Róisín Shortall (Dublin North West, Social Democrats)
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I was waiting for a Minister from the Department of Health to come in.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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I apologise. It is an issue of availability on the Front Bench.

Róisín Shortall (Dublin North West, Social Democrats)
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Is anybody from the Department of Health available today?

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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No.

Róisín Shortall (Dublin North West, Social Democrats)
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There is a senior Minister and three Ministers of State, and not one of them is available.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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They are not available.

Róisín Shortall (Dublin North West, Social Democrats)
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That is really not acceptable. What we are doing has to be done every year. It has been on the schedule since last week. It is not on that no one from the Department of Health is here today.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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I appreciate that.

Róisín Shortall (Dublin North West, Social Democrats)
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Is there a point in going ahead with this?

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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Of course there is.

Róisín Shortall (Dublin North West, Social Democrats)
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I am not sure there is. I cannot understand what the point would be if there is nobody from the Department of Health present.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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The Bill is scheduled to be dealt with. When we were scheduling it, we were not aware as to who would be here. It is scheduled and, therefore, we must proceed.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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It is a busy time towards the end of the year.

Róisín Shortall (Dublin North West, Social Democrats)
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Everybody is busy, but this is health legislation and somebody from the Department of Health should be here to take it. I will cut my comments short because this seems to be a bit of a waste of time. I spoke yesterday evening about what is happening with the health area and the fact there is a symbiotic relationship between the public and private services of the health area. The public service is being run down. The more the public service is run down, the more potential there is for profiteering and making money generally in the private sector.

The official policy is supposed to be about developing a properly functioning public health service. As the Minister of State is a member of the Green Party, he might just take this on board, because it affects all of Government. What seems to be happening is, officially, the Government is in favour of Sláintecare but, while it is talking the talk, more aspects of our public health service are either being run down or privatised and hived off. We are seeing various sections of our public health and social care services taken over by private sector organisations. The aim is to extract wealth from the public health service and that is what is being done. Whether it is home care, disability services or nursing homes, commercial interests see an opportunity to extract wealth from the public services and they are taking that wealth. That, in turn, runs down basic public health and social care services and we have a considerably weakened public health service as a result.

While Ministers talk the talk, they do not walk the walk with healthcare. More and more people feel that if they want to get basic access to healthcare in a timely way, they have no choice but to take out private health insurance. That is especially the case for people who might be regarded as vulnerable, have underlying conditions, older people, or people with a family member who has a disability. It is a shocking way to treat people. They are forced into a situation where they have to fork out for private health insurance in order to have some chance. Nearly half the population feel they have to do that even though large numbers of those people cannot afford to pay for private health insurance, nor should they be made to feel they have no choice but to do that.

On the other side are people who do not have private health insurance, cannot afford it, or are opposed to the very notion of it. Some people feel there should be a social contract. If they are paying their taxes, then in return, they should have access to timely healthcare. Many people believe that and it should be the case, in a properly functioning, modern republic, that if people pay their taxes, they should have access to public services, with healthcare being a fundamental service. This is not working. People are not getting what they deserve.

It is a basic human right to have access to health and social care services when needed. As a result of the failure of successive Governments to honour that commitment to the public, many people in this country lose their lives every year because of the failure of the health system to meet their needs. People die on trolleys, isolated at home, waiting to see a consultant, or waiting to access services. Other people find themselves in a situation where they have an underlying condition that is worsening all the time because they do not have access to services. When people in those circumstances can eventually access healthcare, they often end up finding that their condition has deteriorated significantly. They may have had to give up work, for example, if they have bad arthritis in their hips or knees, meaning they are not mobile any longer. People are often forced into situations where they have to give up work. The family income drops significantly, which has an impact on the entire family. They end up waiting for years to get necessary, basic knee or hip operations or to have cataract surgery. They are immobilised and lose their ability to live life fully and participate fully. That happens on thousands of occasions every year. This huge impact on people's quality of life and their ability to live independently and earn an income for themselves and their families is a significant issue.

The other scandal is the thousands and thousands of children whose childhoods are being marred and held back by the failure of successive Governments to provide access to necessary therapeutic services. There is supposedly a legal right to assessments of need. There are long waiting lists. Children with special needs are supposed to be seen by early intervention teams in those vital early years. How many examples do we have of children ageing out of early intervention? Once they get to the age of five, they are moved to another waiting list, which is a scandal. Years are wasted for children and there is a negative impact on their childhood due to the failure of Government to provide basic services, including an assessment of need and recommended therapeutic or specialist services. This happens all over the country. Parents are at their wits' end because of the failure to provide that basic service.

Due to the lack of timely access to therapeutic services, when people finally get to see a consultant or even when they have been attending a general practitioner over and over again with the same problem, because they need access to specialist care, they are asked if they would consider going to a private service. They are told they will have to wait for two or three years on the public list. People are made to feel they have no choice but to pay to access basic public healthcare. If someone in the family comes up with the €250 it costs to see a consultant, after people have been forced into seeing a private consultant, they may be put on the waiting list for a procedure more quickly. That is exactly what is happening in this country. People are forced into a situation where they feel they have no choice but to borrow, beg or get money however else to pay to access the private service because the situation is so poor and public waiting lists are so long. They are forced into a situation, if they can afford it, where they make other sacrifices so they can pay for private health insurance.

I came across a case that the Minister of State, Deputy Noonan, might raise in Government circles sometime. An elderly woman, who was in her late 80s, was living in a nursing home. She needed intravenous antibiotics. Her GP referred her to an emergency department, so her daughter brought her to the emergency department. She was taken to an emergency department on the north side of Dublin. She waited for six hours. After six hours, her daughter felt that she could not possibly put her mother through that agony for any longer and took her back to the nursing home. The family came together that evening to chip in and come up with the €250 so that their mother could go to the emergency department, following the referral by the GP, the next morning, in the private wing of the same hospital. She was seen straight away. Two other older people in that private emergency department had the same experience the previous day. If that is not a perverse incentive, I do not know what is. In such circumstances the boundary between public and private healthcare and how they are funded is blurred in our supposedly public hospitals. There is an incentive for a hospital to whittle down its public services because it knows that if services are weak enough, patients will do everything they can to go to the private element of the same hospital. That is indefensible and immoral.

This is happening throughout our health service. There are issues with public and private systems, where the money goes and no sight of how much public funding that goes into hospitals is spent on public or private care. There is little or no supervision of where consultants are working. That is the quagmire that is our health service at the moment. We are spending €22 billion on it and about half the population feel they have to take out private health insurance.

It is important for those in Government to see the growing number of people who feel they have to have private health insurance. The number is growing by about 2.5% each year. It represents a political failure in the provision of health services. Health is critical because it impacts our lives so much.

Not to ensure an adequate public health service is a failure of Government. We are going in the opposite direction as more and people feel they have no choice but to take out private health insurance, whether they can afford it or not. As I said, nearly half the population has private health insurance, and it is very expensive private health insurance.

We might look at the spend on health in the country and where the money is coming from. Around 70% of the money for the entire health service comes from taxpayers, so it is State money. We then have what are called out-of-pocket expenses. That is where people, even if they have private health insurance, still have to pay €200 or €250 just to see a consultant. Then there is the expenditure on GPs. In the rest of Europe it is pretty well unheard of that a person who wants to go to a GP, who is the first point of contact when there is an issue, must pay €60. That just would not be tolerated in any other European country. It is another out-of-pocket expense. Then there is the amount people pay for drugs, as well as all the other therapeutic services people need, including speech and language therapy and physiotherapy. Such therapeutic services should be an integral part of our health service but we know they are not. You need to have a medical card, first of all, and if you do, you then go on a long waiting list, and it is so patchy all around the country. Those out-of-pocket expenses account for about 15% of the health spend. The nearly 50% of people who have private health insurance might wonder how much it contributes to the overall spend. It contributes about 14% or 15% to it, and we should bear in mind that, as I said, nearly 50% of the population has private health insurance. That is a very surprising figure. Half the people are paying for expensive private health insurance, yet it only contributes about 14% or 15% to the health spend. The only conclusion we can come to is the public sector is hugely subsidising private healthcare. That is the reality of how our health service is operating.

In the last few minutes available to me I will speak about Sláintecare. There is no excuse for this Minister or this Government not to reform the health service and bring us into line with every other European country that has universal public services which the vast majority of people are happy to use because they function properly. They uphold people's rights and provide that public service because people pay their taxes. We are a complete outlier in that context as our public health service does not function properly. The Government's official policy is Sláintecare, yet it is just not happening. There is massive resistance. Obviously, it is from the many people and organisations making a lot of money out of private healthcare. They are the vested interests that are holding this back. It is not only them but also the private hospitals, as well as certain consultants who want to see more and more private work. We have the drug companies and the insurance companies. I refer to all those organisations with muscle and significant skin in the game. They do not want their profits impacted by any Government decisions. They are the people who are holding this back but they are aided and abetted by a weak Government that does not have the courage or the foresight to drive through a reform programme. Along with housing, this is undoubtedly the biggest failure of Government. It is such a basic thing in life to have access to healthcare and, unfortunately, the majority of our population is being denied that.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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This annual legislation is necessary to support the community-rated health insurance market in Ireland. The risk equalisation credit and stamp duty levies are critical to the sustainability of our health insurance market, which is designed to be equitable and fair by spreading the cost of health insurance across the entire insured population. This ensures everyone pays the same price for the same health insurance product. We must sustain community rating in our health insurance market so older citizens and people with illnesses can afford health insurance and are not discriminated against in favour of younger people.

I had to go through that because I wish to raise a few issues with the Minister of State. The Health Insurance (Amendment) Bill 2022 provides that stamp duties on non-advanced health insurance contracts will decrease to €109, which is a decrease of €12 and comes on top of a decrease of €35 again this year. I welcome that. The stamp duties on advanced healthcare insurance contracts will increase to €438, which is an increase of €32. Despite this, the increased levy on the advanced cover will still be lower than in 2021 when it was €449. However, the stamp duties collected on health insurance contracts do not go into the Exchequer. They are collected into the risk equalisation fund and redistributed in the form of credits to health insurers to compensate for the additional cost of insuring older and less healthy people. People are getting older and it is important we look after them and legislate on this.

I had to look into all this because I have had many phone calls to my office from elderly people who are now cancelling their private health insurance. They are doing so because of the cost of living. They cannot afford to pay their private health insurance. One particular lady came in who was very upset. She had had private insurance for more than 30 years and had worked all her life. It was so unfair for her. She told me she always had the security that, if she got sick in the morning, she could get into a hospital or in for an operation but now she was fearful. While I welcome this Bill, we need to have a good overall look at our health system and ensure people, and elderly people in particular, who always had health insurance do not lose it now because they feel they cannot afford it. Even though these changes are good, I feel that is what is happening. I always feel a medical card is nearly like a gold card because with a medical card you have your GP and your prescription. Many people are now qualifying for their medical card but many of them like to keep both. They like to have their medical card but some, if they can afford it, like to have private health insurance too. We need to do more. We are a country in which people are living longer, thank God. We need to address some facts in our society. People are waiting for operations. I have people waiting on cataract surgery. I have people waiting on hip operations. There are so many people who are waiting on operations. That needs to be addressed first of all and it was brought up by another Deputy, but there are huge issues that we need to look at. I am sure the Minister of State will be aware of them from his own clinics.

As I said, I had to go through all this myself. I want to go back and explain to the people who are coming to me about this particular legislation. We need to do more. We need to help the people who always had private health insurance or would like to have it. It is a bit of a security blanket for people. I am thinking of the people who have paid for it all their lives. I am repeating myself but the people who are contacting me now feel we need to do more for them. I therefore ask that we look at doing more and that we try to help the most vulnerable. I am aware this is not the Minister of State's remit and he is stepping in for the Minister, Deputy Donnelly, but we need to look at the system overall because there are people who really need help. I ask that we look at that.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Deputy Boyd Barrett is sharing time with Deputy Gino Kenny.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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The only reason we need this legislation is because of the shameful fact that we have a two-tier health system. Consequently, huge numbers of people, nearly half the people in this country, are so frightened of what will happen to them when they get sick, given the state of the public health system, that they feel it necessary to pay out large sums of money every year in order to have insurance so they might access private healthcare in the event that they are sick. They do it out of fear. It is obviously not their fault that they are afraid. It is the fault of the Government that it presides over a public health service that is failing people so disastrously.

That is not in any way a criticism of the heroic healthcare staff and professionals we have in the public health service, who work under the most extraordinarily difficult circumstances. The nurses, midwives, doctors, porters, orderlies, cleaners and allied health professionals do their very best for people but they are crushed by the lack of adequate and, for the most part, safe staffing in our hospitals and health services. They are dealing with massive backlogs and record numbers of people. In the month of November in particular, we saw the highest number of people on trolleys on record. When people are faced with that sort of disastrous situation in our public health service, it is no wonder they are terrified into having to take out private health insurance. It is a source of shame that that is the situation, that people are encouraged to buy into the idea that if you have money, you can get a better standard and quality of healthcare than if you do not.

As Deputy Murnane O'Connor has pointed out, as the cost-of-living crisis impacts on huge numbers of working people, they are having to make very difficult choices. With the cost of heating their home, the cost of feeding their family and the cost of just about everything going up, the pressure will come on and they may decide they cannot really afford the private health insurance premiums and will let them drop, with all the associated fear that goes with that.

I was asked by somebody who recently suffered a tragedy to read something into the record. I will only do it because they have asked. It is pretty harrowing. You kind of understand the sense of despair and anger people feel when they go through situations like this. I will not have a chance to read it all but it is from Karen - I will not give her second name - who wrote the following:

This letter is mainly about the health service and what all the ministers of health and all past and present governments did, or [are] doing to help, which is basically nothing to change the system.

On the 6th of November 2022 my brother passed away, it took 55 minutes for an ambulance to arrive to my family home 55 minutes due to your cuts. My family lives 10 minutes away from St Vincent University hospital and it still took 55 minutes.

We couldn't get him down the stairs to get him out to a car, we needed help, we needed our health care providers, he needed them to save his life, that night was a complete nightmare for us. Being helpless, being told after ringing a few times it was on the way, watching out windows and doors waiting on help.

I live further away from my family home, his home, and I arrived before the ambulance did, he was still alive, when I arrived, he was in so much pain. He wasn't a drinker or on drugs, we will have to wait to find out how and why he passed.

I will not get into the political stuff but she goes on to absolutely castigate the parties of Government. She is very explicit in the letter that she is not blaming the ambulance workers, who she says were wonderful when they arrived, but places the blame for all of this squarely on the shoulders of the Government.

Why did that ambulance take 55 minutes to make a ten-minute journey from St. Vincent's Hospital? We probably know the answer, because the ambulance drivers have told us. They are sitting outside the emergency departments because those emergency departments are overrun. They cannot discharge people from ambulances, and so they sit in a queue in St. Vincent's Hospital and other hospitals and are therefore not able to go out as quickly as they should on calls, even ones ten minutes away from the hospital. Why is that happening? Another letter I got this week kind of explains it. It is to do with staffing and our inability to staff the public health service. This letter is from student nurses and midwives. It reads:

Dear Deputy,

Student nurses and midwives are working and training in unprecedented conditions in the health service. On top of this the Government has failed to implement an agreed report to address significant costs associated with travel, subsistence, accommodation, and uniform costs associated with our clinical placements.

We are affected by the same cost-of-living challenges as our qualified colleagues, with many of us struggling to meet the costs of transportation, fuel, heating, accommodation, and other necessities required for students to complete our training, including the additional burden of obtaining accommodation away from home during placements, and the costs of acquiring and laundering uniforms.

The McHugh report, originally published in August 2021, and accepted by Government, was aimed at bringing allowances for student nurses and midwives in line with the expenses incurred as part of their training, and recognizing the additional challenges placed on students while they made their extraordinary contribution to the frontline pandemic workforce. However, many recommendations of this report, which were due to be implemented by September 2022, have yet to be implemented, and student nurses and midwives continue to struggle to meet the costs of our training.

I do not have time to read it all but the writer goes on to talk about the enhanced reimbursement scheme for student nurses and midwives, travel costs, subsistence costs, the fact that even just going to work each day they are paying about €9 in parking charges and the cost of the uniforms they were promised they would be given. Another simple thing is the cost of laundering those uniforms. She also writes:

The COVID-19 pandemic proved that student nurses and midwives are an essential part of the healthcare workforce in Ireland, and that recognising our high level of skills and training was an important part of keeping those skills in the Irish health service. The long delay in implementing these measures undermines that recognition, shows complete disregard to us as student nurses and midwives, and will not encourage the current cohort of students to build their careers in the Irish health service where they are so badly needed. Furthermore, this delay has no regard for the very significant cost of living pressures we are experiencing.

She goes on to plead with the Minister to address that.

We can put the two things together. If this is how we treat our student nurses, is it any wonder that the vast majority of them say, as they have in survey after survey, that once they qualify they will leave the country? Consequently, we are massively understaffed in hospitals so when ambulances arrive at St. Vincent's or any other hospital, there are not enough staff to deal with the people there and to open the wards and beds. Often the beds are sitting there empty but we do not have the staff to open them. Then if you listen to the radio you will hear the ads for the private hospitals, saying "come to us". There are no queues there, if someone has private health insurance and can afford it. There is a sort of hierarchy, is there not? People can get a better package of health insurance depending how much money they have. That is abhorrent. It is obscene. It is obscene that we have the health capacity, or much of it, we actually need to have a decent and dignified health service but it is only available to those who can pay. In our public health service, we cannot retain and recruit the staff we need to prevent the sort of tragedy that woman and her family had to go through because we do not treat the staff properly.

We must have a national health service, with cradle-to-grave healthcare, not a two-tier system or a system where the healthcare people get is dependent on how much private health insurance they can get. The idea of a private health insurance market is frankly abhorrent, with people profiting from this health misery when so many people are suffering.

We need to do away with that two-tier system but in order for that to happen, we need to resource the health service and, crucially, treat the people who work in it properly so we can actually recruit and retain those nurses and allied professionals so they want to work in a health service that actually delivers decent healthcare for everybody regardless of the size of their pocket.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I am disappointed that there is not a Minister with responsibility for the health portfolio here. It is not acceptable. We should have been notified before the debate. I am not blaming the Minister of State as I do not think he should be in this position, but we should have been told in advance that there would not be a Minister present. It makes a bit of a mockery of the debate really. The Chamber is empty as it is but to have no Minister for the brief or from the Department is a bit demoralising to say the least.

I will soldier on because the issue of the two-tier health system is very important and we have had it for decades. There was a glimpse of what could and should be during the pandemic when we saw something that has not happened for a long time in this country: there was no such thing as a two-tier health system. How could a two-tier health system exist when up against the pandemic? The State took over 19 hospitals at huge expense given the vast amount of money that goes into private healthcare. We saw a glimpse of what could happen. I believe the vast majority of people would agree that we need a one-tier universal health system but we have a two-tier system. Once a system is in place where private healthcare competes against public healthcare and the kind of narrative exists where people tell themselves they will get better care if they have private healthcare, there will be inequalities. Once that system is put in place, there will be the terrible inequalities which happen on a daily basis.

There are many people who have worked all their lives and ideologically they will not buy private health insurance on the basis of solidarity with other working people. They pay taxes yet they are second-tier citizens when it comes to healthcare. I think that system is wrong. I am sure the Minister of State agrees with universal healthcare. Everybody seems to agree with it but does not seem to do anything about it. Sláintecare, which is not perfect by any means, tries to address some of the inequalities but even it has its shortcomings. Around the world, including in Europe, countries that have universal healthcare have better outcomes for everybody whether you are social welfare or are a millionaire. It has been proven that health outcomes, both mental and physical, and the health of the country, are better. When there is a system in which 50% of citizens rely on private health insurance, then you are going to have a system of inequality and of hierarchy. We do not have confidence in our public health service. I worked in the public health service. Once you are in it, it is brilliant. The people who work there, across a whole range of jobs, are absolutely incredible. Once you get into the system it is really good and everybody will say that. That is a good thing but there should not be vast resources going towards private healthcare. We need to get away from the model of a two-tier system. I am probably repeating myself with this mantra.

Where will this all end? Sláintecare is trying to address some of the main inequalities. I am not so sure about that as a model. It has its shortcomings to say the least but this and successive Governments still promote the idea of private healthcare and stealth private healthcare. Once that exists in society, there will be inequalities. It exists in education and in the economic system and it is compounded by successive Governments which allowed it to happen. Once it is allowed to happen, there will be a "them" and "us". In that system, people will suffer and die and people will go without.

It is pretty heartwrenching to see somebody who has worked all his or her life, has paid all the taxes and did everything right being left on a trolley for three days. I swear to God, if it happened in any other country, there would have been a revolution. There would be a revolution because it is just not acceptable. People pay all those taxes and in their time of need they are told they have to wait in a corridor for three days. It is absolutely not acceptable. That is why ideologically People Before Profit is against a two-tier health system. We need universal healthcare. The NHS is not perfect by any means but it is revered in Britain, even more so than the royal family, because it does one thing: it is a national health system. From cradle to grave, generally it will look after you. There are obviously progressive elements in British society, but obviously the Tory party has been there for a long time and is not a beacon of progress and socialism but the NHS is a great model. It is a model we should try to copy because once you have a system that is based on equality, it will be a better system for everybody regardless of what you earn.

Michael Lowry (Tipperary, Independent)
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Paying for health insurance is an expense that increasing numbers of Irish people now equate to the importance of paying their mortgage or rent. In excess of 2.3 million people now have some form of health insurance. Between April 2020 and March 2021 at the height of the pandemic, private health insurance companies gained almost 38,000 new customers. Ironically, also due to Covid-19, claims submitted by policyholders dropped by 27% in the same period as people avoided health settings. Despite this, when a semblance of normality returned, all three of the country's health insurers took the decision to increase the cost of premiums for customers. Very few people cancelled their policies. It is easy to understand why Irish people now place such importance on having health insurance. It is viewed as buying peace of mind. In fact the incentive to play on vulnerability when it comes to our health is a powerful sales pitch for insurance companies. They are pushing an open door in the Irish market. Irish people feel a huge sense of vulnerability when it comes to healthcare. Ongoing issues with accessing public healthcare at all levels have caused people to become more afraid of becoming suddenly or seriously ill. People feel reassured by the belief that they will wait less than three months for a medical appointment in the private system. They compare this to waiting indefinitely in the public one. The result is that health insurance is no longer considered a luxury but a necessity. The blame for this lies firmly on our failing public health service. People have lost confidence in a service that consistently fails to meet their needs.

Every day, in my constituency of Tipperary and every constituency, we hear stories of people on lengthy waiting lists for some form of treatment. Children are languishing on lists for all forms of healthcare for unacceptable periods of time. Out of hours GP services such as Shannondoc in north Tipperary provide all night coverage in Nenagh only. Ironically, Nenagh is the only town with a hospital. Meanwhile the services in the town of Thurles and Roscrea close at 11 p.m. Not every family in these towns has the transport readily available to get to Nenagh in the middle of the night yet if they cannot, they must wait until GP surgeries open the next morning. This is risky and obviously highly dangerous.

In recent years it has become impossible to replace retiring GPs in rural towns and villages. Large numbers of patients are without this core service. The centralised ambulance service results in Tipperary-based ambulances being despatched to other counties around the country. This leaves our own county without an emergency service and leaves patients who require urgent care waiting for an indefinite period. The nearest model 4 hospital to north Tipperary is University Hospital Limerick, UHL. Tales of overcrowding at the emergency department there have become almost legendary. In fact people have been quoted as saying they would rather risk suffering at home than laying endlessly on a trolley at UHL.

At the root of all these problems is a lack of staff. The common denominator is that we are unable to retain or entice people to work in healthcare in Ireland. The staff that have chosen to remain in our health service are doing a remarkable job. This is a fact that must always be acknowledged. We have dedicated and competent doctors, nurses and paramedics working at all grades throughout the country. However, we are continually driving them away. They are overworked, underpaid and undervalued. We tend to forget that they have options. More and more of them are taking alternative options. Those who are young enough are leaving the country. Those who are old enough are taking early retirement. Many between these two brackets are switching careers, yet we continue to do little or nothing to prevent this from happening. Many of our Irish-trained doctors and nurses have chosen to emigrate to countries where their skills are reflected in the wage they earn and where they have a proper work-life balance. Some do so shortly after they qualify. Some even choose to train in Ireland with the sole plan to emigrate as soon as they graduate. Irish-trained medical professionals are sought after and valued all over the world yet our own health service provides neither the incentive nor the encouragement to stay in Ireland. Instead we send private recruitment companies to far-flung places to recruit doctors and nurses to care for Irish patients, while our own medical professionals wave goodbye. It was recently revealed that the HSE cannot state how many healthcare staff have been successfully hired by these private companies. This is despite the fact that the HSE has paid these companies no less than €15.5 million since 2020 in their efforts to tour the globe and attract staff. When questioned by media recently, the HSE claimed that the figure is not centrally available. Has the Department this information? Can I get an answer to that question?

We are here today to debate amendments to the Health Insurance Act, particularly the issue of adjusting the risk equalisation scheme for 2023. When will we be here to reopen discussions on Sláintecare? The concept of providing a single-tier healthcare system was published in 2017. It was afforded a ten-year timeline for implementation. This Government is set to remain in power until 2025, just two years short of that timeline. Despite the problems encountered to date with Sláintecare, will the implementation of the single-tier health system be something on which this Government will focus in the next two years? If something is not done to address the crisis the exists in the provision of healthcare, the problems will continue to spiral out of control. This has the potential to surpass the enormity of the accommodation crisis that currently exists. The solution lies in the political will to take immediate and assertive action.

I ask the Minister of State for assistance. Earlier today I contacted the office of the Minister, Deputy Stephen Donnelly. Will the Minister of State take a personal interest in this and see whether he can get his Department and the HSE to move? I have a letter, and I will not read out the name or address of the child involved, but the parents wrote to me regarding the lack of provision of community-based paediatric palliative care in the south east. The Minister of State is familiar with the south east. They write on behalf of their seven-year-old son, which no parent should even have to contemplate in their situation. Their son has been battling stage-4 cancer for almost two and a half years. He has endured a gruelling treatment schedule. Unfortunately due to the aggressive nature of the condition, he has relapsed and the disease is progressive. He has been under the remit of the palliative care team in Crumlin since February this year. They were informed that due to where they live, community paediatric palliative care services will not be available. This has been the case for all terminally ill children in the area since the services were withdrawn in 2017. To date, they have done everything in their power to ensure that their son’s care is home based. They want and expect their son to be afforded the opportunity to die at home, to have the same access to community-based paediatric palliative care services that he would have if he was an adult in their area, or indeed was a child in most other community areas in the country. It is unacceptable that their son may have fewer choices with regard to end-of-life care due to geographical, political, financial or resource issues. Time is not on their side. As such they need a response to be actioned urgently.

Since diagnosis, their son has endured endless cycles of chemotherapy. He had his kidney removed, high doses of chemotherapy, a stem-cell transplant, and 39 sessions of radiation, as well as multiple bone marrow aspirates, innumerable blood transfusions and other medical procedures. They travelled with him to hospitals in Barcelona and Utrecht in the hope of accessing further treatment and clinical trials not currently available in Ireland. He has had the best medical care available in Ireland and has bravely fought every step of the way. He received excellent care from his oncologist and all the staff of St. John’s ward, Crumlin hospital whose help and support are greatly appreciated.

The point being made is that the child undoubtedly is in the last phase of his battle against this horrendous disease. The least he deserves is the chance to die at home with his family, in his own community, surrounded by those who know and love him. This should not be considered a privilege or something that parents should have to question when every moment they have left together as a family is so precious. They are not looking for special treatment, just equity of care that their beautiful seven-year-old boy would have the same access to end-of-life care as adults in his community would, and as most other terminally-ill children in the country have. These parents do shifts driving 14 runs to Dublin every week. They know the prognosis for their child. They are obviously emotionally distressed and have the physical burden of driving to and from Dublin for two hours each way. The mother does it by day and the father at night. To be told by officials in the Department and by the HSE that they cannot bring their son home to die in his own home because the palliative care services will not allow it is not acceptable.

I will give the details of this case to the Minister of State and ask him, if he does anything meaningful or positive this evening he will be doing this family a great service if he could knock some sense into the HSE services in this area, and find a resolution to allow this boy to come home and enjoy the support, comfort and companionship of his mother, father and brothers in his own home.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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That is a heart-rending story. If the Deputy wishes to table that for a Topical Issue matter on Tuesday, I guarantee I will select it. We will do our best to ensure that some of the Ministers from the Department of Health will be here to deal with it. That is not something that should have to be brought up to the floor. I appreciate the fact that the Deputy saw no other alternative. It needs to be deal with.

Michael Lowry (Tipperary, Independent)
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Thank you, a Cheann Comhairle. I appreciate that. I appreciate that the Minister of State will do his best.

The reason I raised it is because of the urgency of the situation. If it has to go through officials without encouragement from the Minister, I do not think we will get a result in time.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Perhaps the Minister of State, Deputy Noonan, will work on it. If the Deputy wants to table it for Tuesday, we will do that. I call the Minister of State to respond to the debate.

Malcolm Noonan (Carlow-Kilkenny, Green Party)
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Before I reflect on the contributions of Deputies, I give my commitment to Deputy Lowry that if he passes on the details, I will do all I can. It is a heartbreaking story and my thoughts are with that young boy's family and with him. It is a traumatic time. For end-of-life care, it is critical there is coverage throughout the country. The manner in which the family’s wishes are respected is very important, whether it be in hospital, in palliative care or at home. The wishes of that family in that young boy’s end-of-life care are very important and it will be comforting to them in the future that they have had that care. I ask the Deputy to please pass on those details to me and I will relay them back to the Minister on his behalf. I thank him for that.

I want to reflect on some of the contributions of Deputies so far. At the outset, I note a number of Deputies have been critical of the fact there are no Ministers from the Department of Health here. I am a Minister of Government and our officials are here, and we are taking note of all of the comments and contributions of Members. It is a busy time towards the end of the year. I acknowledge that Ministers are incredibly busy but I am doing my duty in being here to represent the Department and the Minister.

I will start with a general comment in regard to Deputy Shortall. It is disappointing to see language that is talking down our public system. We have an excellent public health service, although the Deputy used language like “extracting wealth from the public services” and she said the Government is “officially” in favour of Sláintecare. We are actually delivering Sláintecare as per the programme for Government, and I want to state that. I feel there is general commentary and a tone to the contributions that it is public versus private and that our public service is somewhat not to be trusted. That is not the case. We have an excellent public service, and I know Deputy Gino Kenny reflected that with regard to people accessing services. It is somewhat disappointing to hear Deputy Shortall in particular say the Government does not have the courage to implement Sláintecare. Deputy Shortall had an opportunity to participate in government and did not have the courage to see that through either. That is quite disappointing. Health outcomes are improving across all services, which has been reflected, although, again, Deputy Shortall referenced a case.

On the points raised by Deputy Murnane O’Connor around stamp duty, the Bill provides for a decrease in the age-related risk equalisation credits payable across approximately half of age groups over 65. These decreases are to facilitate the redistribution of high-cost claim credits which result in a more targeted distribution of credits based on health status rather than on age, which is a fair approach.

Deputy Boyd Barrett referenced the cost of living, coupled with the ability to retain staff in the health service. Again, while it is not related to this Bill, the Government has implemented a very significant cost-of-living package in budget 2023 that the ESRI assessed and found was progressive and targeted. The interventions we are putting in place are trying to support families in terms of the cost-of-living crisis we are facing.

Deputy Lowry raised points in regard to increased premiums and the out-of-hours services in Nenagh. I take on board those comments.

I thank the Deputies for their support for the Bill and their contributions to the debate yesterday and today. As was discussed many times throughout the debate, a large number of people hold health insurance. This is a choice for some while others, unfortunately, may view it as a necessity. The Government is fully committed to the Sláintecare vision of a universal single-tier health and social care system. Work is continuing within the Department of Health and the HSE to progress work on Sláintecare, and the Minister for Health and the Government remain fully committed to the continued delivery of Sláintecare reform.

Private health insurance policy aims to align progressively with Sláintecare reform objectives. A number of Deputies referred to the consultant contracts and moving this forward as being a vital step. The Government is committed to introducing a Sláintecare public-only consultant contract in a timely manner in the near future. This process is ongoing under a new chair agreed between the parties, Mr. Tom Mallon. When the date of the implementation of the new contract is set, the new consultant contract will apply to all consultant appointment offers from that date.

Various other issues were raised over the past two days. If Deputy Ó Laoghaire or any other Deputy with specific constituency queries would like to send the details to the Minister for Health, officials will look into the matter. A number of constituency issues were raised today by Deputy Murnane O'Connor and others, and I urge the Deputies to bring those specifically to the attention of the Minister for Health.

This Bill allows us to maintain our support for the core principle of community rating, which is long-established and well-supported Government policy for the health insurance market. The Bill will ensure we can continue to provide the necessary support to ensure the costs of health insurance are shared across the insured population. The provisions of the Bill increase the effectiveness of the risk equalisation scheme by reallocating credits based on age to credits based on health status in the form of high-cost claim credits without increasing the stamp duty payable.

Deputy Duncan Smith questioned if there is a policy decision on community rating and if it is still needed. The Government is committed to improving public health services under the Sláintecare programme and this Bill shows the Government is committed to community rating. As access to public services improves, the Department of Health will monitor the impact on the private health insurance market.

The programme for Government commits to retaining access to private healthcare services for people, ensuring choice for those accessing healthcare. The Bill continues our policy of ensuring solidarity with, and affordable premiums for, less healthy or older people. I commend the Bill to the House.