look at the waiting lists in the public system? There are 900,000 people on some form of health waiting lists, despite all the promises we had from the Minister, Deputy Stephen Donnelly, and his predecessors that we would see waiting list strategies. In fact, the head of the Sláintecare implementation body, who has resigned her position, is on the public record as saying there was a waiting list strategy already there and ready to go but it simply was not published and advanced by the Minister. Why is that? All we are seeing is waiting lists going in the wrong direction. It is bad enough that 900,000 people are on some form of public health waiting list but 200,000 of those patients, many of them children, are waiting more than 18 months. That is the reality for many people.

I do not have time to go into all the promises made as part of the delivery of Sláintecare. Commitments were given to enhance community care, which would involve more investment in community and primary care and ensuring people are treated, as far as possible, in their own home in the first instance and, for people with chronic pain and cardiac and respiratory illnesses, that their care would be managed in the community. This is not possible for many people because the community infrastructure simply is not there. Anyone to whom I have spoken who knows what he or she is talking about when it comes to healthcare says the HSE simply does not understand the community sector. It has outsourced huge amounts of public money, as we know, to section 38 and section 39 organisations and, indeed, to a large number of private organisations, when it comes to the delivery of home help and home care packages. That is the reality of what is happening.

One of the representatives of HIQA who came before the Oireachtas health committee a number of months ago when we were discussing the private nursing home sector and the subsidies the State pays for the sector, said: "The HSE does not understand the private sector that it spends so much of taxpayers' money on." I would say the executive also does not understand the community sector. I have put in parliamentary questions, as other Deputies do all the time, trying to establish where all the money goes, how many community beds are funded and how many staff there are in all these organisations and across all the different layers of community care. We get different responses or, on some occasions, no response because the data are not available. That is crazy when one considers the billions of euro of taxpayers' money that goes into community care. Much of that care is not driven by the HSE and is not publicly owned, managed and controlled. We then have all the issues that flow from that, with section 38 and section 39 organisations paying wages below HSE rates and not being able to attract staff at the same level as the HSE does because of the terms and conditions of employment they offer. We know there is a need to overhaul this sector. Community care is an area in which there has not been investment and where the step change that was needed, which Sláintecare promised, has not been delivered.

The two major areas in which very little progress has been made and that are relevant to this Bill are, first, removing healthcare from public hospitals and, second, expanding universal GP access and free GP care. On removing healthcare from public hospitals, we had the Sláintecare report in the first instance, which set out a strategy for how that would be delivered. It was followed up by the de Buitléir report, which again set out a clear strategy for delivering this objective in terms of public-only consulting contracts and grandfathering out those consultants who remain on the types A and B contracts, with some form of enticement, if possible, for the latter to move onto the public-only contracts. Very few advances were made in this regard. Despite there being the Sláintecare report and the de Buitléir report, we still have not made any inroads in this area at all. That will continue to be the case until the political will is there to do it. The lack of action is driving much of the private sector activity in healthcare, which is embedded in our public hospitals. We need, once and for all, not just to agree but to deliver on the commitment to disentangle private healthcare from public hospitals.

The cost of that, according to the de Buitléir report, was €700 million. Juxtapose that with the €200 million private sector funding that was made available as part of the winter plan, the access to care fund. That is in addition to what has already been paid in respect of the National Treatment Purchase Fund. That is an additional €200 million, the vast majority which will go into the private sector and into private hospitals. Yet, the cost of removing private healthcare from public hospitals would be €700 million. In the general scheme of healthcare funding, that is not a huge cost. It strikes me that cost is not the problem here but it is the political will to make it happen. It is not happening. It was a big promise that was made but it simply is not being implemented.

The expansion of free GP care will be important if we want to ensure people come off private health insurance and that we wean the State away from subsidising private healthcare through the National Treatment Purchase Fund and all of the short-term measures the Government comes up with at the last minute as we go into winter to give a veneer that it is doing something to deal with waiting lists and the crisis in hospitals. All it is doing is outsourcing more funding and giving more funding to the private sector. We need to grapple and deal with those two big issues that I have outlined.

Look at what happened in budget 2022 in relation to expanding free GP care. It was meant to be done by 2023, as I understand it. We are nowhere near that. What was funded in the budget was for seven- to eight-year-olds, I think, to receive universal GP access. That is still being negotiated. There are still ongoing talks with the Irish Medical Organisation, IMO. Even though it was funded, it still has not been implemented. In fact, many people who are medical card holders have problems getting access to some services already. Bloods, for example, is one of these services. There are huge challenges in that area. Despite the commitment to move to universal GP access for everybody within a five-year period of Sláintecare being committed to and delivered, it has not happened.

I am afraid that when the Minister of State and the Government give themselves a pat on the back for what they have done in healthcare reform, they only have to look at the people who are tasked with responsibility for doing that. The chair of the Sláintecare implementation advisory council, SIAC, walked away. The person who was the lead in the HSE for delivering Sláintecare walked away. The vast majority of people, or many of them, on the advisory committee walked away. That is being restructured. The Minister has given responsibility to the Secretary General in the Department and the head of the HSE. However, there has been no sense of urgency from those two individuals in regard to those two big issues. As long as that continues, we are going to be back here every year. Yes, this is technical legislation but I am not prepared to continue to support a two-tier system, which is broken and which does not work for the vast majority of patients. I want to see urgent delivery on the commitments that all parties signed up to in Sláintecare. It strikes me that some people and some political parties who signed up to Sláintecare did not believe in the principle of it. If they did, they would have moved much quicker.

Patricia Ryan (Kildare South, Sinn Fein)
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I welcome the opportunity to speak about this Bill. It is an issue that is dealt with every year around this time, in a similar Bill to provide for risk equalisation. Risk equalisation is a mechanism designed to give effect to the objective of a community-rated health insurance market, where customers pay the same premium for the same health insurance plan, regardless of age, gender or health status.

The Health Insurance Act has provided for a risk equalisation scheme for the market since January 2013. Under the scheme, insurers receives risk equalisation credits to compensate for the additional cost of insuring less-healthy or older members. This year’s scheme will differ from the current one by introducing high-cost claims credits. Treating these claims separately will mean that the risk equalisation subsidised provided to insurers will be more accurate and effective by removing distortive high-cost claims.

As a result of lower claims activity due to Covid-19 a surplus of around €100 million has built up in the risk equalisation fund. The Health Insurance Authority has recommended the return of this €100 million to consumers by the way of a reduction in stamp duty for contracts commencing or renewing in the period of 1 April 2022 to 31 March 2023. This is likely to be a once-off reduction because of Covid-19 imposed restrictions on access to public and private hospitals, which resulted in lower credits being paid out of the fund.

Some 45% of the population is covered by private health insurance and pay out more than €2.5 billion in premiums. For many workers and families, health insurance is a necessary evil. They make great sacrifices to pay for it, hoping that they will never have to use it. The only reason they pay is that our health system is so bad and they fear the long waiting lists in public hospitals. There are hundreds of thousands of people languishing on long waiting lists and this Government has no credible plan to address this. We need to fix the imbalance in healthcare to remove private healthcare from our public hospitals and our public healthcare system.

It is time we moved away from a two-tier health system. There are many people falling through the cracks, who earn too much to qualify for a medical card, or too little to afford health insurance. This is wrong. Ability to pay should have no bearing on how we are treated in the healthcare system.

People are languishing on waiting lists and are getting sicker, while those with health insurance are fast-tracked to the front of the queue. In some cases, they are treated by the same doctors and, in some cases, the same hospitals. For those who have to wait, their mental health is suffering and in some cases their life expectancy will be lowered. The Minister of State is aware that we have discussed our elderly many times. This is not good enough and health insurance exploits a failed public health system. It is a public health system that is being killed off by successive Governments to favour a private health system. As with the commodification of housing, the commodification of our health service is hurting those who need it most, like our elderly and like those on low income, in other words, the working poor.

I spoke to a lady last week who has been waiting for more than three years for a tonsillectomy appointment for her child. She was initially told that the wait would be 18 months. If the family had health insurance, it could be done within a week. Instead, the child endures pain of recurring sore throats - six in the last year. Children are suffering and it is a disgrace. Sinn Féin in government will deliver an all-Ireland health system that is free at the point of delivery and one that is based on need and not on income.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I thank the Leas-Cheann Comhairle for the opportunity to make a brief contribution this afternoon. The Minister of State said the programme for Government commits to retaining access to private healthcare services for people in Ireland and ensuring choice for those accessing healthcare and that while such a high proportion of people hold health insurance across Ireland, it makes sense to maintain a community-rated health insurance market. It would make more sense to have targeted investment and specific planning in our public health service. That makes real sense. An all-island health service would also make sense. Of course, for the moment and for as long as those who are intent on strangling the health service have control over it, there will always be a growing market for private health insurance. Governments such as the one in power at the moment will always lead the charge and act as a great advertisement and a great recruiter for the private health insurance market.

Just so the Minister of State is aware, people do not get private health insurance because they want to skip the queue, get one-up on their neighbours or, in many cases, because they can afford it. Many people cannot afford it and they go without, just to have private health insurance. I do not have private health insurance. I am lucky that I have never needed it, touch wood. I would not get it as I do not support it. I live by that but I know many people who have it. They do not favour private health insurance, but they do not want to find themselves on one of the Minister of State’s waiting lists. They do not want to find themselves having to wait years in pain simply to see a doctor. They find the money somewhere to ensure they can pay for private health insurance.

The Minister of State acknowledged that we have a high level of private health insurance in this State. I do not think we have a high level, or a disproportionately high level, of people who favour private health insurance. They simply favour being able to see a doctor when they need to see a doctor. They cannot do that in the public health system very often. The Minister of State knows all of the reasons. Just because the Minister of State does not fix it does not mean she is not aware of what has caused it. She knows the reasons our health service has the waiting lists that it has. She does not deny it - in fact, she was nearly celebrating it there in her statement.

In any event, we have this debate every year because we have to have it. It is a necessary debate and I fully appreciate that.

However, it would be preferable to hear a credible plan from the Minister proposing the legislation to ensure such a massive incentive for private health insurance is not stacked into our public health system. We live in hope.

While I have the floor I will raise an issue that affects a very small number of people. I ask the Minister of State to look at this or get someone in her Department to do so. It relates to restricted membership undertakings, RMUs, that is, where a person is a member of a scheme by virtue of the fact that they are married to someone in a particular type of employment, such as the Garda. I am not specifically referring to the Garda medical aid but that is one example. If someone is married to a member of An Garda Síochána they are covered under their spouse's scheme. The scheme was devised when we did not have divorce but if such a couple got divorced then clearly that person would not be covered by the scheme anymore as they would not be a spouse. However, there is no obligation in the legislation for them to be told of this. There is no obligation in law for the spouse who is being divorced from the serving member to be told and that can create problems because of the way the insurance market is structured. That person, through no fault of their own because they might not know their former spouse discontinued their membership of the health insurance scheme, can find themselves on the outside of the health insurance market, and it is harder for people to get private health insurance in their mid to late 50s. In the case that was brought to my attention, the person involved only found out by accident that they did not have private health insurance. It is a very small and niche thing but it is something that could be addressed.

I asked a parliamentary question about this matter and the response stated:

In the case where a person ceases to be a dependant of a member, for example where they cease to be married to the member of the medical society or where their spouse ceases to qualify as a member, an RMU is not obligated to continue to provide insurance cover to that person.

That is fine but they are also not obligated to tell these people. I am not saying there are large numbers involved here but a small fix would be in order. I am using the opportunity this afternoon to bring this matter to the Minister of State's attention. I am happy to discuss it with her afterwards but she might get someone to have a look at it. It is a small thing but since it has happened once there is a small chance that it could happen again and it would be appropriate to have a look at that. I thank the Minister of State for her attention on the matter.

Duncan Smith (Dublin Fingal, Labour)
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I thank the Leas-Cheann Comhairle for the opportunity to speak. Annually, we have a debate about the health insurance Bill wherein we establish the regulations and legislation around the private health insurance sector. It is a difficult thing for those of us who have fundamental issues with how the Irish health sector is set up at the moment, and how it has been set up for many years. In the past two years the deep problems of our healthcare system have been clearly exposed for all to see. As a State, we operate a two-tier health service and we attempt to operate these systems in tandem while not having enough capacity within our service to meet the basic public need. That is underlined by massive issues in recruitment and retention. Essentially, our health system is failing to cope with the basic needs of the State and has been for many years. This has led 2.2 million Irish residents to have private health insurance. That is 45% of the population. In the UK, the figure is 13%. While the NHS is not perfect - far from it - it is one of the great achievements of public health in Britain that the vast majority of its population do not pay for for-profit health insurance, because they believe in their health service. They strive for their health service to be better and they are invested in it.

It is not just about comparisons with the UK. According to the WHO, Ireland is "unique among EU countries in not providing universal coverage of primary care." It states:

Its system of entitlement to publicly financed health care is also complex ... gaps in coverage in Ireland already create significant financial barriers to access, particularly for people who do not have medical cards or [private health insurance], resulting not only in unmet need but also in inequitable and inefficient patterns of use ... these barriers are often substantial relative to most other EU countries, especially for primary care.

That is absolutely damning of our health system and we know it. We see the outworkings of it every day in our advice clinics, in our communities and in our families and we discuss the outcomes in various debates in this Chamber. Much of it boils down to the complexities of the two-tier system and trying to unravel that. Believing that Sláintecare is the answer to that is slightly misleading.

Sláintecare, if delivered in its entirety or nearly in its entirety, would not replace private health insurance. It would create what will hopefully be an attractive alternative to private health insurance, namely, a public health system in which people have so much confidence and that has such ease of access in terms of cost across many different aspects of healthcare that we feel we do not need private health insurance. That is a huge offer of faith in terms of a health policy. Most people are behind Sláintecare, or say they are, but even if it is delivered we will still have a private health insurance market in this country. It will still be actively touting for business from Irish residents and will be coming from a position of huge advantage because of where it is at the moment, the facilities and resources it has and because it is unconstrained by having to provide pure holistic public health policy. It is a huge ask just for Sláintecare to be delivered and then we have this offer of faith that if it is delivered it will be so attractive and function so well that the private health insurance market will be diminished to an extent similar to the UK, where it only covers 13% of the population. That feels light years away in the Irish context.

We need to have some hard conversations about what Sláintecare can and cannot achieve. I do not have faith that Sláintecare will achieve what we need it to when it comes to our reliance on private health insurance. A reliance on private health insurance is what the State has at the moment. That is something we need to move away from. Looking at news articles on private health insurance, two consistent trends are clear. You will see the price of health insurance going up and the profits of health insurance companies going up. What you will not see is waiting lists in the public health system coming down or costs for health insurance coming down. Inequality is widening. Due to the way we have it currently set up this House is hamstrung. No matter what your ideological bent, because of where we are right now this Bill will have to pass. However, we will back here again next year having a very similar debate. Even if great strides are made and we catch up on the delays and make strides where we need to, Sláintecare is not going to fundamentally solve the problem of our two-tier health system and the hold private health insurance companies and private health providers have. We need to get real in that debate. We are where we are with it now.

It is another example of a deeply flawed structure within our health system. As I said, we see its outworkings across many areas. We have a huge recruitment and retention problem. Part of that is due to the fact that private healthcare providers can provide better pay and conditions for staff who are then taken from the public health system. Consultants are working in both private and public healthcare and so the same person on the same list could be offered the same consultation 18 months or two years down the line or they could have it in a week or two with the same person, sometimes in the same room. That is just immoral and that has to change.

Turning to our GPs and the pressure they are under, our primary care sector has performed Herculean tasks over the past 20 months, but Covid has laid bare just how stretched the sector is. Real investment in public and primary care will have to come hand in hand with an approach to private health insurance that removes the guilt factor for people who feel that they need to have insurance. It is fantastic if people who are on their own do not want to get private health insurance and decide to take their chances, but if their circumstances change - they get married and have families or other dependants - the pressure on many to stretch their household budgets to include private health insurance tips hard-working people who are just trying to get by onto the edge of the poverty line. This is because they do not have the primary care access that they need and the certainty such access brings. Every Deputy knows and understands that but not everyone is providing the solutions to change it.

John Lahart (Dublin South West, Fianna Fail)
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I enjoyed the research on this Bill, mainly because a constituent came to my clinic last night who raised the issue and brought along his and his wife's private health insurance policy. He had noted that the premium for 2022 compared with the premium for 2021 had reduced but the credit for the risk equalisation had also reduced, resulting in little change in the overall cost of his premium. He was wondering about the risk equalisation piece. I am in a much better position today to tell him, having read through the research, briefing notes and some other bits and pieces. Notwithstanding everything that has been said because this is, to use a term that has been used this week, part of the peculiarity of the Irish health system, I was amazed that this couple in their 70s were paying almost €3,000 between them for their health insurance for the year. That is unacceptable in this day and age.

Like every other Deputy present, I strongly support Sláintecare and yearn for the day when there is universal free healthcare, universal access to healthcare on an equal basis and good and decent healthcare. I do not just mean universal access, but universally timely access to every sort of procedure, every sort of consultant and every sort of care that is necessary for individuals.

I am also mindful, though, of the great Republican Party slogan during an election a number of years ago when the Democrats were putting forward the virtues of Medicare and Medicaid, an issue that arises consistently in the USA. The Republicans had a scary slogan: "If you think health care is expensive now, just wait until you see what it costs when it's free". Something that strikes me, and that was mentioned by another Deputy, is that we will always have people who can access private healthcare. Even if we had the resources in the morning to produce a universal healthcare system, there would probably be a splurge in the development of even more private hospitals, including private specialist hospitals. There would then be an even more striking elite with access to that kind of healthcare. However, there is no aspect of Sláintecare that is not virtuous.

I was lucky enough to go to and graduate from college. When I got my first job, my parents' advice was to take out a pension and private health insurance. It was part of the DNA. I never thought I was gaining superiority over anyone else. I just assumed it was something that everyone did and to which everyone had access. It was a seamless decision in a world that probably was not characterised by as many inequalities and inequities in terms of accessing the health system.

The purpose of the legislation and the reason for the risk equalisation fund being revisited every year have been well rehearsed by other Deputies. It is a good. Whatever about having private healthcare, imagine if we had a system of private healthcare like the system in the US, which is unbridled and unfettered and where no account is taken of someone's age. In fact, the older one gets and the more likely one is to get sick, the larger the payments one must make and health insurance moves out of ordinary people's reach. I am not giving bouquets to our system. Far from it. I believe in an equal system and it is what we all strive for. I certainly strive for it. For example, and to go slightly off topic briefly, the National Treatment Purchase Fund could be used to provide access to psychological services that are otherwise not available. As a society, we could examine this matter. I recently had a case of a child who waited four years for an assessment and, after getting that assessment, must now wait another four years for treatment. The child will have gone through every developmental phase by then. It will be over developmentally for that child.

We understand that the reason for the risk equalisation fund is to ensure that people who are in their advancing years and who are more likely, although not always, to become more ill, develop ailments or require hospital admission or specialist care do not pay any more than younger cohorts who are regarded as being stereotypically fit and health. I wish to make two points on this. I enjoyed reading the Health Insurance Authority's paper on this matter. It was well explained, provided good background information and was detailed, but the authority only had 20 respondents to its public consultation. That is risible. The Health Insurance Authority ought to be more robust in its public consultation. It could request that all private health insurance providers include a consultation piece in correspondence to all their members, including a feedback form and the authority's questions. The questions that the authority asked were legitimate and explained to many people the need for risk equalisation, but when one thinks of the millions of people in Ireland who have their health insured privately, that there were only 20 responses to the consultation indicates there was something lacking. We need to do something about it.

The Minister of State will be aghast to know that there are more than 380 different health plans. The bulk of them are held by Irish Life. Next is Laya, with VHI holding the fewest plans. Regularly, Claire Byrne and Pat Kenny do the State some service when they have a specialist on who tries to navigate the public's way through the myriad of plans. How can anyone reasonably hope to get value for money in a health insurance plan? I am confident that there are thousands of people who, if they had a helping hand in buying their private health insurance, would save a great deal of money. We could do the State some service, to use that phrase a second time, if we asked the health insurance companies whether they really needed so many plans. I believe Irish Life has 180. Why does a health insurance company need 180 different plans?

Ruairi Ó Murchú (Louth, Sinn Fein)
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We are all dealing with a situation where a large number of people engage private health insurance. It amounts to 45% of people in the State. On some level, this Bill, which is a process that we go through every year, is an element of accepting the failure of our system, in that we do not have the public health system that people deserve and require. We all accept the necessity of this legislation and that, through risk equalisation, we insert an element of fairness into a system that is unfair across the board. There has already been much comment on the need to deliver a national health service and the promises of Sláintecare.

That is what Deputy Lahart and others said when they talked about universal, timely access. That is what is required within a system that works. If people had some faith in Sláintecare, it has been rattled by the fact that some of those involved in shaping its delivery have walked away from it. That emphasises the point that we must be serious about this. We need to put a coherent plan in place and deliver upon it.

Deputy Cullinane spoke about some of the other gaps we have in the system. We do not have an adequate primary care system which gives rise to a hospital-centric system. That has created particular difficulties during the pandemic, whereby people who could have their care delivered in the community in primary care and other settings are not getting the care they require, which means more people go through the logjam that is the hospital system. That is before we get into private healthcare being operated in public hospitals.

In the short time remaining, I will deal with waiting lists. We could talk about the numbers in hundreds of thousands. When my youngest child had an issue with glue ear, he required two operations to release it. I heard an interview with a lady whose son had been on a waiting list for 18 months, or possibly even longer, and she spoke about the damage done to his ear during the period. There was a lifelong impact on his learning. That is the cost of the system we have. We must put in place a public healthcare system that delivers for people. It is not beyond the Government to do that.

Róisín Shortall (Dublin North West, Social Democrats)
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Insofar as the purpose of the Bill is to get the approval of the House to establish the risk equalisation mechanism in order to support community-rated health insurance, and the decision must be taken on an annual basis, I have no difficulty with it. I recognise it for what it is. In the context of a private health insurance market, it is better that there is risk equalisation, lifetime community rating and so on, in order that people who have certain illnesses or are of a particular age that would make them more likely to develop illness are not penalised. The principles underpinning that are good. They were agreed many years ago, in 2013. In the context of the private health insurance market, risk equalisation improves it and makes it fairer and better.

From that point of view I do not have a difficulty with the Bill, nor do I have a difficulty with the additional provision in this year's Bill, which specifies the amount of risk equalisation along with a high-cost claims credit to enhance the risk equalisation. This credit will assist people of different ages and those who are unlucky enough to have serious illnesses and end up in hospital receiving very expensive treatment and staying for long periods of time.

The original risk equalisation was to provide something of a level playing pitch among different insurers and ensure the VHI in particular, which had a greater proportion of older members, would not be disadvantaged relative to other newcomers to the market. Just as risk equalisation was agreed, it is also important that there is equalisation to address a situation where an insurer has a disproportionate number of people with serious illnesses and therefore much higher claims. That is a positive development in this year's proposal. Insofar as it goes, I agree with that in the context of the private health insurance market.

I made the point on the previous occasion we dealt with such a Bill that we are having the wrong conversation. The conversation should be about how we run and fund the health service. At the moment, for many historical reasons, including undue influence of business and significant vested interest within the health service, we have a two-tier health service. It is a totally dysfunctional health service that achieves neither the best health outcomes nor the best value for money. That does not make any sense.

We have never had a properly functioning public health service, going back to the establishment of the State. In the 1950s, there was the mother and child scheme and all that flowed from that in terms of the political opposition to it. That is sometimes underrated. We hear a lot about the religious objections to the mother and child scheme, but the objections from the medical profession were just as strong, if not stronger, and they were supported and, let us say, indulged by the political system at the time. It is incredible that we still have not achieved proper, free public healthcare for mothers and children. It is outrageous.

We are a complete outlier when it comes to the rest of the Europe. We are the only European country that does not have a single-tier universal healthcare system. We are also the only country in Europe where a large majority of the population must fork out the full fee to see a GP. That is just unheard of anywhere else. In most European countries, primary care is free at the point of access. There are other countries where there is a nominal or small charge to see a GP, but we are the only country where large numbers of people must fork out €60 when they want to see a GP. That makes no sense at all. We should be encouraging people to get early access to healthcare so that when they have an ailment they get it seen to and treated at an early stage, rather than having a situation where an awful lot of people simply cannot afford to visit a GP because the cost takes too much out of their family budget. As a result, people leave conditions to fester and get worse and often end up having to go to accident and emergency units or being admitted to hospital for much more serious treatment.

Early diagnosis and intervention are key in healthcare. For this reason, rather than being scared of people visiting their GP too much, we should be encouraging them to avail of primary healthcare at an early stage to ensure there is early intervention, which is very important, and they are enabled to return to full health as quickly as possible and make a full contribution to society. That is not the attitude that is taken.

The very fact that nearly half of the population feel they have no choice but to take out private health insurance is damning of the State and successive Governments. Ireland, alone in the European context, has utterly failed to introduce a modern, universal public healthcare system. It is an absolute tenet of any modern democracy that there is a properly functioning public health service. We have utterly failed to provide that since the State was founded.

We are told that this legislation is about achieving equity and equity of access to private health insurance. I accept that is what it does, but the other issue of equity - equity of access to healthcare - is much more important. Private health insurance enables people to buy access. That means skipping the queue and going ahead of other people. We must consider why people do that. The reason is that it enables them to get early access to healthcare. We all want that. We have such a dysfunctional system. People on very low fixed incomes, who cannot afford private health insurance, will sacrifice many other things to be able to pay a health insurance premium.

It is such an appalling reflection on the state of our health system that people have to scrimp and save and make all kinds of sacrifices in order to achieve the kind of assurance that when they need healthcare, they will get it. We should not be putting people in that situation.

Others have spoken about other countries where, even with a properly functioning public national health service, people still take out private health insurance. Yes, they do and that is fine and they are welcome to do that, but the state is not promoting that, nor is the state subsidising it - that is the whole thing. In the UK, there is the NHS and it was originally very good, although starved of funding over recent decades, undoubtedly. However, even in that situation, almost 90% of people in the UK are more than happy to use the NHS. These include people on good incomes, high incomes and all of that and they are perfectly happy to use it because it is accessible, they can get seen to quickly and they are happy with the standard of the service. People talk about the NHS and the fact there are waiting lists and all of that, but it is a measure that the vast majority of people in the UK are happy to use it. They give out about delays and so on, but they are happy to use it.

That is not the case in Ireland. As I said, almost half of the population feel they have no choice because the public system is so unreliable. A Deputy spoke of a couple spending €3,000 on private health insurance and that is probably at the lower end of the scale. However, even where people fork out a number of thousand euro per year for private health insurance, and for the kind of peace of mind that gives them, it is still very bad value for money. They still have to pay to see a GP, they still have to pay to see a consultant, they have to pay to see a physiotherapist and they have to pay through the nose for diagnostic tests because these things, in the main, are not covered. It is about getting into hospital; it is about skipping the queue and getting early treatment in hospital.

It is bad value all round but it also creates that dysfunction within our two-tier system. There are all kinds of perverse incentives within our two-tier system so there is a huge pull factor for people to buy private health insurance and there is also a huge pull factor for staff to work in the private sector. The bottom line in all of this is that the better the public healthcare system is, the less profit there is to be made in the private sector. Equally, one would say that the worse the public healthcare system is, the more money there is to be made in the private healthcare system. There is never money made out of people being well. There is money made out of people being sick. If the public healthcare system does not work properly, as ours does not, if it does not meet the needs of the people, then it provides that huge incentive for the private sector to profiteer from the provision of healthcare.

That has been aided, abetted and facilitated by successive Governments down through the years. There are moral questions about that. It is a fundamental failing of government that the Government is incapable of providing a public healthcare system where equity of access to healthcare is guaranteed. Access to healthcare is fundamental to our existence for all of us.

That was where Sláintecare came in. It was to achieve the kind of universal public healthcare system that, as I said, every other country in Europe has. There was cross-party agreement on that. Regrettably, the progress on implementing it has been desperately slow. Successive Ministers have been happy to wrap the Sláintecare flag around them and talk the talk of Sláintecare, but not actually deliver the fundamental reforms that are contained in it. Unfortunately, earlier this year, we had the very high-profile resignations of two key people who were charged with leading out the Sláintecare programme. Again, that is absolutely damning of this Government and the last Government and their failure to give political commitment to the implementation of the universal public healthcare system.

We are told that those two people have been replaced by the Secretary General of the Department and the chief executive of the HSE. It is a very disappointing move because if the Department of Health and the HSE were capable of reform, they would have done it long ago. They are not capable of reform. There is institutional resistance to reform. The idea of putting the two senior people there in charge of the rollout of Sláintecare is laughable in many ways. We need political courage and we need political commitment to the principle of equity of access to basic healthcare. That is what has been lacking, that is what we need to see the Minister doing and we need the full Government behind that. Implementing fundamental radical reform of the health service is something on which we must have cross-government support. The Taoiseach has been running away from this, as have the Ministers. It is the responsibility of the entire Government to deliver on Sláintecare. This Government will be judged on its failure or otherwise in respect of that, rightly so.

It is also important to acknowledge the principles that were identified in terms of the emergency response over the last two years to the dire situation we face in the context of the pandemic. At an early stage, it was recognised that we have to treat everybody the same on this. Because there was a complete lack of capacity within the hospital system, the private hospital system was brought in and created that additional capacity in terms of hospital beds generally, of staff, of ICU beds and of high dependency unit, HDU, beds in particular. We could not have survived without that. However, in terms of accessing those, there was a very important principle, which was that access would be on the basis of health need. To a large extent, that is how the country has survived the full impact of the pandemic because the healthcare system became a single-tier system, so access to healthcare was on the basis of need, not ability to pay.

Imagine that through the big waves of Covid, and we are currently on the fourth wave, we were saying to people they could only get treatment for Covid if they could afford to pay. It would be totally intolerable. Imagine if we said to people they could only get access to vaccines if they were prepared to pay and if they were not able to pay and could not afford it, tough luck, they go to the back of the queue, they do not get the vaccines and they do not get the protection. That is exactly what we are saying to people who need other life-saving care. We are saying it is available to them if they can afford to pay, but tough luck if they cannot because they go on a long waiting list. We have to realise that this is such a basic thing for people and that the Government has such a responsibility in regard to ensuring proper access.

There are a couple of further points that need to be made. The first is in regard to the understanding about Sláintecare. Some people think they will not be allowed to have private health insurance under Sláintecare. That was never the case. If people want to buy private health insurance, they are free to go and do it. However, the whole approach in Sláintecare was that we would develop a high quality, universal healthcare system so people did not feel they had to take out private health insurance, irrespective of whether they could afford it or not, and I have used the example of the NHS.

We know, of course, that the Exchequer directly subsidises private health insurance to the tune of €377 million. However, that is only the topline figure that we are aware of and in a whole lot of other areas where tax relief is allowed for healthcare, the figures are not even collected by Revenue in such a way that they can be reported.

There is a huge element of hidden cross-subsidisation by the public purse of the private system, which again is bad value.

The other thing provided for in this Bill that I cannot understand is in section 4. The Bill proposes to increase what is referred to as the benchmark of reasonable profit from 4.4% to 6%. I do not know what the justification for that is. Health insurance companies are profitable and we know that when people get their annual notice to tell them what their premium is, many do not just accept that. Rather, they pick up the phone and tell their health insurer they have received a better quote and ask if it can do something about that. Within seconds the company agrees to drop the premium by 5% or 10%. We should encourage everybody to do that when renewing their insurance and people get that immediate reaction if they ring up, say they got a better quote and threaten to leave. If companies can drop their premiums in an instant then why are we saying their reasonable profit levels should go up? I ask the Minister of State to explain that. We know the health insurance sector was worth €2.64 billion last year so it is a massive market.

Some 47% of people in Ireland are paying for expensive private health insurance. What does that contribute to the overall health spend in the country? It is an amazing figure. It only contributes 13% to the overall health spend in the country. The public purse, which is funded from people’s taxes, funds the health service to the tune of 69%. There is massive cross-subsidisation from the public purse to the private sector. That figure tells it all and it is quite startling. We need to start making progress on this. What we have done on Sláintecare so far is not good enough; the public deserves better.

Martin Browne (Tipperary, Sinn Fein)
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This Bill primarily deals with risk equalisation, which seeks to ensure that costs are constant across the lifespan of the individual and are not influenced by factors such as age, gender and health status. It is the only element of equality that is brought to the private health insurance market. The fact that this must be done shows how it divides ready access to healthcare in favour of those who can afford to pay the costs associated with private health insurance.

According to the Health Insurance Authority, the average price being paid by policyholders on 1 January 2021 across all levels of products was €1,440. It is a massive amount of money that many people simply do not have to spare, especially when the cost of living is rising at such a rate. It is indicative of the inequality within the system that ability to pay for private healthcare determines how quickly you get seen. It is not just me or Sinn Féin saying this. Recent research by the Economic and Social Research Institute found that patients with private health insurance receive both outpatient and inpatient care more quickly than those without insurance. This is the two-tier health system that has long been promoted by Fianna Fáil and Fine Gael in order to make up for the shambles they have presided over when it comes to resourcing our health service. This is evident in the fact that under the Governments of the same two parties, Sláintecare has been ignored to such an extent that only recently, two top board members stepped down from the programme because of the lack of urgency in its implementation.

The Minister of State should ask any of the over 900,000 constituents who are on the waiting lists. Sláintecare called for a maximum wait time of ten weeks for an outpatient appointment and ten days for a diagnostic test. Let us take Tipperary University Hospital as an example. Of the 3,979 people on the outpatient list, 1,799 or just under half have been waiting over six months or 24 weeks. This is why we should be discussing universal healthcare where timely access is not dependent on how much you can afford, or on how much you are prepared to scrape together in order to avoid the lengthy lists. Privatisation seems to be the buzzword of this Government. The Minister of State will be aware of St. Brigid’s Hospital in Carrick-on-Suir. It has been closed by this Government and the public was told that private nursing homes would be relied upon instead.

Public community care is on the way out and community inpatient care will be on the chopping block if this Government has anything to do with it. In talking about beds in the community, will the Minister of State tell me if funding is being allocated in the national development plan for refurbishment of the wonderful Dean Maxwell Community Nursing Unit in Roscrea, and if the deadline of 1 January after which long-term stay residents will not be accepted will be extended? While we are talking about private healthcare, why is the Government not talking about providing proper funding to voluntary mental health organisations like CARMHA in Nenagh? It is doing tremendous work for people with addiction and mental health issues but it is facing the prospect of possibly having to close its doors in the new year if it cannot secure funding in the near future. CARMHA is operating on local donations alone, since the funding it received under the Rethink Ireland initiative has run out. It makes a huge contribution to our health system by providing services that are in short supply overall. I have written to the Minister of State asking her to meet CARMHA to discuss the issue and I hope that she will do so.

The Joint Oireachtas Committee on the Future of Healthcare of the Thirty-second Dáil recommended ceasing all private care in public hospitals and achieving a model where private insurance would no longer confer faster access to healthcare in the public sector, but would be limited to covering private care in private hospitals. We cannot delay on that any longer.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I want to set out my stall from the outset. It is no secret that People Before Profit and I do not believe in a two-tier health system. Even though we have a two-tier health system, I think the vast majority of people in this House do not believe in that system any more. If you look at other countries around the world that have a universal healthcare system, the outcomes are much better. The Minister of State can call me old fashioned or out of date but my party and I are ideologically driven by that and in favour of universal healthcare. That is why we will not vote for this Bill. It compounds the inequalities in our health system.

I understand that the Health Insurance Acts have to be renewed every year to bring a sense of solidarity and equality into private healthcare. The inequality in this is that we need to examine is the question of why people need to get private healthcare in the first place. Many Deputies have said that half of the population in this country have access to private healthcare and you would have to question why that is so. If you put the facts on the table it is clear that the vast majority of people believe in public healthcare and they also pay for it. The reason people take out private health insurance is that they believe they will be waiting X amount of months or years for access to public healthcare. That is correct, and Governments have allowed that to happen. Once a parallel system is in place in healthcare or in any area, you will have inequality. That inequality cannot be escaped once that parallel system is in place. Vast amounts of money are spent each year on public funding of private healthcare. This money drifts off and I argue there is no cost or social exchange to that. This is at the heart of a system that has gone wrong.

I want to go back to last year when the State took over 19 of the private hospitals in the State. I hope that in the future there would be no such thing as private healthcare, as people having to jump the queue or as people having to seek out private healthcare. There should be one system of healthcare. I do not know if the Minister of State believes in that personally or on a political basis but all evidence shows that where a healthcare system is universal and there are no stages to it the outcomes are much better.

The NHS in Britain is revered more than the royal family. It was founded after the Second World War because of what the British working class went through during the six years of that war. If the NHS had not been set up, there would have been a revolution in Britain because working people had enough of suffering and wanted a cradle-to-grave public healthcare system.

Many things have changed over the past 18 months. This public health emergency has showed us many things good and bad, but mostly good. Humanity has stepped up to the plate and public medicine has done so as well. Many things have gone wrong that cannot be fixed here, but one of the main effects of the ongoing public health emergency is that people and governments are asking themselves many questions. They are asking what is the right thing to do and what people want most from life and society. Some of those questions emanate from the last general election, which was defined by a number of issues, the main one being public service and our health system in particular. When asked if they want a health service that delivers, regardless of whether patients are on social welfare or millionaires, the vast majority of people in this country will say that they want a health system for all. The qualities of solidarity and equality that are the main thrust of most healthcare systems in Europe place them at the cutting edge.

I do not know if Fine Gael or Fianna Fáil can ever change their ideology. I do not think so because they are embedded in the market system of healthcare. On a personal level, the Minister of State might agree with me that there is no basis for a two-tier health system but actions and words must match. We can talk about Sláintecare, which is a good policy, but is it largely aspirational? We will see. We have been talking about a universal health care system for many decades but people will be judged by their actions. Can we deliver for the citizens of this country a system of universal healthcare? I believe fundamentally that Fine Gael and Fianna Fáil in government cannot do that. Once we have private healthcare in our system, we will always have inequality. That is why we need transformative change in how politics is done in this country. Unfortunately, that will not happen with Fine Gael and Fianna Fáil in government.

Denis Naughten (Roscommon-Galway, Independent)
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I welcome the opportunity to speak on this legislation. In this House on 9 November, the Taoiseach suggested, in response to comments from Deputy Tóibín about the reconfiguration of Navan hospital, that the Deputy should visit Roscommon University Hospital to see the expansion in the range of services there. I noticed that the Taoiseach said that when I was not present. He might have taken a different approach had I been present. However, having said that, I want to see if the Taoiseach is prepared to live up to his words and I hope that we can see some progress in relation to services. It is true that elective services have improved in Roscommon hospital but ambulance services have not. We also have the scandal that more services could be made available and more people could be treated in Roscommon University Hospital were it not for the deliberate blockage by the Saolta Hospital Group of the provision of the sterilisation facilities that are so urgently required.

I have with me a letter from the then Minister for Health, dated 9 October 2018, regarding the progression of the central sterile services department, CSSD, at Roscommon University Hospital. In fact, a state-of-the-art room in the hospital has been lying idle since 2018 because funding for the equipment has not been provided so that we can fully utilise the two theatres at Roscommon University Hospital. While some parts of the country are struggling in terms of staffing, we actually have the staff to run our theatres but we do not have the sterilisation equipment to ensure that we can maximise the throughput of patients. We have patients from right across the west of Ireland and the middle of this country who are waiting in pain on waiting lists. Some are waiting, sadly, to go to private hospitals, via the National Treatment Purchase Fund, NTPF, to access treatment that could easily be available at Roscommon University Hospital if the funding was provided for sterilisation facilities.

A headline from a local newspaper on 25 October 2018 reads, "New CSSD Unit for hospital confirmed". That was on foot of a commitment I obtained from the then Minister for Health, Deputy Harris, at the time. The newspaper outlined that agreement had been reached between Roscommon University Hospital, HSE Estates and the Saolta Hospital Group to proceed with the unit. The then local Senator, now Aire Stáit at the Department of Health, Deputy Feighan, said at the time, "Based on my discussions with Minister Harris, I am confident this project brief will be progressed to design stage as quickly as possible next year". He went on to say that he had "repeatedly highlighted the need to put a long-term solution in place". Absolutely nothing has happened since then. A brief was prepared and presented to the steering group on 13 November 2019 and there it has sat since.

On 15 September 2020, the Minister for Health, Deputy Donnelly, told me in reply to a parliamentary question that further information was currently being collated in order to future-proof the decontamination requirements of the whole Saolta Hospital Group. That had been going on for 12 months at that stage. The Minister went on to tell me that the HSE had advised him that this exercise would be completed by the fourth quarter of 2020. However, I was told in a recent reply that this is exactly where the project stands today. We have been waiting for three years for the naval gazing to finish because the Saolta Hospital Group and HSE Estates are determined not to fit out a state-of-the-art building. I will tell the Minister of State what is in that building today. The Minister for Health visited Roscommon University Hospital recently to see the new endoscopic facilities there. He passed by the door of the CSSD unit. Inside that unit are walking frames, crutches, beds and wheelchairs because it is now being used as a storage facility. This is a facility that could be used to help to provide treatment to people who are waiting in pain. Instead of that, those people will eventually, through the NTPF, access that treatment in private hospitals. It is just not good enough that for the sake of a small amount of capital funding, we cannot fit out a building that is there already. It is very disappointing.

As the Minister of State will know, I have tabled an amendment for Committee Stage that we will deal with tomorrow. I am not sure if the Minister of State, Deputy Butler, or one of the other Ministers of State in the Department will be taking Committee Stage.

The reason I am questioning the commitment in respect of Roscommon University Hospital is because there is a lack of commitment generally within the health service to our smaller hospitals. The difficulty is that, in the main, consultants do not like travelling. They do not like travelling from the regional centres to the smaller hospitals where there is capacity, where patients can be treated and where we could address some of the monumental backlogs and waiting lists we have. If consultants do not travel, it does not happen. I can give practical examples from what has happened in Roscommon. The Taoiseach is right that the services have increased there and that, thankfully, we have a problem with car parking at the hospital. However, that is because we have had two very progressive consultants who happen to come from County Roscommon, who have dramatically expanded the services there and who provide services that are the envy of any other hospital in the country in the context of urology and plastic surgery. Why is it that we have to rely on our native consultants to provide those services? Why are we not seeing other consultants from within the Saolta Hospital Group providing services? Saolta was the first hospital group established in the country. It had claimed that it was committed to expanding the services and the level 2 hospitals, but that is not happening.

Tomorrow we will see the exact same thing happened with my amendment and health insurance. This will be the fourth year in a row that I will raise the specific issue of smaller hospitals not being covered by Irish Life Health. It has specifically discriminated against the smaller hospitals that could help to ease some of the pressure of the bigger hospitals across the country. To be fair to the previous Minister for Health, Deputy Simon Harris, back in 2019, he did give a commitment to look at the matter. However, the current Minister for Health in a recent reply to a parliamentary question told me that he will not be doing that. I was told that Sláintecare is being implemented, that it is about taking the private health insurers out of public hospitals and that we will use smaller hospitals as guinea pigs in that context. If we want to use guinea pigs, surely it should be the major hospitals that we use because you would start with where there is huge pressure on beds and waiting lists. Of course, that would have an impact on the consultants, the same consultants who will not travel to the smaller hospitals, and they do not want to see their income being impacted in the regional centres. That is why the smaller hospitals are not being protected by the Government in the context of the decision taken by Irish Life Health.

I will make two final points. I echo the comments of colleagues, particularly Deputy Shortall, on Sláintecare. It is imperative that we do drive forward with the reform relating to Sláintecare. However, that does not mean we should use the small hospitals as guinea pigs for it when clearly we are not - as with the example I gave in the context of Roscommon - prepared to put the capital investment in to deal with it. The Minister of State should not come in and spin this yarn to me that the Government is not putting the thumbscrews on Irish Life Health because we want to use the smaller hospitals to drive forward the Sláintecare reforms. If that was the case, the Government would be putting the capital investment into the smaller hospitals but that is not happening.

I want to see Sláintecare come to fruition. We need a single, unified health system. That is why, along with former Deputy Michael Harty, I insisted during the negotiations on the programme for Government in 2016 that there be an all-party committee established to look at this matter and to set down a long-term plan for our health system. That was because I had seen during the previous 15 years I had been in politics that it all depended on the Minister who was it behind the desk on a particular day. As soon as that Minister left, the permanent government would revert to form and the new Minister would come in and would have to start the battle again. It was important, therefore, that there was consistency across Government and political parties. It is imperative that, despite the push-back from the permanent government, we see the Parliament, parliamentarians and politicians taking ownership of Sláintecare and driving it through.

This legislation will reduce the cost of insurance but this will only happen in April when the bulk of people will have already renewed their health insurance. I actively encourage every single person who gets a renewal of their policy to please shop around because there are significant savings to be made. There are a number of companies out there which specialise in that. I actively encourage people to go to those companies, shop around and make those savings, because that will bring about some of the change that is needed.

Matt Shanahan (Waterford, Independent)
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I welcome the opportunity to contribute to the debate. We are talking about reducing the amount of money paid to insurers by way of risk equalisation on the basis of the criteria of age, gender and level of cover, also known as age-related health credits. We are introducing a new system of high-cost claim credits and reducing the stamp duty payable on all health insurance policies that feed into the central support fund. I presume these actions have been costed and are deemed to be beneficial or else I do not expect the Minister of State would have proposed them. She indicated that the scheme is revenue neutral and that any surplus or deficits that might occur will be rolled over into subsequent years. She has noted the high take-up of insurance which stands at 2.3 million. That is to be applauded. However, I would also point out that there is a large discrepancy between policies, as the Minister of State knows well. People tend to gear up their policies as they grow older because, notwithstanding risk equalisation, the chances are that policies at the lower end will not cover you for some of the serious health obstacles you may face as you age. As mentioned by previous speakers, there may be a couple of pensioners paying between €3,500 or €5,000 for a high-level scheme. That seems very difficult for people who have generally paid tax all their lives. It may be that this Bill will deal with some of those inequities.

Private and public hospitals and private and public work have been raised several times during the debate. It is very hard to compare what happens in the public hospital sector with what happens in the private hospital sector as they generally relate to different streams of activity. Someone in the private hospital system will be looking for fast, straightforward, repeatable exercises that you can turn around and that basically create fee income. That is what private hospital care is largely based on. The public system is the social contract that we have whereby we decide that we will look after everybody regardless of their health needs. That also includes those with very chronic health needs across a range of medical areas who require lots of care and ongoing treatment both in hospital and in community. That cost is picked up largely by the public purse. When we talk about Sláintecare, therefore, we are talking about trying to get the efficiencies of the private system while having public good at the heart of the policy. It will be a very difficult circle to square, to be quite frank, because there is a great deal of work to be done to try to generate that.

Others have spoken of the need to implement Sláintecare, but I would point out the significant obstacles in the recruitment of qualified medical personnel.

At present, we are engaged in talks on a new contract for hospital consultants. Many newly qualifying doctors will tell you they are not going to work in the public system for the contract that is being offered to them but are going to emigrate instead. Thus, we will have spent the money educating them but we do not have any system or bursary to provide medical training that would contract them to work in the system for one, two or five years, as is done in other countries. We just educate them and let them fly. At the other end of the scale, there are people who have worked as hospital consultants for 20 or 30 years and may still have time to run on their contracts but they are not going to stay in the system much longer because, quite frankly, they have had enough of a lot of it. We have much reform to deliver on that.

I raise also waiting lists, tests and scans. Deputy Naughten has just highlighted how level 2 hospitals can do much of this work and I agree. They should certainly be funded by the private health ensurers and that is an easy initiative to put in place if the will is there. There are also a couple of schemes around the insurance-backed long-term care. I point to the VHI Hospital@Home, which is system where a VHI patient whose needs are chronic, not acute, may be able to get minded in his or her home. Essentially, VHI will pay for people to come and deal with the patient at home. That is a very efficient system for releasing beds in our public hospitals as well as in the private ones. Similarly, there is the outpatient antimicrobial therapy, OPAT. At the moment, we have patients coming into hospital and taking up a bed for half a day or a day to receive antimicrobial therapy. That can be done quite easily in the home if we have the nurses or qualified doctors to do it. I am aware there is a pilot being discussed at the moment but we do not need to pilot that. This is simple stuff. We should just decide we are going to do it and see what resources we have to do it with. I will be supporting Deputy Naughten's amendment. It is discrimination against model 2 hospitals that any health insurer would not be paying for procedures that they pay for in other hospitals. They are the same procedures. I agree with him they should not be remunerated under the fund until that case has been levied.

As I said, I wonder if Sláintecare is realistic in the form we are currently discussing. The Minister of State knows I have been around healthcare for a long number of years. One of the things I have notice about many policy discussions is they generally do not include those who actually have to deliver the service. We talk about what we are going to do on efficiency but we do not speak to the nurses. We talk about what we are going to do on high-level clinical management but we do not speak to the clinical nurse managers and we rarely involve the consultants, to be quite frank. I do not take the view, as other Deputies might, that somehow the consultants are an outlying class in medicine and all out for money. I know very many who are quite the opposite. They are very much pastoral people and their first inclination is to serve, mind and look after their patients. We have created the consultants' contract they work under and many of them are quite happy to work under the system. However, they want support and the proper resources. They want resourcing at junior levels that is adequate to their needs, that is, they need registrars, house officers, junior doctors, clinical nurse managers or secretaries. The consultants are getting tanked off, basically, because when they go into the system they do not have that. That is why we are hearing so many people saying the system is dysfunctional. The system is difficult and it will remain so while public healthcare is offered to all. We must learn from the efficiencies in the private sector and see how we can bring them across into the public sector while getting risk and payment equalisation for all.

Sorca Clarke (Longford-Westmeath, Sinn Fein)
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I welcome the opportunity to speak on this Bill because it provides important measures to ensure age and health status do not lead to price discrimination. However, it would be a real dereliction of my duty as a TD if I did not take the opportunity to outline the current state of healthcare provision in my constituency of Longford-Westmeath. I think all parties in the House have at some point given a commitment to working towards a universal public system where people are treated on the basis of need and not on ability to pay but are we actually any closer to providing meaningful healthcare reform? No, we are not. Are we any closer to that universal, national health service? No, not really. That is why 40% of people in the country rely on health insurance in a market worth €2.5 billion annually across three main providers. The number of people availing of and reliant on private health insurance has increased consistently since the recession. One of the main reasons for that, and the reason people who can ill afford to spend hundreds if not thousands of euro on these premiums annually do so, is fear. They themselves fear they will get sick or that a family member will, and we all know the fastest route to assessments and treatment is private health insurance. That is a fact. It is one I find abhorrent but it is a fact nonetheless. It is also indisputable that those who cannot afford private health insurance are left languishing on a public waiting system watching the days, weeks, months and in some cases years go by as they wait for that all-important appointment to arrive.

I have a constituent who maintains that while the official cause of death of his beloved wife was cancer, in reality she died from poverty. She had gone to the doctor and was waiting for an appointment for scans and diagnostic tests but without private insurance time was passing by and her condition was deteriorating. Martina presented to her doctor while in severe pain. Frustrated and concerned the GP rang an ambulance and she was admitted through accident and emergency, where she got the necessary tests and the treatment began. She was in hospital for her fourth dose of chemotherapy when her first public appointment letter arrived. Now, her widower is left torturing himself with the what-ifs. What if they had private health insurance? What if her diagnosis and treatment had begun sooner? It is hard to dispute his logic and his conclusion that his wife died because she did not have insurance and therefore did not have access to the timely care and treatment she so desperately needed while she was still alive.

There can be no denying we have a two-tier healthcare system that needs to be phased out once and for all. The reality is that people get treated more quickly based on their monetary work and their bank balance rather than their health needs. That shameful situation needs to end. We should have no more cases like Martina's. There should be no more tortured widowers.

Richard O'Donoghue (Limerick County, Independent)
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This health insurance Bill is about looking at the risk equalisation scheme for all health insurance providers. This is one of the many Bills that have been brought forward so the amount of money paid to the health insurance companies by way of credits can be reduced. These risk credits are paid on the basis of age and gender. Risk needs to be spread so newer entrants coming into the market also bear the cost of risk. The money paid into the equalisation fund comes from a stamp duty paid from every policy sold. There are two distinct pay-outs, namely, risk equalisation credits and hospital utilisation credits. Risk equalisation makes it easier for insurers to carry higher risk profiles, for example, those with higher medical costs because of age, medical history etc. so they can compete in the market with other providers. As happens with all insurance claims, there must be an incentive for the insurance companies to fight a claim. On this, instead of paying out excess amounts, the Government is now proposing to pay a portion of the claim. This should also help reduce the stamp duty paid on all policies. Sections 5 to 7, inclusive, will revise the section relating to equalisation credits, health credits and the high-cost claims. I understand this will be enacted in January 2022.

The National Treatment Purchase Fund, NTPF, indicates 644,458 people are now waiting for their first appointment. The number of people waiting on a day care procedure is 74,662. This is harrowing and very upsetting. The NTPF also pointed out 217 people have been added to the public hospital waiting list every day since the start of the year.

Some nine people every hour are added to our waiting lists. The Minister of State said earlier that costs are escalating in hospitals. Where is the money going? People are paying insurance to sit on a chair for a day or two or to sit on a trolley for a day or a week. Where is the money going, if it is not going into front-line services? It is not going towards paying our nurses. Most of the positions that have been advertised are managerial or administrative. Why are so many of our Irish nurses leaving the public hospital system? Some of them are going to private hospitals and some are leaving altogether because of the way some of the hospitals are being run.

When will we audit the CEOs of all the public hospitals and the management system? I will make it very clear that a public hospital should be run the same as a private one when it comes to its management system. I see that private hospitals, if they are not run properly, will not stay in business. I am the person who said in this Chamber that some public hospitals have shorter waiting times, shorter waiting lists and their patients spend less time waiting on trolleys and chairs to be seen. One or two of the public hospitals have an ongoing record, since the CEOs were appointed to them, of a situation that is spiralling out of control. I am disappointed to say that one of the hospitals with the highest numbers is always University Hospital Limerick. I want the management and CEO structure in that hospital to be audited and checked to find out why it has the largest number of people waiting on beds. Why does it have the largest number of people waiting on trolleys for hours and hours, and even days, to be seen?

The front-line staff are not the problem; it is the management system. We cannot, at any stage, blame our front-line staff, especially when other hospitals do not have the same issue. Public hospitals do not have the same issue. I did not realise I could speak on my first day in the Dáil. All I had was a small piece of paper on which I wrote one or two notes to give me something in case I got airlocked.

Mary Butler (Waterford, Fianna Fail)
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That would not happen.

Richard O'Donoghue (Limerick County, Independent)
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No. I have been in business all my life and the one thing I have always said is that you have to have a management structure. I want to know why the hospital system has changed so much. When I was in Barrington's Hospital as a young lad, which is now a private hospital, a patient was released no later than 11 a.m. If that patient was not well enough to be released by then, he or she stayed in. The structure of the bed system meant the patient stayed in until the following morning when rounds were done by doctors and consultants and, if the patient was fit and well enough, he or she was released. I receive reports day after day from the hospital system of people being released at 7 a.m., 9 a.m., 11 a.m., 2 p.m. and 7 p.m.

The system is completely wrong. It is a management system and not a front-line care system. All public hospitals need to introduce a system whereby a patient who is not released by 11 a.m. is not released at all. In that way, those working in front-line services are given the chance to go to the computer to check whether they have five beds free on a given floor and will know what they have. There will not then be nurses ringing upstairs and downstairs to see if a bed is free for somebody who needs it. That is where the chaos arises. It is a management and structural problem and not one of front-line staff. That change has not happened.

I am in the Dáil for almost two years, I have been asking for this structure over that time and it still has not happened. I want the Minister of State to tell the hospitals that this is the structure that must be implemented. Not only will beds be released by 11 a.m., front-line staff who have to prepare those beds for the next patients will be given a chance to return beds to the ward by 1 p.m. and nurses will then know that they can manage their hospital. That is a structure. If that structure was introduced, it would take the stress and anxiety away from nurses and healthcare workers trying to make sure that people are in beds. It would also relieve the trolley crisis.

I have seen people waiting in hospitals for two days to see a consultant. When they came out, after meeting a consultant, they got huge bills from their insurance companies, which they had to sign if they did not sign them in the hospitals. They refused to sign until they saw the huge costs in those bills for waiting and taking up a bed from a person who could have been terminally ill, or very sick, and waiting to get into hospital. That person was left on a trolley downstairs while the insured person waited for a consultant to see them in the public system. I want the help of the Minister of State, the Minister and the Government with this.

I support what is being done in this Bill. When supports are being put in, I support them. At this stage, the issue is bigger than this Bill. It is about the waste of money, waste of people's time and waste of bed units. We can help people, front-line staff and hospitals with a structure, but not until we get the CEOs and management structure right and audited. If a person is in a job and is not doing it properly, he or she should be removed. Let us put in somebody who can manage the structure. I will do whatever I can to help implement this, but I want a commitment from the Government that it will honestly look at it. I see this issue as the biggest reason our nurses are leaving some of our public hospitals. I have checked other public hospitals where nurses are not leaving. It is because a structure is in place whereby they can do their job, and help and care for people, without the stress of trying to manage and run a hospital with no structure.

I ask for the Minister of State's help to help me get the right people in place, including the Minister, Deputy Donnelly, to audit the CEOs of the hospitals. I said that I am disappointed that I have to stand in the Chamber as a Limerick Deputy and say that University Hospital Limerick has one of the highest waiting times in the country, which has been the case for a number of years. Covid is not causing this situation. Every other public hospital has the same issues with Covid. University Hospital Limerick has a management and structural problem. I ask every Deputy and Minister to help put a structure in place and audit the management of our public hospitals.

If any public hospital has gone above and beyond and has an excellent structure, let us introduce that into Limerick and fix the problem there. That is what I am asking for. Let us stop people coming to the Chamber to complain about the front-line service. It is not the front line; it is the structure. I ask for the Minister of State's help.

Thomas Pringle (Donegal, Independent)
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I want to read in some records on assessments and care plans:

There is evidence that these plans were updated regularly by staff, management and on occasions by a multidisciplinary team however, the contents of the plans rarely changed, nor did Brandon's behaviour change or improve over this period of time, except during periods of ill health... This can be best understood by comparing the first recorded plan for Brandon in November 2003 with the final available plan twelve years later in January 2015.

"All staff need to be aware that Brandon has a history of inappropriate behaviour.. Brandon needs to be supervised at all times by staff... Any untoward behaviour documented..." (Management plan, 20th November 2003).

"Brandon has touched other service users in a sexually inappropriate way... Brandon should not visit other houses... Brandon should not have access to newspapers, magazines and photographs during the day... Brandon is to be supervised when watching TV" (Proactive strategy, January 2015).

In a risk assessment and management plan dated 31st August 2004 the guidance for staff was that they should familiarise themselves with the Health Boards policy "Prevention of Challenging Behaviour" as a means by which to manage Brandon's sexual assaults on other more vulnerable service users. However, there was no evidence that staff were provided with training, at that time, in the implementation of this policy.

Management strategies for Brandon's behaviours

A common management strategy employed to deal with Brandon's sexually assaultive behaviour was to move him around various wards. Brandon was moved a total of nine times in the fifteen year period of this review. The movement of Brandon from ward to ward began on 12th July 2005 when a decision was taken to move him from 'Breaffy to 'Abbeyside' because "Abbeyside would be a safer environment due to (the) level of supervision and male staff available". Brandon was moved to 'Abbeyside' that day, however, due to his level of distress and the fact he wanted to go back to 'Breaffy', he was moved back again that night. Four days later on 16th July 2005 Brandon was then transferred to 'Castledaly'; "transfer to Castledaly due to his nursing care needs - hoist".

On 3rd January 2006 it is recorded that 'Brandon needed an urgent transfer from 'Castledaly' ward'as he was causing major upset to clients, he was subsequently moved from 'Castledaly' back to 'Breaffy' on 2nd February 2006. On 14th June 2007 he was transferred from 'Breaffy' to 'Abbeyside', due to his 'increased aggression towards others. Brandon very difficult to manage...Brandon require(s) male staff 24 hours...Brandon transferred to "Abbeyside" today'.

By December 2008 he was transferred to House 1, in the Stillwater complex. While each of these moves provided some respite to the staff and residents of the ward Brandon was vacating, unfortunately they also gave him access to other residents many of whom became new victims of his abusive behaviour.

At a staff meeting on 4th May 2011, it was also confirmed that a particularly vulnerable resident targeted by Brandon (resident 1) who had no speech and was unable to call out for help had been moved to a different house for his own safety. The decision to move this resident was subsequently reversed five weeks later in a review meeting held on the 9th June 2011 which stated "Resident 1 to return to house 1 in Stillwater because a management plan is in place regarding Brandon's behaviour. The physical environment had been made secure. Alarm applied to bedroom door". The decision to return resident 1 to this unit with Brandon after he had moved for his own safety is very concerning. The review panel believe the assumption the bedroom alarm on Brandon's door would ensure this vulnerable resident's safety is erroneous, as the alarm on Brandon's door had been in place since 30th June 2008 with limited success. In a staff meeting one week later on 15th June 2011 it is recorded: "(it was) acknowledged that Brandon has the capability of opening and closing the door to sound the alarm in an effort to dupe staff"suggesting that Brandon had figured out how to beat the alarm.

Six Month's later on the 22nd December 2011 Brandon was moved to house 2, in the Stillwater complex to live by himself, away from other vulnerable residents. While this move resulted in a sharp reduction in the number of sexual assaults recorded, unfortunately, on 4th September 2013 he was again moved back again to house 1 to live with residents he had previously assaulted.

Brandon's move to house 2 appears to have been the only successful strategy employed in the management of Brandon in that it did provide some protection, albeit short term, to other residents. The reason for Brandon's move back to house 1 was recorded in a "Protection of Vulnerable Adults Strategy Meeting", 19th September 2013.

"...on the 15th August 2013 Brandon became unwell and following this was unable to weight bear and as a result required additional staff to manage his care needs so he was transferred to House 1... It was agreed that due to Brandon's recent deterioration in his health he was no longer able to participate in inappropriate sexual behaviour".

The assessment that Brandon was no longer a risk to others turned out to be inaccurate. According to a document referred to as a "Primary Risk Screening Form" dated 9th September 2015 (two years later) the risks of physical and sexual harm to others from Brandon continue to be identified...

A risk rating scored '25' is the highest risk rating score that can be applied to risks as per the HSE's 'Integrated Risk Management Policy' (2011). On 9th May 2016 Brandon transferred to a nursing home. The nursing home has documented that the reason for Brandon's admission to them is: "Nursing Home) received a request to assess Brandon for long term nursing care in April 2016 from (Stillwater) services. Disclosure was given on an alleged pattern of sexually abusive behaviour and that the transfer was essential because the alleged victim was still resident in the same accommodation as Brandon".

This extract from the nursing home documentation demonstrates that management in the HSE believed Brandon continued to be a risk to other residents in Stillwater and that his abusive behaviour was continuing.

This view is shared by the CHO's Safeguarding and Protection Team's (SPT's) principal social worker who, on 31st October 2017, spoke to the CHO's Chief Officer and said:

"Brandon poses a risk to other vulnerable adults of sexual abuse. Responses to date are that the risk Brandon poses are minimised due to his now limited mobility, however, I do not agree that this is an accurate reflection of the risk as Brandon's behaviours were primarily centred on exposing himself to peers and exposing peers to sexually inappropriate behaviours... Clearly, limited mobility does not minimise the risk of this to an extent whereby other vulnerable adults are protected"...

"The staff at the current environment within the resources available try to limit these incidents which are on-going. If the move to the new house happens now this could reduce the number of these assaults for the most vulnerable group and improve the quality of life for all concerned".

On two occasions psychiatrist (1) also sought a second opinion from other external psychiatrists. The first external opinion was from psychiatrist (2) who reviewed Brandon on 19th March 2008. Psychiatrist (2) brief note states:

"Very difficult management problem...sexualisation probably due to underlying affective disorder...no quality of life due to mental state".

In April 2011 a second external review was sought from a psychiatrist (3) who completed an assessment of Brandon on 12th April 2011. Psychiatrist (3) submitted her report to psychiatrist (1) and service manager (1) on 27th April 2011. This five-page report provides a concise synopsis of what psychiatrist (3) describes as Brandon's "seriously abnormal sexual behaviour". The report outlines two particular problems: "excessive masturbation"and "contact sexual behaviour". The psychiatrist (3) described the residents living with Brandon as "very vulnerable to the sexual threat of opportunistic, predatory and recidivistic approach of this man". Psychiatrist (3) report went on to make a number of recommendations including: - "It is totally inappropriate to allow this man to continue to live with and sexually exploit vulnerable learning disabled men...

-The fact that relatives of his known victims have not been informed of the episodes of abuse could be interpreted as collusion or complicity if the situation were ever the subject of an investigation...".On 4th May 2011 at a staff meeting the issues referred to in the psychiatrist (3) report were discussed and it was concluded that "the residents of house 1 are at risk of sexual advance from Brandon at any time"...

Reports to external managers.

...The first reference of concerns about Brandon being escalated to senior management was in a letter by psychiatrist (1) to his GP dated 7th February 2008 which stated; 'I will be speaking with senior nursing staff in relation to the management of Brandon's behaviour. I will be raising the issues in managing this type of individual within current resources with the local health manager'.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I rarely interrupt Members, but it is some stretch of the imagination to relate that case to the subject matter of the business-----

Thomas Pringle (Donegal, Independent)
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We are discussing a health Bill and I listened to other Members who did not strictly adhere to that.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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I ask the Deputy to connect the subject matter-----

Thomas Pringle (Donegal, Independent)
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I will connect it up at the end.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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We are getting there.

Thomas Pringle (Donegal, Independent)
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I was working towards that-----

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Go on.

Thomas Pringle (Donegal, Independent)
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-----because it is vitally important.

On 6th July 2008, psychiatrist (1) subsequently wrote to the local health manager in the area referencing the'relocation of residents from Abbeyside...to the 'Stillwater complex'and urging the relocation to take place sooner rather than later. The letter also stated "three residents in particular are at a significant risk of both physical and sexual assault from the other residents". The letter also stated "one patient requires constant supervision due to a combination of frontal lobe damage and mental illness as he is opportunistically assaulting others sexually".

The general manager (2) in his capacity as acting local health manager for the County Community Services responded on 15th August 2008, "We have commenced the process of recruitment of staff nurses which will enable us to complete the opening of Stillwater complex... by October... The move to the new houses should take place in October and this could reduce the number of these assaults and incidents on this most vulnerable group..."

It is clear from this response that senior management viewed the move to the Stillwater complex as the solution to Brandon's inappropriate behaviour. However, a short time later in or around December 2008 Brandon was also moved to the Stillwater complex to share house 1 with five other vulnerable residents. It is not clear why the decision to move Brandon to the Stillwater complex was made, however, the consequences of this decision turned out to be devastating for all the other residents living in house 1...

The letter from six staff members, 26th February 2008.

The concern and frustration of staff working with Brandon is evident in a letter dated the 26th February 2008 addressed to the multi-disciplinary team meeting (which took place on 4th March 2008). This letter was signed by six nursing staff members. This letter is a significant milestone in the overall account of Brandon's assaults on others and demonstrates the deep level of concern that these six staff members had about vulnerable individuals in their care. The letter described Brandon's behaviours in 'Breaffy' ward and how these behaviours continued in the 'Abbeyside' ward. The letter stated that"although initially well behaved (when he moved to the Abbeyside) Brandon soon resumed sexually assaulting his fellow residents".

The letter goes on to say that "the more staff intervened to prevent this behaviour, the more violent, aggressive and argumentative towards staff he became". The letter also warns that "despite the higher level of supervision... Brandon's assaultive nature was increased where he will... blatantly touch others in the company of staff and within seconds of staff providing a duty of care elsewhere..."