Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I move: "That the Bill be now read a Second Time."

I am pleased to introduce the Health (Amendment) Bill 2025, by means of which it is intended to enhance the oversight and accountability of the Health Service Executive to both the Minister for Health and the Minister for Children, Disability and Equality. The Bill addresses a number of goals arising from the Sláintecare implementation plan, which highlighted the need to shift away from the previous directorate structure of the HSE towards an independent board overseeing a chief executive officer. The HSE board was established through the Health Service Executive (Governance) Act 2019 and has been in operation since then.

Given the implementation of the HSE health regions and the accompanying changes to the governance and structure of the executive, this is an opportune time to introduce these amending provisions and strengthen the oversight relationship between the Department of Health and the HSE. The provisions in the Bill will ultimately enhance the governance of the HSE, the relationship between the executive and the Government and subsequently improve the standard of care offered to those who make use of its services.

Since the foundation of the HSE board, the Department of Health has extensively consulted with the HSE and, more recently, with the Department of Children, Disability and Equality to develop robust and effective governance, oversight and accountability structures and processes. The structures and processes are guided by the founding legislation of the HSE, the executive's code of governance, the separate but complementary oversight agreements between the two Departments and the HSE, and the code of practice for the governance of State bodies of the Department of Public Expenditure, Infrastructure, Public Service Reform and Digitalisation. The Bill's provisions will build upon these structures and processes to further enhance the HSE's accountability while retaining the independence and autonomy of the HSE board.

The purpose of the Bill is to ensure a more formal alignment of HSE and Government planning processes and to introduce more robust financial oversight measures, particularly in regard to any expenditure that exceeds the maximum amount allocated in the annual letters of determination issued by both the Department of Health and the Department of Children, Disability and Equality. This is achieved through the introduction of a number of new measures.

The Bill introduces an obligation on the Minister for Health to prepare a strategic direction statement in respect of health service priorities to guide the HSE in the preparation of its three-year corporate plan. The statement will specify the Department's priorities for the three-year period in question and may also specify particular goals or outcomes related to those priorities. The statement will be prepared in consultation with the Minister for Children, Disability and Equality. Similarly, the latter will have an obligation to prepare a strategic direction statement in respect of specialist community-based disability service priorities. These statements will issue to the HSE simultaneously no later than three months before the expiry of the corporate plan in operation at the time. The statements can be amended at any time throughout the three-year period if and as necessary.

The Bill provides for the replacement of the national service plan with a performance delivery plan. It places an obligation on the Minister for Health to issue an annual statement of health service priorities to the HSE. The statement will guide the executive in the preparation of the performance delivery plan and will contain priorities that are consistent with the contents of the strategic direction statements in operation at the time. The annual statement of health service priorities will be prepared in consultation with the Minister for Children, Disability and Equality. The latter will prepare a similar statement of priorities for specialist community-based disability services, to issue simultaneously and at a date no later than the issuing of the annual letter of determination from each Minister. The statements can be amended by either Minister in consultation with the other.

The Bill places an obligation on the chief executive officer of the HSE to notify in writing the executive's board, the Minister for Health and the Minister for Children, Disability and Equality if the CEO forms the opinion that the HSE is likely to exceed its allocated expenditure for any given year. When doing so, the CEO will be required to submit corrective action proposals for the approval of the HSE board. These proposals must outline the reasons for the projected overspend and the actions taken to attempt to avoid it. The proposals must be in line with the strategic direction statement and statement of priorities at the time. Either Minister may request that the HSE amend the proposals if they are deemed to be inconsistent with the strategic priorities or corporate plan in operation at the time or do not have sufficient regard to Government circulars or priorities.

The Bill makes a number of miscellaneous amendments that are required by outlying changes or to address practicalities arising from other provisions. These include, for example, the extension to 28 days of the 21-day deadline for the submission of the HSE performance delivery plan and the HSE capital plan to the Departments of Health and Children, Disability and Equality. A number of provisions correct references to sections of the Health Act 2004 that are being amended, removed or substituted by the Bill. The Bill also makes an unrelated amendment to the National Cancer Registry Ireland, NCRI, establishment order, which seeks to increase the membership of the board and amend the quorum arrangements accordingly. This addresses a recommendation in the Scally report to review the composition of the board of the NCRI.

I will now outline the provisions of the Bill section by section to clarify its content. The Bill comprises 28 sections. Section 1 is a standard provision giving the Title of the Bill and when it will come into effect.

Section 2 defines the Health Act 2004 as the principal Act referred to in the Bill.

Section 3 repeals sections 10A and 10D of the principal Act, which relate to the setting of priorities for the HSE by the Ministers for Health and children. The proposed new process for the setting of priorities is outlined in sections 17 and 18 of the Bill.

Section 4 inserts a definition for an approved performance delivery plan, which is to take the place of the definition for an approved service plan contained in the principal Act.

Section 5 amends the object and functions of the HSE to include a specific and explicit obligation to have regard to Government circulars related to expenditure as well as other relevant documents in the performance of its functions.

Section 6 updates a reference to the service plan to refer instead to the performance delivery plan being introduced in the Bill.

Section 7 amends the principal Act to account for the repeal of section 10A. Specification of priorities and performance targets to the HSE by the Minister for Health, which is currently facilitated under section 10A, will instead be provided for in section 17 of the Bill.

Section 8 updates a reference to the service plan to instead refer to the performance delivery plan being introduced in the Bill.

Section 9 amends the principal Act to account for the repeal of section 10D. Specification of priorities and performance targets to the HSE by the Minister for Children, Disability and Equality, which is currently facilitated under section 10D, will now be provided for in section 18 of the Bill.

Section 10 amends the functions of the HSE board to include an explicit obligation to ensure systems are in place to provide assurance the HSE is achieving the highest standards of budgetary management and value for money and is operating within authorised resources. It also requires the board to ensure compliance with Government circulars related to expenditure as well as Government policies, codes, guidelines and other relevant documents. Section 11 similarly amends the functions of the chief executive officer to include the same provisions as those in section 10.

Section 12 inserts definitions for each of the new strategic direction statements and removes the definition of an approved service plan.

Section 13 inserts a number of provisions outlining the obligations of the Minister for Health regarding the strategic direction statement in respect of health service priorities. These provisions include instructions on the content of the statement, the time of issue and the amendment process. The statement must be issued in consultation with the Minister for Children, Disability and Equality. Section 14 similarly outlines the obligations on the latter in regard to the strategic direction statement in respect of specialist community-based disability services.

Section 15 outlines the new obligations of both the HSE and the Government regarding the preparation, content, submission and approval of the HSE corporate plan. The section requires the plan to be prepared within three months of receipt of the strategic direction statements and in a manner consistent with the priorities of the Departments of Health and Children, Disability and Equality.

Section 16 corrects a reference to a provision that is repealed by the Bill. The section updates the reference to account for the new structure of section 29 of the principal Act.

Section 17 outlines the obligations of the Ministers for Health and Children, Disability and Equality and the HSE in regard to the annual statement of health service priorities that will guide the executive in the preparation of the performance delivery plan.

It also details the contents of the statement deadlines for issue, the amendment process and other relevant considerations. Section 18 similarly outlines the obligations of both Ministers and the HSE in relation to the annual statement of priorities for specialist community-based disability services.

David Cullinane (Waterford, Sinn Fein)
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On a point of order, will copies of the speech be circulated?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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We can do that. I might speak to the Deputy about that matter again.

Section 19 details the obligations of the Minister for Health, the Minister for Children, Disability and Equality, Deputy Foley, and the HSE in relation to the performance delivery plan, which will replace the service plan. The section also outlines the requirements for the preparation, timeline for submission and content and approval of the plan.

Section 20 outlines the processes for amending an approved performance delivery plan. Either Minister, after consultation with the other, can issue a direction to the HSE to amend an approved plan and can specify the manner in which it is to be amended. The amended plan must adhere to the same requirements as the initially approved plan.

Section 21 deals with the implementation of an approved performance delivery plan. The HSE is required to deliver services in line with the approved plan and to ensure that the expenditure incurred for the period relating to the plan does not exceed the authorised amount.

Section 22 increases the deadline for submission of the HSE capital plan to the Department of Health and the Department of Children, Disability and Equality from 21 to 28 days.

Section 23 introduces corrective action proposals and outlines the obligations of the HSE, the Minister for Health and the Minister for Children, Disability and Equality in the preparation, approval and implementation of these proposals. The proposals are to be developed by the CEO and approved by the HSE board.

Section 24 outlines the process for amending corrective action proposals. Either Minister, after consultation with the other, can issue a direction to the HSE to amend the proposals and can specify the manner in which they are to be amended. This direction includes a timeline for the submission of amended proposals.

Sections 25 to 27, inclusive, update references to the service plan in order that it will be referred to as the performance delivery plan, as introduced under the Bill.

Section 28 amends the National Cancer Registry Board (Establishment) Order 1991 by increasing the membership of the board to ten members and adjusting the quorum to account for this change.

The purpose of the Bill is clear. It builds upon the foundations of the Health Act 2004 and the Health Service Executive (Governance) Act 2019 to further enhance the governance, oversight and accountability of the HSE. Through the introduction of strategic direction statements and annual statements of priorities, this Bill represents an opportunity to more formally align the planning processes of the HSE with those of the Government. The introduction of corrective action proposals means a shift towards a solutions-based approach to potential overspends and allows for early intervention with the full approval of the HSE board. Importantly, this Bill also ensures that the HSE board will retain its independence and autonomy while simultaneously ensuring sufficient oversight alignment with the priorities with the Departments of Health and Children, Disability and Equality. Ultimately, the Bill represents an improvement in governance and oversight of the executive through which an improved quality of care for the nation's citizens can be achieved.

I look forward to Members' contributions and welcome the opportunity to engage in productive discussions on its provisions. I commend the Bill to the House.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I thank the Minister. Will she make a copy of her speech available to Members?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I will reflect on it.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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The Minister will reflect on it.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I will certainly give a copy to the Clerk. I made available copies of prepared notes last night which I expressively said I would not depend on, but they were quoted back to me. I need to reflect on how I provide information. This is a technical Bill. That is one thing. I can certainly do that. At the same time, however, this is a matter arising from what happened last night. We can manage it separately.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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It just might help with the debate.

David Cullinane (Waterford, Sinn Fein)
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The official notes given by the Minister can be read back to the Minister because those are the notes that are circulated.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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As long as that is done accurately.

David Cullinane (Waterford, Sinn Fein)
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That is a different matter.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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That is a different matter, and it is the matter at hand.

David Cullinane (Waterford, Sinn Fein)
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It is a bit petty that the Minister does not share the-----

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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There is no need. I am not required to do so.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Deputy Cullinane-----

David Cullinane (Waterford, Sinn Fein)
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I do not need to be corrected. I know how the Dáil works.

Accountability and good governance have always been at the fore of any debate about the health service. There is much great work is done by our front-line workers who strive every day to do their best. The efficiency with which many in the health service work, particularly in overcrowded emergency departments and under-staffed wards, is genuinely never credited. Unfortunately, that good work is often overshadowed by colossal waste and mismanagement across the HSE.

Since 2020, the health budget has ballooned, but the return on that investment has been questionable. While it is true that more services are being delivered than ever before, waiting times are, at best, stagnating rather than coming down substantially in the way that was promised when the Government parties signed up the Sláintecare. That is why this legislation is so important in the context of bringing governance and accountability arrangements up to a higher standard. We must ask whether the Bill will achieve that or whether it is simply more window-dressing to allow the Government to pretend it is doing something meaningful. Unfortunately, this Bill is a wasted opportunity. I will outline why.

The substance of the Bill is dealt with in Part 2, which provides for an improved performance delivery plan - this will replace the HSE's annual service plan - to be approved by the Ministers for Health and Children, Disability and Equality and developed on the basis of the statement of health service priorities. The Bill also places new obligations on the HSE regarding its three-year corporate plan, which is already done on a three-year basis, and provides that the Minister for Health and the Minister for Children, Disability and Equality, Deputy Foley, will issue strategic direction statements to inform the HSE’s priorities. Given that this retains the annual approach to the service plan as the default and that the Minister currently issues priorities annually to the HSE through a letter of determination, this appears to be a rebranding exercise rather than any substantive change. Notably, it allows the Minister to extend the performance delivery plan over any period the Minister wishes, but it does not require a multi-annual plan by default.

The Bill also places an additional legal requirement on the HSE to exercise:

... the highest standards of prudent and effective budgetary management, including with regard to the achievement of value for money and recognition of the importance of managing within authorised financial and employee resources ...

One would have thought that this was already a legal responsibility for any public body.

The remaining substantive element of the Bill is the new process for ensuring that the HSE remains within budget and provides a legal basis for what is called corrective action proposals. There is already a requirement on the HSE to operate within budget. I do not think the CEO of the HSE allows the organisation to run over budget intentionally. This again seems to be rather meaningless. Notably, the Bill provides that where the HSE goes over budget, it must pay for this out of the following year’s budget. Where it makes a saving, it may, subject to approval, retain that money for the following year. There is a concerning stipulation in this regard. As we know, health services are demand led. If, after taking corrective action and every measure tolerable to the Minister and the public to curtail spending, the HSE still runs over budget, there could be severe knock-on consequences for services. Such a proposal would only result in us returning to a situation that we had last year where a deficit is accumulated within the HSE’s budget over a time period only to be bailed out after several years when it is no longer tenable to carry that deficit forward.

While these are important changes, they are nothing new. These amendments to the Health Acts are largely reflective of changes which have already occurred in practice between the Minister, the Department and the HSE. The truth is that this Bill does not implement any meaningful change. It seems to be a way for the Government to pretend it is being tough on the HSE for budget failures without providing the reforms that are truly necessary.

The Bill retains the shortsighted focus on annual-based planning. Year-to-year planning in the health service does not work. No multibillion organisation operates on a year-to-year basis in the same way that the HSE does. The Government parties signed up to multi-annual frameworks in the programme for Government, but they have failed to translate that into this Bill. That is deeply disappointing. While the Bill provides for a three-year corporate plan, which already exists, it does not provide for multi-annual frameworks in respect of funding, staffing and capital delivery. That is why, unfortunately, I see this Bill as a wasted opportunity. It is a wasted opportunity because of what is not in it.

When the health committee conducted pre-legislative scrutiny, one of our recommendations was that the Bill would provide for capital funding to be approved, indicatively on a multi-annual basis, to facilitate a proactive, multi-annual capital planning framework. That has not been incorporated into this Bill. While the HSE has to be expected and held accountable for operating within budget, it also must be enabled to make the very sizeable investments in digital infrastructure, bed capacity and primary care reform that are needed to make health spending more sustainable. The health service is inefficient by design. It is hospital-centric and working on pen and paper. Not only are there trolleys strewn across corridors, but there are also trolleys full of paperwork that are being pushed around.

When it comes to capital spending, there is a need to ensure that health is not forgotten in any revision of capital expenditure. We have to look at all of the needs across the health service over the next number of years. We had a good discussion in the committee today on digital transformation. That is going to cost a lot of money. The previous Minister for Health launched a comprehensive bed plan. That must be delivered and funded. We have all sorts of projects at a local level that every TD, whether in government or in opposition, will jump up and down for. They have to be funded.

The children's hospital has to be completed. The new elective hospitals will have to be built. The new maternity hospital will have to the built. Unless there is a substantial increase in capital funding, I do not see how any of that is going to be paid for. Then the focus will be on the Government, the Department of Health and the Department of public expenditure and reform to explain to people which projects will not be funded and what will not be done if health does not get its fair share of any increased capital expenditure.

There is an issue with accountability, even with regard to parliamentary questions. The purpose of the public-only contract that we put in place was to facilitate public work on weekends, but insourcing has allowed private practice in public hospitals on weekends, which is far more lucrative. When I asked the Minister for Health and the HSE about the level of Saturday activity happening on a public-only contract, the question could not be answered by the HSE. When I asked the HSE how much was spent on locum cover for consultants who are not able to fulfil their out-of-hours obligations, the HSE could not answer it. When I asked about how much individual consultants, in anonymised fashion, were making from private work on public lists through insourcing arrangements, I was told this information is not available at a national level. How can we know what is happening if we are not collecting the data? An awful lot more work needs to be done in that area.

Mark Ward (Dublin Mid West, Sinn Fein)
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The Bill before us is a Bill of optics to create an illusion that the Government is dealing with a health crisis that it created. It is like rearranging the deckchairs on the Titanic or an old-fashioned three-card trick that moves people from list to list without getting them the necessary treatment at the end of it. I will give the Minister some examples. In 2015, there was an agreement to place a much-needed primary healthcare centre in Rowlagh in my constituency. Planning permission was granted in 2018, followed by fire safety certificates and disability access certificates. It is now 2025 and not a sod of earth has been turned on this much-needed facility. The latest response I got from the Government is that the primary health centre for Rowlagh is currently on hold while the HSE evaluates current service needs.

The health needs of the people of Clondalkin and the families I meet daily have increased dramatically since 2015 and the people of my area feel abandoned by Fine Gael and Fianna Fáil. When I say the health needs have grown in my area, the Minister does not have to believe me. She just has to look at the latest figures that have come from the HSE about children with disabilities waiting for assessments of need. The number of children awaiting assessments of need is now expected to pass 25,000. That is 25,000 families and children who will be left in limbo. A total of 11,500 of these children are left waiting for first contact with the HSE, with nearly 8,000 of these children waiting for over a year before the HSE will even pick up the phone to contact their parents. When they finally receive the diagnosis, which could take years, these children are left on waiting lists for occupational therapy, speech and language therapy and psychology.

I have said numerous times that the Government is denying children in this State every right and every chance to reach their full potential. We have also spoken about the shortage of GPs in the State and how difficult it is for patients to get an appointment, but there are bureaucratic delays in the HSE that impede this. I will give an example. The Rowlagh medical centre in my area opened last year at the site of the old Rowlagh credit union building. This is something that I have been working on for a long time. The centre provides a range of health services, including GP services, in an area of high disadvantage. It wants to provide a GP medical card service. It sourced the GP, which is fantastic. It took some time to get him registered with the Irish Medical Council. This was finally resolved and now the centre is waiting for the general medical services, GMS, contract to be sorted out through the HSE. I am happy to announce that once this is approved, the Rowlagh medical centre could have the capacity to take more than 500 new medical card patients, which will be fantastic for my area.

There is also a shortage of public health nurses in Dublin Mid-West, in the Rossecourt resource centre in Lucan, the Lucan health centre, the Rathcoole health centre, the primary health centre in Clondalkin, and the Rowlagh health centre. Newborn babies' brains develop more in the first five years of their lives than at any other time. If children do not get the necessary developmental checks, something missed could have a lifelong impact on them. I have been getting the same answers from the HSE for the last two years, that there are recruitment and retention issues for the HSE getting public health nurses in the area. I want to know what is going to be done about that. Parents in Dublin Mid-West feel the burden of trying to spot any developmental challenges their baby is experiencing. Can you imagine the guilt parents feel if they fail to spot something? I want to be clear that the guilt is not on parents-----

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I agree.

Mark Ward (Dublin Mid West, Sinn Fein)
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-----but rests solely and squarely on the shoulders of Government for not providing public health nurses in Dublin Mid-West. I am calling for action now so that no more children fall through the cracks.

Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Fine Gael and Fianna Fáil introducing legislation to provide for revised governance and accountability for the HSE is farcical. In effect, the most substantive aspect of governance I see is a chief executive whose grossly substantial salary facilitates their operating as a mudguard for the Minister of the day. Regarding accountability, with scandal after scandal in our health service, the one certainty is always that no one will be held to account and that there will be no transparency. This should not come as a surprise to anybody, because it is part of a culture that is not limited to the HSE. It pervades every inch of Government itself. The Taoiseach, not content to be unable to admit that he and his Government have made mistakes in the past, has in recent weeks sought to rewrite history to cover up for his failure to protect services in Cavan and Monaghan while he was in government.

The facts are plain to see. The health boards had been abolished by the time Monaghan emergency department closed. The HSE was in place when accident and emergency services were stripped from our hospital in Monaghan under a Fianna Fáil Government. If the Taoiseach would like to backdate the decision to his own tenure as Minister for Health, he is free to do so, but the situation today is the Minister, Deputy Carroll MacNeill's responsibility. The minor injuries unit in Monaghan hospital does incredible work but this is not enough. We need an emergency department. A person can wait over 24 hours in Cavan emergency department without the necessary services. This is just not good enough. This hospital in Cavan is servicing three counties.

I can give the Minister an example. A person from Monaghan with an injury - for example, a suspected broken bone - may find themselves in the minor injuries unit in Monaghan hospital and will be asked to go to Cavan hospital emergency department. God knows how long people will have to wait there. I have waited there for 24 hours with my mother. After that wait, because you have a suspected broken bone, you will be asked to travel to Drogheda to wait again. The Minister might find it hard to believe this, but this is what the people of Cavan and Monaghan are dealing with.

What is the Minister going to do about it? Past Ministers and the HSE have utterly refused to even examine the situation. If we ask about additional equipment in Monaghan, for example, a CT scanner or MRI scanner, currently exclusively located in Cavan hospital, we are told there is not a need because people can access them in Cavan hospital, but despite this, hundreds of people are on waiting lists, and waiting times in Cavan hospital are unacceptable. I ask the Minister again for a feasibility study and for this to happen in Cavan and Monaghan hospital so that we have the correct equipment in those hospitals. Can the Minister appreciate how frustrating it is for the people of Monaghan that they have to travel to Cavan and Drogheda to be seen and not have such long waiting lists? Why are we being treated by this?

I am utterly convinced of the need to restore services to Monaghan hospital that were stripped away by previous Governments but the Minister can make a change. My appeal to her is straightforward. Will the Minister agree to review the current operational framework of emergency care in Cavan and Monaghan, particularly the need for CT and MRI scanners in Monaghan hospital?

Ruairí Ó Murchú (Louth, Sinn Fein)
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I do not think anyone has a particular issue with providing corporate governance arrangements and accountability for the HSE. Deputy Cullinane dealt with this from the point of view of the smoke and mirrors we are seeing here. We are not seeing any real change with any of this. It is all well and good to look like the State is getting tough with the HSE about budget failures and overruns, but the necessary reforms need to be ensured.

We are talking about the multi-annual framework. We are dealing with the other inefficiencies within the system.

I do not know how many times we have spoken about everything, including ensuring we have the best of primary care, we have those pieces of community care in place and we have the best fit-for-purpose IT systems. We keep talking about digitalisation. On some level, some of that seems to be wrapped up in regard to the national children's hospital. Too much has been said in regard to that in latter days. We need that delivered but we need to be able to deliver the idea of digitalisation. Many people have spoken to me about that and it is generally a problem they have when dealing with accident and emergency departments. I have spoken to many people recently who have been in Our Lady of Lourdes Hospital, Drogheda, and have been dealing with staff who are doing a huge amount of work and are under severe pressure. It is down to the number of people and the number of cases - sometimes complex cases that should be elsewhere - that there is severe pressure there. They about individual cases where sometimes they are dealing with a system that is not computerised as it should be. That is even in regard to communications between GPs and the hospital and notes taken in the hospital, particularly in the emergency department. That does not make any sense whatsoever in 2025. We all know the dangers that occur when we do not have the best of information provided in the most easily accessible way. That leaves room for things to go absolutely wrong.

We need to see we are resourcing hospital beds. We need to make sure we have the step-down facilities required. We know the huge issues in regard to care facilities and specialists to look after people so that they can get a package and free up the bed for other people.

Similar to Deputy Mark Ward, we, in Dundalk, would like to see delivery on the primary care centre. It is not just about the primary care centre; it is about those community pieces related to everything from mental health services right through. If I am talking about mental health services, I must mention we are still awaiting delivery on the ten-bed extension to the Drogheda department of psychiatry, DDOP, in Crosslanes. That would only provide Louth-Meath with, I think, 14.1 beds per 100,000, which is way below the State average, and the State average is not particularly good.

I have spoken to the Minister before about the pieces of work that need to be delivered in Louth County Hospital, Dundalk, regarding orthodontics. It is hard not to mention last night's debate on endometriosis. Recently, I and many others went to a meeting organised by Sinn Féin in my constituency and I was absolutely shocked. It was very similar to an awful lot that was said here. I am taken aback by the number of emails and contacts I have had from constituents about their personal plight since that debate. That is an issue we need to see delivery upon.

Marie Sherlock (Dublin Central, Labour)
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When I was reading the substance of this Bill today, my overriding sense of it was that the one consistent feature of the health service over the past 20 years is change. Since the Health Act 2004 there has been so much chopping and changing with regard to our health management system. Some of that was out of necessity. There are some very real questions as to the timing of this Bill, particularly given that we are only a few months into the new regional executive officers, REO, structure. The question has to be asked: is this coming at a time to effectively tighten the screw on how resources are going to be managed and overruns dealt with within the HSE? On the face of it, this is a technical Bill, designed to give the Minister greater influence over the HSE delivery plan. That can only be a welcome thing because, to be honest, for far too long successive Ministers have been more commentators on the HSEs performance as opposed to drivers. I believe the Minister very much wants to drive what the HSE is doing.

The niggling question at the back of my mind in regard to the proposals here, in particular section 24, is what happens when something goes wrong? What happens when the CEO must inform the Minister that the HSE will likely exceed its capital or non-capital budget for the year, and then, what corrective measures does it need to take? Financial controls are important, and crucially important in the health sector, but the critical question here is: is the purpose to stay in budget or is it to meet the actual health demand that is out there?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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It is both.

Marie Sherlock (Dublin Central, Labour)
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The answer may be that it is both. When we look at the individual issues within our health service, there are fundamental questions about the operability of, in particular, section 24 into the future. I am looking in particular at budget 2024 announced in October 2023. With the benefit of hindsight, it was a complete work of fiction. The HSE had to come out and effectively out the Government by saying what the budget was providing for 2024 simply was not enough. We had to have a summer economic statement. We had to have a supplementary budget of €1.5 billion in the middle of 2024 and an additional €1.2 billion this year. The Government obviously messed up its figures and did not adequately or appropriately account for very predictable and ongoing challenges within the health service.

If that was to happen again and the political system was to fail to take responsibility for the level of demand within the health service, on whose shoulders should that responsibility for the underfunding lie? Is it with the Minister for Health? Is it with the Minster for public expenditure? Is it with the CEO and the board of the HSE? Section 24 of the Bill is very much putting it on the HSE. Will cutbacks be the norm over the next number of years in order to try to meet the straitjacket of a health budget set down every October?

The other key question is in regard to the accumulated deficits, particularly within the voluntary hospitals, which is a very real issue. The accumulated deficits across a number of the voluntary hospitals were reported at €340 million. Efforts were made last year to reduce some of those voluntary hospital deficits. We have had media reports that pharmaceutical companies have had to put accounts on hold, in particular with regard to the Mater hospital because bills were not being paid on time. The Mater hospital itself is facing a deficit of almost €25 million. Beaumont Hospital is carrying forward €66 million. The reality is there have been bailouts. There has been some sort of agreement, but the reality is there is fundamental questions about the voluntary hospitals' continuation into the future and how the Department of Health is hoping to remedy that. We can have a conversation another day about whether we should have every hospital in the country run as a HSE-owned hospital or whether we sustain those voluntary hospitals but the reality is the State is severely reliant on those voluntary hospitals and how we keep them in operation. A critical question is whether those corrective measures apply to the voluntary hospitals or not.

The other elephant in the room for me relates to the National Treatment Purchase Fund, NTPF, which is not being addressed here as I understand it. This has been the subject of lots of committee hearings and interactions in the Dáil over recent weeks. However, there is a commitment now to ending insourcing, a very controversial measure to try to reduce waiting lists, albeit it has reduced waiting lists in some hospitals. The other thing is that some people have made a lot of money out of the use of State assets and HSE-directly employed staff.

There are very serious questions about who has been making money to reduce those waiting lists. The commitment now is that we will have it ended by next year, but who is going to make good on that money? This is a separate funding pot to the NTPF. Will the hospitals that have been appropriately using the insourcing funding get the additional resources to try to beef up with regard to staffing? To be very frank, the revelations about the period between the end of 2023 and start of 2025 in which sums of between €71 million and €91 million were spent are outrageous, particularly when we understand that a number of serving HSE staff are currently providing those services. Every company is entitled to provide a service, but there are real questions there about the duplication of work and incentives to work. I know the Minister has very eloquently been on the record calling this out and raising concerns, but the critical issue for those hospitals that have been relying on the NTPF money to reduce their waiting lists is what will happen to that funding.

There is a separate question with regard to Naas and Beaumont hospitals in how they have used NTPF funding for what we understand are routine activities. There is a separate question about the oversight of the NTPF and its oversight of its own activity. While a big song and dance was made about how it is overseeing waiting list validation, we hear much less about its oversight of what accountability is expected when it signs the cheque for the individual hospitals. What is it getting in return? There are very clear questions from me and the wider Labour Party with regard to this Bill and how it will deal with this sum of money.

One of my last questions relates to population-based resource allocation. This was the big idea last year. It is very consistent with Sláintecare, something the Labour Party hugely supports and is not well understood. Obviously, it is in its infancy. We still have to see a lot of the detail as to how population-based resource allocation will ultimately shape the allocation of financing within the health service.

Last year, the Secretary General of the Department of Health stated: "It is [very] clear that it is not sustainable over the long term to continue to increase health expenditure in line with demand each year." That is a particular perspective. How demand is defined is something in and of itself. However, the reality is that there is a huge amount of unmet demand in certain parts of our health service at the moment. We spoke this morning about dental care, which is on the brink of collapse. Last night, we talked about endometriosis. The Minister has heard me talk lots of times about the lack of supports within GP care and the patchy GP service we have throughout the country. The key question now is how this tightened financial control of the HSE will be consistent with the roll-out of the population-based resource allocation into the future. The ideal is that the money follows the need. If there is going to be a political decision about what that need is as opposed to the actual reflection of the need on the ground, one validated by our clinicians and everybody else on the ground, then there is real potential for a disconnect there. Sláintecare is about ensuring that money follows the need. That is one of my biggest questions that has arisen today.

We have not really had an opportunity to talk about population-based resource allocation, PBRA. Our understanding is that, in terms of the current plans of the Department, nearly half of all HSE expenditure is likely to be excluded from the proposed PBRA mechanism. Those exclusions will cover the primary care reimbursement service, PCRS, for GP and dental care and the fair deal scheme. That is a massive part of our health service and there is a lot of unmet need within it. Will we truly have a proper system of population-based resource allocation in terms of a model of funding if we exclude that whole swathe of the health service? That is a conversation for another day-----

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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We should have it.

Marie Sherlock (Dublin Central, Labour)
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There are key questions about how this very good model is consistent with this very political decision to effectively try to make the HSE deal with any cost overruns itself and take corrective measures and to pass the buck on to the HSE for what may be understandable cost overruns into the future. We need to be extremely careful about section 24 of the Bill in particular.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I welcome the opportunity to speak in support of the Health (Amendment) Bill 2025, which is a timely and necessary step to strengthen governance, transparency and accountability in our health service. This Bill delivers on a core commitment in the programme for Government to embed productivity and ensure full transparency in how healthcare services are delivered. It recognises that strong, accountable structures are essential if we are to meet the needs of a growing and ageing population and deliver better health outcomes for our citizens.

This legislation addresses a long-standing gap in the Health Act 2004 by clearly setting out how the CEO of the HSE and the board must engage with the Minister for Health and, in the case of disability services, the Minister for Children, Disability and Equality. It introduces a more structured, accountable framework for how the HSE plans and delivers services, including strategic direction statements that Ministers will issue to guide the HSE’s three-year corporate plans; a new system of performance delivery plans, replacing the old service plans and informed by annual statements of priorities from each Minister; and, most importantly, a new statutory requirement for the CEO to bring forward corrective action proposals where expenditure is expected to exceed allocation. This is about real accountability, not just in how money is spent, but in how performance is measured and managed.

The scale and complexity of our health service has grown rapidly over the past two decades. The HSE now operates with a budget of €26.9 billion, a €1.6 billion increase on last year alone. That includes nearly €300 million in new service developments within mental health, older persons and disability services. With that level of investment comes a responsibility to ensure that we are delivering the best possible return for patients, staff and the public.

We know the challenges. Demand in our hospitals is rising by 5% to 10% annually. The number of people over the age of 75 has increased by 26% since 2019. We are dealing with the long-term costs of high inflation and post-Covid activity spikes.

Despite these pressures, progress has been made. Waiting times are falling, and are now down from 13 months to just longer than seven months for outpatients. Trolley numbers are also down 11% year on year. Free GP care has been extended and hospital charges abolished. This progress is possible because of the record levels of investment. Now, thanks to this Bill, we are building in the governance structures to sustain that progress into the future.

The return to a board-led governance model for the HSE, first legislated for in 2019, was a vital reform. The 2013 directorate structure was rightly found by the Sláintecare report to be unfit for purpose. This Bill builds on that by ensuring that the CEO is directly accountable to the board and that the board, in turn, is accountable to the Minister. It also reflects the significant transformation under way with the establishment of the six new health regions. These regional structures aim to deliver more integrated care closer to home and tailored to local needs, a key ambition of Sláintecare.

The Bill reflects the values of the Government more widely and of Fianna Fáil, namely, responsibility, reform and better outcomes for patients. It ensures that the HSE is not only better funded, but better managed. It also complements the work of the productivity and savings task force, which is delivering efficiencies across the system. Last year alone, and as the Minister alluded to, €251 million in savings were delivered. A further €382 million is targeted this year. These are not abstract numbers; they translate directly into shorter waiting times, more staff and better care.

While this Bill focuses on management and accountability, we also need to see continued capital investment in buildings, infrastructure and equipment. I think of the need for the expansion, of which the Minister will be well aware, of the National Rehabilitation Hospital in our own constituency, an objective to which we are both very committed. Hopefully, we will see the capital funding arise for that in the upcoming budget.

St. Michael’s Hospital, Loughlinstown hospital and St. Vincent’s University Hospital also all have ambitious plans.

Of course, while the big ticket plans grab attention, it is equally important that we support smaller capital projects in communities, for example, delivering on housing and respite facilities for people living with disabilities. I know the Minister will continue that focus in budget 2026.

I commend the Minister on introducing this legislation forward. It will help to ensure that health spending is tied to clear plans, clear targets and clear accountability. That is what the public expect and that is what the Bill will deliver. I am pleased to support it. Go raibh maith agaibh.

Joe Neville (Kildare North, Fine Gael)
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Sometimes, I come to the House and I am not exactly sure of the relevance of individual Bills or of what negative point the Opposition might make that day. The Opposition could not make a negative point today because this Bill speaks to the core of something we talk about in the country so often. We talk about money being spent, who spent it, why it was spent, who is to blame and where the accountability is. Unfortunately, we sometimes see increases in budgets but we do not necessarily get the returns. On Leaders' Question yesterday, the issue of all the extra money we are spending came up. It is a question of whether we are getting enough back. This Bill allows the Minister to be able to hold people to account, ask questions and do so in a robust and systematic way we may not have been able to do formerly.

Since coming to Leinster House, I have seen different parts. At the public accounts committee, that is what we do quite often - we ask afterwards. We ask questions about how money was it spent. This Bill will allow the Minister to have a key role in that.

I am a TD in north Kildare, which is a rapidly growing location. It is in rapid need of improved community service. This will help with that. It will reinforce the shift towards better-managed community care with clear leadership and planning. Ultimately, that is what we need.

The Bill also clarifies and strengthens the responsibility of the HSE board itself. It makes the board and the CEO legally accountable for good governance. We know that the CEO's intention will always be to do the best while always ensuring there is good governance, but that does not necessarily end up being the case. As an accountant myself, I have seen it over the years as an auditor. There might be financial controls in place but they are not always the best controls. Indeed, the service is not always delivered in the best way possible. However, this Bill gives the Minister for Health a more hands-on approach and a possibility of ensuring those jobs are being done well.

The HSE itself, as we know, and as Deputy Devlin said earlier, has a significantly larger budget. It has a huge budget - the largest health budget we have ever set. Sometimes, the problem is that so many people have a view about this. It has been said over generations, even when the budgets were much smaller, that no matter how much money is put into the health system, we will not fix it. That is an awful way for any country, any set of politicians or the public to view any system. It is awful that our health system, the most important part of our government, should be perceived in that way. Once again, the Bill will help to stop that.

If spending limit thresholds are broken, the CEO must notify the board and the Minister for Health and must propose corrective actions to stay within budget. That has not always been the case historically. Sitting at home listening to the radio over the years before I was involved in politics, there was always the fear that these issues could arise and we would only find out after. With this Bill, there will be a stronger role for the Minister. The Minister will have greater oversight powers to ensure compliance, service plans are delivered and there is financial accountability. If the HSE itself fails to act on overspending or underperformance, the Minister can take directive action. It is important we have that in legislation because that is key. Ultimately, we want our politicians - I include myself in that - to be held accountable. We also want to be in a position to hold others accountable who are acting on behalf of the public and, in many cases, the taxpayers who enable us to run the State as we do.

The annual performance review will require detailed annual reports on how the HSE is meeting service targets and financial responsibilities. As we all know, financial reports are not about a set of numbers. There is also the picture behind that and how it builds towards it. Therefore, it is important that we are clear because that will help to emphasise the transparency and accountability to the Oireachtas and to the public, to whom we are all beholden as Oireachtas Members.

The Bill will support the Sláintecare reform programme, which aims to build a unified and equitable accounting health system. Most of all, though, it will be there to prevent a systematic failure. It is designed to avoid the kind of systematic failures we have seen in past HSE governance issues, namely, with CervicalCheck and budget overruns. This Bill can be part of that improvement, giving us power to ensure we can carry out corrective actions beforehand and hold those people to account. That is something we must support. Hence the reason I want to be standing here, as a Government back bench TD is this case, supporting our Minister as she leads the way in ensuring we have the best health system we can possibly have. Money has been put aside and significant budgets have been put in place, but we need to ensure our system delivers for our people in the way it should and in the way they deserve. I thank the Members for the time today. I think this Bill will pass.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I appreciate that the Bill before us will provide for revisions to corporate governance arrangements within the HSE. I welcome this. If ever an agency needed governance reforms, it was the HSE. There have been too many incidents of governance failures at this agency. I refer to the CervicalCheck scandal, which revealed 162 women were not informed about missed abnormalities in their smear tests; the 2023 nursing home review, which revealed serious governance lapses after a resident was raped by a staff member in the HSE nursing home; and we will all remember the treatment of the whistleblowers who faced suspension and disciplinary action for raising concerns of financial misconduct and care home abuses. However, I have concerns that this Bill will do little to implement meaningful change in respect of its stated aim of exercising the highest standards of prudent and effective financial and budgetary management. If the Government really wanted to enhance budgetary governance, it would introduce the multi-annual funding framework it promised in the programme for Government. Sinn Féin will be tabling amendments on Committee Stage to provide for multi-annual funding and for staffing frameworks, because that is the right thing to do. This is the only way proper planning can take place and efficiencies can be made.

I take this opportunity to ask the Minister for Health to please address persistent staffing issues across the HSE. The Government claims the recruitment embargo in the HSE has been lifted since last July but there have been no positive effects in Mayo. I met representatives of the INMO last week again. In fact, I have very direct experience of being in the emergency department in Mayo University Hospital in the last number of weeks. I commend the staff there for the job they are doing but they are expected to do that job even though there are not enough of them. I know the Minister wants to answer me back and I know she cannot in this situation. She should please let me tell her that there are not enough staff members.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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There is a 32% increase in Mayo.

Rose Conway-Walsh (Mayo, Sinn Fein)
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The INMO is telling untruths, then. It is telling untruths, as it says there are not safe staffing levels. You can hold up whatever documents you like, Minister.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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There is a 32% increase.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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Will Members address their remarks through the Chair?

Rose Conway-Walsh (Mayo, Sinn Fein)
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The Minister can hold up whatever document she likes, but I am telling her that there are not enough staff in Mayo University Hospital in the emergency department section to provide safe service there. I am also telling the Minister that it is a deterrent for so many people who want to, and probably need to, go to hospital. They want to do everything to stay out of hospital. Those nurses and other staff members are absolutely run off their feet. They are expected to operate on a corridor with trolleys each side of it, patients in pain moaning, looking for help and trying to get a bed when they cannot get a bed, yet the Minister is telling me the hospital has enough staff. It does not have enough staff. I can tell the Minister that. I am very grateful for the service the staff provide but there is not enough of them there. Whatever the Minister is doing, I ask her to please address that and to look at it. I was not even going to bring this up but the Minister saw the women in the Public Gallery last night for the endometriosis care motion. The Minister pointed out phantom clinics they were to go to in all these places and implied there were so many services about the place that they just were not going to.

Why then are those women in such pain? The Minister spoke about them choosing to go to abroad when the services are not here for them. The Minister can shake her head all she wants but she needs to recognise what is happening on the ground. The health of the women who were here last night is deteriorating. The organs in their bodies are being eaten by endometriosis and the Minister is saying there are enough services and support.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I ask the Deputy to conclude.

Rose Conway-Walsh (Mayo, Sinn Fein)
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I am sorry but the Minister needs to get with the programme.

Pádraig Rice (Cork South-Central, Social Democrats)
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I welcome Second Stage of the Health (Amendment) Bill 2025, which regrettably is the first health legislation to be taken on Second Stage since the general election last November. This is one of only two health Bills listed for priority publication yet it was only published last Friday, just shy of the summer recess. Nevertheless, it is worthwhile and modest legislation.

To pick up on some comments by the previous speaker, we hear two different narratives constantly. There is a narrative from the Government that there is plenty of staffing and an increase in staffing. We hear from nurses, doctors and people working in hospitals that they are short-staffed, posts are not filled and there is no maternity leave coverage under the pay and numbers strategy. Some services are particularly short-staffed. There is a juxtaposition which needs to be teased through to see if certain parts are understaffed and resources are stretched. We constantly hear there is enough staff but that is not what is said on the ground.

One of the main purposes of this Bill is to replace the HSE's annual service plan with an annual performance delivery plan. I have no objection to this in principle but I would appreciate if the Minister outlined in more detail how this new performance delivery plan will be different from the service plan. I assume it is more than just semantics. I note the Minister of the day will have a clearer role in shaping and influencing the final performance delivery plan. Under section 17, the Minister for Health, in consultation with the Minister for disability, will prepare an annual statement of health service priorities to guide its development. While welcome, this is a small change. There have been serious issues in recent years with what have been characterised as HSE overspends. I argue that Government underinvestment is the root of this issue. That is not to excuse the HSE's ballooning spend on outsourcing and agency staff but there must be an acknowledgement that funding has not matched what is required to deliver services and Sláintecare reforms. This has been repeatedly pointed out by the Irish Fiscal Advisory Council.

Health spending has undoubtedly gone up in recent years but there was a lot to catch up on after decades of underinvestment. There have also been population increases and demographic changes, not to mention the money that should be front-loaded into the Sláintecare reforms. At the core of health funding issues appears to be a different view between the Department of Health and the Department of public expenditure. This is despite the fact that the entire Government has a collective responsibility to ensure there is an adequate level of patient care. That is why the greater level of oversight provided for in this Bill, while welcome, will not address the real problem, which is the dysfunctional method of allocating the health budget.

The provisions in the Bill related to corrective actions are a necessary safeguard but we should focus on addressing those problems further upstream. What is more urgently required and should take precedence is the move to multi-annual funding. We raised this during the Estimates process in the health committee. That would provide a more sustainable and coherent model of service planning, especially with respect to staffing and major service developments. Multi-annual funding was first committed to in the 2016 confidence and supply agreement between Fianna Fáil and Fine Gael. Almost a decade later, with the same parties in government, it remains undelivered. A commitment to multi-annual funding appears in the new programme for Government but delivery must be accelerated. Without this important change to the budgetary process, this Bill just tinkers at the edges. The existing annual cycle of service planning is not fit for purpose, especially in the context of implementing Sláintecare reforms. In fairness to the Minister, I have little reason to doubt her commitment to delivering multi-annual funding. My fear is the Department of Public Expenditure, Infrastructure, Public Service Reform and Digitalisation will continue to be a barrier to implementing this crucial reform, which is ironic given that reform is in the title of the Department.

The HSE corporate plan under this Bill would also inform the strategic direction statement. Given that the new HSE corporate plan for 2025 to 2027 was published just last week, I will use this opportunity to discuss some of its contents. While I agree with the sentiments and objectives expressed in the new corporate plan, it is difficult to have faith in them being realised. This is an aspirational three-year plan with aims that are not matched by deadlines or key performance indicators, KPIs. I appreciate it is the job of the service plan to say how, but the corporate plan should at least say when.

Women's health is a priority under the healthy communities section of the corporate plan. My main concern in this regard is there is no commitment to replacing the women's health action plan. The current plan runs out at the end of the year and the corporate plan is for the next three years. Many initiatives in the first two action plans have yet to be delivered, for example, the long-promised mother and baby unit. It was first recommended in the 2017 specialist perinatal mental health service model of care. According to the implementation plan for Sharing the Vision, the new mother and baby unit was to be delivered by quarter 4 of 2024. That unit is nowhere near being established. St. Vincent's, the proposed location, no longer seems able to accommodate the unit or at least not any time soon. Despite being promised in the 2022 and 2023 women's health action plan, this commitment was quietly dropped from the successor plan for 2024 and 2025. These units are commonplace in the UK, France and Australia yet Ireland does not have a single unit. Delivery of this unit must be prioritised. The adverse effects of separating mothers and babies are well documented.

In terms of dental care, the HSE corporate plan also makes a vague commitment to improving access to emergency and routine dental care. When will this happen? Public dental care waiting lists are at breaking point. The medical card scheme is haemorrhaging dentists but one would not think it from reading the corporate plan. Where is the ambition? I cannot understand why we are still waiting on the Department to publish a new dentists Act. The current Act remains largely unchanged since its enactment 40 years ago. It is not fit for purpose. A complete overhaul of the underpinning legislation and the medical card scheme is urgently required. They are relics of the past and must be modernised, not just modified.

I also mention laboratory services, which get a passing reference in the corporate plan. However, there is no mention of the eroded medical scientist workforce, which is jeopardising the ability to deliver safe laboratory services. There is no reference to the botched medical laboratory information system or how the HSE intends to get the project back on track. My understanding is this new IT project was to be delivered to more than 40 public laboratories but to date one has only been rolled out in Beaumont hospital. There are serious questions about the HSE's procurement process for this project and many others, yet procurement is not mentioned once in the corporate plan. This is disappointing considering only last year the Comptroller and Auditor General identified serious levels of non-compliance with procurement rules in the HSE. According to the Comptroller and Auditor General, "The HSE's control systems are failing to highlight the level of non-compliant procurement occurring", yet the corporate plan is silent on this issue. The corporate plan also mentions the long-promised reforms of home care but makes no mention of the statutory right. Is this no longer a priority? It is one of the most important parts of the home care reform programme. The Tánaiste, Deputy Harris, first committed to a statutory right to home care in 2017 during his tenure in the Department of Health. Eight years later, we are still waiting. Not even the regulations needed to underpin the statutory scheme have been legislated for. Never has the case for alternatives to nursing homes been greater. This must be prioritised.

My final point about the corporate plan relates to elective hospitals, one of the most non-committal parts of the whole document. The best the document could do was state, "We will continue the development of the ... elective hospitals in Dublin, Cork and Galway." This document covers a three-year period. The four new elective-only hospitals were to be delivered by 2028. While I accept that target is no longer achievable, one would expect by 2027, the final year of the corporate plan, planning applications would at least be submitted. There is no mention of that, just a vague commitment to continuing development. Overall, the corporate plan is a disappointment. I accept the service plan, soon to be the performance delivery plan, is a more specific document but that does not excuse how flimsy the corporate plan is. I hope this will change in the future but it is regrettable that we must wait another three years to find out.

The Social Democrats will support this limited legislation but I call on the Minister to be more ambitious. Multi-annual funding needs to be delivered as soon as possible. We need the Minister and her colleague, the Minister for public expenditure, Deputy Chambers, to set out a definitive pathway to multi-annual funding and to increases in capital funding. Otherwise, we will keep seeing the same budgetary issues in health year after year.

Liam Quaide (Cork East, Social Democrats)
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There is a close relationship between this Bill and the HSE's corporate plan. In the HSE's corporate plan for 2025 to 2027, there is a stated commitment to, "Reduce waiting times for primary care therapies by standardising the management of referrals, waiting lists and discharges."

There is no mention of a recruitment drive for services that have been hollowed out by years of recruitment restrictions imposed by successive Governments and senior HSE management, so much so that waiting list figures for them are so stratospheric that they have to be read more than once to be believed.

I raised the crisis in primary care waiting lists for young people with the Minister in the Dáil two weeks ago, with particular reference to psychology services. I highlighted that people are being moved from one waiting list to another with no intervention in sight, and that there has been a stranglehold on recruitment in primary care services for young people resulting from the pay and numbers strategy, the official recruitment embargo before that and years of passive neglect even prior to that.

I referenced from a reply to a parliamentary question a wait time in the Dublin and north east health region involving a child initially referred to disability services nine years ago, who is now facing yet another wait of unknown duration for primary care psychology. I set that out at the time and the Minister's response was to quote figures referring to generalities in primary care staffing in the context of the pay and numbers strategy. These generalities did not in any way relate to the waiting lists I raised. There was no acknowledgment that there was a crisis in primary care services for young people. There was a suggestion made of an alternate reality in which these services were actually better staffed than ever, which is clearly not the case.

This week, at Leaders' Questions, my colleague Deputy Cian O'Callaghan highlighted the scale and depth of the crisis across health regions and across disciplines revealed by further parliamentary questions I submitted in recent weeks. He raised the fact that the longest wait times nationally are up to seven years for physiotherapy in Cork North Lee; up to six years for speech and language therapy in Dublin North-West; up to nine and a half years for occupational therapy in Dublin North; and a staggering 13 and a half years for psychology in Dublin North-West. I have mentioned Dublin and Cork quite a bit but it is a national crisis. We have also had, for instance, a wait of nine and a half years for psychology in Galway. The Taoiseach's response was:

There has been no recruitment embargo. We do need to get a bit real here.

[...]

so do not say we are cutting back or are not allocating. The Deputy cannot say that with credibility.

He said this to Deputy Cian O'Callaghan with clear impatience, bordering on disdain, for the questions being put to him around the need for a comprehensive recruitment drive in primary care services for young people, as if he was dealing with an unserious, politically motivated and entirely unreasonable line of attack. Both of these responses, from the Minister two weeks ago and the Taoiseach yesterday, reflected either complete detachment from the reality of primary care services for young people or a wilful denial of that reality. If I was a clinician working in one of these services in Cork, Dublin or Galway, where recruitment has been so restricted for years, or if I was a parent whose child was on one of those epic waiting lists, I would have been left feeling utterly distraught hearing those responses. You cannot address the crisis if you do not even recognise the reality of its existence.

The Government's only consistent response to questions on the primary care service crisis has been to refer to a need to change disability legislation, strongly hinting at a dilution of the right to an assessment of need. The Minister has made the case that clinicians are overly embroiled in completing assessments of need and not available for interventions as a result. There is a small grain of truth in that but the Government narrative ignores the broad context and the fact that under-resourcing of services is pushing more and more families into the assessment of need process because that is the only right they have in law. The main reason is that a shorter therapeutic assessment in primary care services - for those children who are eligible for primary care - followed by timely intervention is not remotely available to them. It is a complete fantasy.

I ask the Minister to please engage with the clinicians on the ground and the families affected. She will see what various types of recruitment restrictions, as well as the redirection of large numbers of children from children’s disability network teams, CDNTs, without following up with the necessary recruitment, have done to primary care services for young people. This is a disaster with regard to service provision that has been growing in plain sight for years now.

The idea of a single point of access for child services, which is being trialled at present by the HSE, has merit in that it will reduce the practice of children being moved from one waiting list to the next but it will not even paper over the cracks of years of under-resourcing. The reason children are being moved from one waiting list to the next in the first place is that the services are so restricted that they are attempting to manage their waiting lists by becoming rigid in their inclusion criteria. There is no getting away from the need for proper workforce planning and investment in primary care services. We need a clear benchmark for a clinician to population ratio and an urgent, comprehensive recruitment plan to follow that.

A paragraph on trust in the HSE’s corporate plan states: “We will be open and transparent in how we provide services. We will show honesty, integrity, consistency and accountability in decisions and actions.” I was involved in a campaign to oppose the closure of a residential mental health service in Midleton over a number of years. It was an epic struggle, involving the deployment of several Oireachtas committees, multiple freedom of information requests and a litany of parliamentary questions, to expose the serious infringement this abrupt closure imposed on the rights of the residents and people in east Cork who will require residential support in future. The residents, some of whom did not have family support, received a letter from the HSE in June 2021 telling them that, in the context of refurbishment works at the facility, it had become clear that the building could not be made fit for purpose “to meet the high standards of the Mental Health Commission”. The letter went on to say that the building could not be “brought to the standard needed and that you deserve”, addressing the residents directly. The letter reassured the shocked residents that the HSE would “work with each resident individually and with their loved ones to make sure you have a new placement that suits your needs.”

Little did those residents know at the time, as revealed the following year through an FOI request, that the HSE had been planing to move as many of those residents as possible from their single-room, town-centre, long-term residence where they had built up a wealth of connections in the community over years and in some cases over decades. As many as possible were being moved into long-stay wards in St. Stephen’s Hospital, Glanmire, an institutional setting removed from anything resembling community living, surrounded by fields, without even a footpath to the nearest service station, which is 1.7 km away. Added to that, they would have most likely suffered the indignity of sharing dormitories in these long-stay wards and residing in settings that had received some of the worst Mental Health Commission inspection ratings of any mental health service nationally. Meanwhile, Mental Health Commission compliance ratings at the service being closed in Midleton, which is known as the Owenacurra Centre, both at the time of this proposed closure and since, were exceptionally good. The HSE banked on people observing this closure to not even read those Mental Health Commission reports, or not even read the building reports, which also did not stand up to scrutiny. It relented from its plan to close the service, not as a result of self-reflection or being persuaded by the very obvious arguments around patient rights, human rights and the United Nations Convention on the Rights of Persons with Disabilities, but because management caved in under a sustained barrage of negative publicity.

If we are true to that value of accountability, as set out in the corporate plan, where is the accountability for managers who operate in this way towards people with such a high level of vulnerability? Where is the accountability for the managers in the Emily case, who allegedly obstructed the extension of a safeguarding review into other possible cases of abuse within the same facility? If this was a ground-level clinician who was breaching the HSE’s communications policy by criticising the HSE publicly, the sanctions would be swift and decisive.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I thank the Cathaoirleach Gníomhach for facilitating the time for me to contribute to this Bill. I appreciate his helping me out.

When I look at the Bill and see the different approaches being taken to corporate governance and accountability, I am happy to support it. These types of reforms and changes, and a lot more, are necessary. I will go with the content of the Bill but a lot more needs to be done to make the HSE accountable and transparent and to ensure public trust in the health services is restored. We can only do that by taking action and living by the word of the legislation.

In my world of business, what gets counted gets done. For far too long, we have had a lot going on in the HSE that was neither counted nor being done. Any of the changes that were suggested were suggested off the cuff. Reform was introduced but without drivers of reform - in line with the legislation and the changes that are necessary - to direct and change, there was no change. That is what has happened over the years. Legislation and actions have been taken in good faith but were never implemented in full.

One only has to look back over the parliamentary questions asked every day the Dáil sits to see what TDs are asking about. They are asking about medical cards, delays in delivery, appointments not being filled, people on waiting lists waiting far beyond an acceptable time limit, complaints within the health service, the delivery of capital programmes and so on. As long as those questions are being asked, the Minister can be sure that the services, the capital spend and the accountability and transparency that we all talk about are not being delivered in the counties, the regions or nationally. That is an undeniable fact.

People will measure this by the delivery of services. When older people are in hospital beds waiting to be discharged to go home, their families are given a care plan. They are told they will be looked after from Monday to Sunday and these are the hours they can expect. However, as soon as they are in the family home to be looked after they find out that none of this is true. They may get a fraction of the hours they have been promised. That is not acceptable. Even more perverse is the fact that the families, I would say, are conned into believing they will get the services, but they do not. This puts massive pressure on families who want to contribute to the care of their loved ones. They will put in the hours themselves but are restricted in what they can do and need support. These families should be supported. They should be told exactly what they are going to get. I would love to know where the thousands of hours that have been allocated to the services for the care of people at home are all gone. I do not see them being implemented or used in counties Carlow and Kilkenny. I just see a stream of people coming into my office complaining, not that they have not got hours but that they have not got the hours they were promised when they were taking their loved one home. Nor have they received supports such as hoists and wheelchairs and other provisions that would make life easier for them and their families at home. I ask the Minister to take a serious, deep look at what is happening in regard to the delivery of those services. What is happening to those hours?

The other theme that runs through health services is the ambulance service. You cannot talk about the health service without talking about the ambulance service. I have met some of the ambulance crews and paramedics in the headquarters in Carlow. There is capital investment going on there. Patients, drivers and paramedics tell us stories of turning up to a scene, a house or a random location two or three hours after a call was made. For three hours, whatever happened to cause the ambulance to come has been waiting to be dealt with. A gentleman wrote to me recently to say a man had a heart attack on Patrick Street, Kilkenny. The ambulance was so delayed that people rang the Garda. Hours later, the ambulance came, only to find that gardaí had taken away the heart attack victim. That is not uncommon. In another location in Kilkenny two ambulances turned up. I witnessed it myself. What kind of service is that? What kind of waste is that? Where is the governance and transparency there?

I spoke to a lady yesterday who was on a trolley in St. Luke's hospital in Kilkenny for two days. The past two days were particularly warm, yet she was on a trolley in the corridor with the heating on at full blast. There was no way it could be turned down. Her requests fell on deaf ears. That is a small thing but what does it tell the public about an organisation when it disregards complaints that are made? What householder would not turn down the heat if they were conscious of the cost of heating, let alone the effects of it in a confined space?

In terms of money being spent, SOS Kilkenny is a fine organisation. It celebrates 50 years in existence on Thursday. It was delighted when told it would have an extra €1.6 million in its budget. It has not been paid yet. Where is that money? Why has Teac Tom, which provides services as a matter of urgency to those who are mentally challenged, not got the €50,000 it was promised? It is nickels and dimes in the context of the €26 billion or €27 billion the health services get.

In regard to planning in the health service, why has it not planned for endometriosis and the care of women affected? Why has that not been planned, staged and developed so that we do not have that kind of debate we had last night and instead, the difficulties women face are dealt with? I spoke with a group of women regarding the vaginal mesh issue. They could not get a pathway to care. It is shocking that we allow the citizens of this State to be treated in this way. We should be to the fore in the delivery of services to people who need them, particularly when we are looking at an overall budget of €26.9 billion or whatever it is.

Regarding the infrastructure within the HSE, Castlecomer District Hospital, for example, is a leading light in the delivery of care for those of a particular age who are in most need. It has to fight for the funding. The entire upstairs of that building is empty and could be developed. Fire requirements and so on must be fulfilled but it could be done in this modern age. We are not even taking the best model in the class. We are just ignoring the best model and moving to private sector care of the elderly.

A state-of-the-art hospital is being built at Thomastown. It is a wonderful facility. I would like to see more public facilities and hospitals caring for the elderly. I would feel a little bit more comfortable in that setting than in a private sector setting. The recent exposé on television has frightened the life out of those who are in care and those going into care and the families involved. We have to restore trust and it is only through action, investment and delivery that we can do so.

In regard to IT investment and an organisation of the size of the HSE asking for money, I go back to my original comment that what gets counted gets done. What has changed in relation to the IT systems? Do they now talk to each other? Is IT taking up every piece of spend in the HSE? Do they know what they are asking for in terms of where that money is going? Should they get it? In other words, is the budget real? Is it based on fact? Should we go back perhaps to zero budgets to make sure that whoever asks for money, whatever hospital or organisation, must provide an appropriate plan that it will be delivered within budget and on time.

The message I want to leave with the Minister is that care of the elderly and the marginalised is paramount in my politics and my response to people.

I want the direction of the HSE to change in order that it will be fully inclusive of all services that are being delivered to the marginalised and elderly.

Complaints relating to hospitals should be answered by the manager of the relevant facility. Too many complaints are being totally ignored. Instead of learning from them, they are covered up.

Ann Graves (Dublin Fingal East, Sinn Fein)
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I acknowledge the staff in our health services. Every one of them should be proud of the excellent service they provide despite the challenges they face every day in our hospitals, healthcare centres and community programmes. The health service is challenged by growing waiting lists, longer waiting times, an undersupply of key workers and low morale. Almost every part of the health service is attempting to muddle through in the absence of an overarching strategic plan. This Bill is a great opportunity to change all that but it fails to provide for multi-annual frameworks. Sinn Féin would implement multi-annual funding frameworks to provide funding certainty and improve accountability. This would enable more effective public service delivery once the health regions have assessed their population-based care and capacity needs.

One of the most frustrating aspects of the current healthcare system, which I am dealing with at the moment, is the volume of cancelled appointments. A constituent of mine last week spent his sixth week in hospital with major heart problems. He was discharged with the promise of an early emergency appointment for heart surgery. He cancelled his family holidays. So far, his preoperative appointments have been cancelled twice.

We also have so many scandals in the health service, including in respect of endometriosis and the Government's disgraceful amendment to the Sinn Féin motion last night, hip dysplasia surgeries and vaginal mesh implants. Children are waiting for years for assessments. There were also scandals in respect of surgical cancer and nursing homes. Those are just some examples. The list is endless. Those scandals are all happening while we wait for the opening of the €2.24 billion national children's hospital. This is no way to run a healthcare system. It is not good enough.

Sinn Féin has a plan to deliver a truly all-island national health service for Ireland, fitted to the Irish context and learning from the best across Europe. We would introduce a healthcare for all Act to set out a phased expansion of entitlements to commit the State to full public health cover by 2035.

Tackling the causes and consequences of addiction is central to developing a comprehensive healthcare system. Addiction needs to be seen as a public health issue and not a criminal issue. The Citizens' Assembly on Drugs Use supported a comprehensive health-led response to drug use and addiction. This would ensure that the State responds to drug use as a health issue and not a criminal issue. A comprehensive health-led response diverts people towards health services and away from the criminal system. The health-led response would greatly reduce or eliminate the prospect of people being charged and convicted. Funding for local and regional drug and alcohol task forces must return to pre-recession levels to ensure that sustained and appropriate funding increases every year to continue service development.

I welcome the commitment to open a primary healthcare centre in Swords. I have campaigned for it for years so I am delighted it is now going to happen. It is long overdue. It is important that we have a publicly run healthcare centre for Dublin Fingal East, providing a full range of health services to Swords and all of the surrounding communities. I know the staff are currently moving into the premises, which is great news. It is now essential that the Department of Health delivers the project on time. I will be working tirelessly and contacting the Minister regularly to ensure the health centre is fit for purpose, fitted out and open on the target date in 2026.

This Bill is an opportunity to provide a fit-for-purpose health service for all. I hope the Government will use that opportunity to deliver for the people.

Brian Stanley (Laois, Independent)
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I welcome the opportunity to speak on this Bill. I will do the easy bit first. I have gone through the Bill and welcome a lot of what is in it. It is welcome that the service plan will be replaced with a performance delivery plan. It is welcome that we will be able to measure things. The Minister for Health is to prepare a strategic direction statement in respect of health service priorities to guide the HSE in preparation of its corporate plan. That is welcome. The Minister for Children, Disability and Equality is to prepare a similar strategic direction plan in respect of community-based disability services. That is laudable. The Minister for Health will also prepare an annual statement of the health services' priorities. That is very important. The Minister for Children, Disability and Equality will undertake a similar task. The performance delivery plan will be due within 28 days of the receipt of the determination of the maximum net non-capital expenditure that can be incurred. That is all good. Importantly, the CEO will be required to inform the board, the Ministers for Health and Children, Disability and Equality if the HSE is likely to exceed the capital and non-capital budget allocation for any particular year. That is all fine.

As I stated previously to the Minister, there is a substantial budget going in and I have no argument with that. Coming from a left republican position, I welcome that. The more we can put in the better. Outcomes are the whole thing.

The following is the hard bit. The most recent health sector employment report was published by the HSE in March. In December 2019, 18,851 staff members were listed in the management and administration category. In March 2024, that number had increased to 25,477, which represented a substantial increase of 35%. When we track it, we can see that the numbers employed in those grades are increasing at a faster rate than the numbers of clinical, care and front-line staff. That is a big issue I have with the HSE. I am not saying that all managers are bad or anything like that. I know managers in the HSE who are doing their best. What I am saying is that it has become very bureaucratic. There are several layers. I understand there has been a big ship to steer. Health systems are complicated and the HSE is a big organisation with 120,000 workers. It can be hard to manage. I understand that. However, we must keep an eye on the services and the budget provided for them.

A situation was highlighted recently in respect of clinical insourcing. On many occasions we have complained about outsourcing, but I am talking about insourcing. It was interesting when that report came out. Surgeons were taking patients who came to them during the week out of the public system and doing private work through a private company they had established so they could do the work at weekends and receive a different price for it. That became a cash cow for those individuals and companies. The bewildering thing about it was that the hospital's own facilities were being used. If it were a private facility, that would be fair enough. If a private hospital wants to operate, let it operate. That is grand. I do not have any particular grá for privatised health services but if a private hospital wants to operate and people want to pay for it privately, it is grand. However, we must disentangle that from the public system, which we were supposed to be doing with Sláintecare. It was clear that what those surgeons were doing was exploiting public facilities and scarce taxpayers' money that needs to be going to front-line services. We must move away from that.

I welcome the fact that the Department and the chief executive of the HSE, Mr. Bernard Gloster, has managed to get weekend work operational in hospitals. They must work seven days a week. There is expensive equipment. We do not have enough equipment and we have a growing population. I get all that. For now, we need people to work at weekends. I welcome the fact it is happening.

I know that the numbers on the public-only contract are increasing. That needs to continue and to accelerate.

Again, that is nothing against people who want to work in private healthcare - that is fine and dandy - but we have to disentangle the two systems. This is a clear example of the public system and public facilities being exploited in terms of their use for private profit.

I refer to the lack of transparency in outcomes and delivery. The Minister was a member of the public accounts committee when I was the Chairperson of it and she was fairly good at drilling into things - I will give her that - as regards disabilities and so on. She focused on that a lot, as well as on health services, and she made a good contribution there, as did many of the members, but I remember her focusing in particular on these issues. We need to really give attention to this. The lack of transparency in outcomes and delivery damages the reputation of the healthcare system and can cause long-term financial problems. It restricts the public information. We must have full transparency to see how hospitals and services are performing and to get a better insight into waiting lists. Without that, public trust will be eroded.

I know the Minister was unavoidably absent this morning - the Minister of State, Deputy Butler, was here in her absence - but I hope she gets a chance to read some of what I said, and indeed other contributions that were made because they were made sincerely. I raised the issue of dental care and, in particular, the public dental schemes. There is €230 million going into that per year. It is clear that we are not achieving what we need to achieve in terms of the schemes. It is clear that the dental treatment services scheme, DTSS, for medical card patients is non-existent in many parts of the country, including in County Laois, where no dentist is taking patients under it, except one on the edge of Carlow town. The dental treatment benefit scheme is also very limited. Up to 2009, a range of services were provided under it but now it is just cleaning and examination. I suggested that we should examine a voucher system for that, which is in operation in other countries, to give a better service for workers paying PRSI, USC and PAYE.

I will say what I said this morning just to bring it home to the Minister. There is a particular problem with children and adults with special needs who need treatment under anaesthetic. There is over a two-year waiting list and there are some awful examples of young people and adults in desperate need of dental care on long waiting lists and going nowhere. I have had family members come to me about this and it is terrible. They cannot be treated. Some of them are suffering with toothache and some are suffering with oral dental health problems. That will all cause further health problems down the line. I ask the Minister to really take that on board because they are a very vulnerable group.

The issue of agency staff is in some ways an old chestnut but it is one we have to deal with. When he took over, Bernard Gloster said he was committed to trying to pare that back, and I know that is easier said than done, but the over-reliance on agency staff is concerning, with €276 million spent in 2024. It is a lot of money spent on services, recruitment agencies, etc. That €276 million was only for 11 months of last year. The HSE's records showed that this finance was spent on services such as administration, management, nursing, medical, dental, and paramedical services and supports, as well as maintenance and technical supports. In the Midland Regional Hospital, in Portlaoise, a relatively small but very busy hospital, almost €20 million was spent in 11 months last year. Some €19.7 million was spent there on agency staff in 11 months of last year. As I understand it, that spend has never been higher.

The Minister will be doing the capital development plan. She will be swotting around the Cabinet table over the next week with this. I know there are hard decisions to be made. The cake has to be divided up. I ask her to do what she can about primary care centres and health centres because we all know that if we catch people, and if we are able to help people in the community and provide services at community level, it keeps them out of expensive hospital care.

In particular, I ask the Minister about the primary care centre for Portlaoise. It is promised and it is agreed that it will happen, and everybody is on board with it. It needs the cash - the capital allocation. Portlaoise town now has a population in the region of 30,000. There is a huge catchment area around it. It is probably the only town of its size in the country that does not have a primary care centre. Some of the smaller health centres - in Mountrath, Borris-in-Ossory, Rathdowney and Graiguecullen - need some upgrading as well, and I ask that they not be forgotten about. They need works as well.

We have had the ambulance services before the Committee on Public Accounts and we have had reports from them. I do not care what the senior staff in the ambulance services say about dynamic deployment. There are ambulances chasing from Portlaoise to Waterford or to Wexford. When they are within a mile or a couple of miles of where the accident or the patient is, they get a call telling them to turn back as another ambulance got there before them. Meanwhile, back in Laois, somebody is after having a heart attack and there is nobody to pick them up.

Whether we like it or not - and I know there are no easy solutions to this and that nothing is perfect - we have to get to a system. The optimum is to keep the ambulances within a 45 km or 50 km area. By all means, ambulances should be able to cross county boundaries. Portlaoise ambulances should be able to go into south Kildare, west Carlow, north Tipperary or east Offaly. Of course, there has to be flexibility there, but we cannot have them chasing literally to Cork, which is happening. That needs to change.

I welcome the start of the midlands hospice. This has been going around since I came here 15 years ago, and I would say before that. I welcome wholeheartedly the fact that that will now be done. It is located in Tullamore and not in Laois, but people will live with that. This is a service in the midlands, a really important end-of-life care facility, and I welcome that.

I started by saying there is a big shift this year as regards the health system. I understand that. Bernard Gloster has done a good job. I know of some changes he has made. He has made some good changes to this. The Minister is taking a very hands-on approach to it. We may differ sometimes on ideology or other things, but what is really important is that we shorten the distance between budget and delivery and that we can see that it is a straight line. We must remove the diversions that allow people to talk around issues, sidestep and get around this. In big organisations, we need to shorten the distance between the money going in and the top of the organisation and the service delivery on the ground. We must remove all places for people to hide and keep this in a straight line. Let us make sure we get value for taxpayers' money and improve public services at the same time.

Peter Roche (Galway East, Fine Gael)
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I support the Second Reading of the Health (Amendment) Bill 2025. The Bill is timely and necessary and fundamentally about one thing: accountability in how we plan, manage and deliver healthcare in Ireland. The central purpose of the legislation is to ensure the Health Service Executive operates under the highest standards of prudent and effective financial management. It replaces the old service plan model with a more accountable performance delivery plan, strengthening the role of Ministers and the HSE CEO in financial oversight and correction.

Since 2015, health spending has exceeded its initial allocation almost every year. These overruns not only challenge our public finances; they ultimately threaten service delivery. The people of Galway East, like communities across our country, deserve assurances that resources are being used efficiently to deliver timely and effective care. This Bill gives the Minister the capacity to question these finances and work for the communities that need care and intervention.

This Bill introduces several key reforms and brings in: strategic direction statements from the Minister will help guide the HSE’s corporate plan, ensuring alignment with national priorities; mandates early warning and corrective action mechanisms if the HSE is projected to overspend; and, crucially, places legal obligations on the CEO and board to stay within approved financial parameters.

I welcome the clarity and discipline this Bill imposes. However, will the performance delivery plan give local health services, like Portiuncula Hospital in Galway and community care hubs in east Galway, the flexibility they need? Will funding allocations truly reflect the demographic demands of rural regions like east Galway, which has an ageing population and growing waiting lists for inpatient and outpatient care? Accountability must not become bureaucracy rather it must lead to outcomes.

This Bill rightly brings sharper tools to financial governance but it must be paired with real insight into what drives health spending. We know, for example, that east Galway continues to suffer from GP shortages, delayed disability assessments and pressure on mental health services. Budget discipline must be matched with strategic investment, especially in primary and community care, in line with Sláintecare.

In east Galway, the community is ready to embrace integrated, regionally led care models but we must see more visibility around the HSE's performance locally and not just nationally. How will this Bill ensure that people in Ballinasloe and Loughrea can see tangible improvements on foot of national reforms?

I fully support the power of Ministers to direct the HSE when it comes to corrective actions, but we must go further in the context of clarifying accountability between the Department and the HSE. Oversight without consequences is not accountability.

This Bill is a strong step forward. It reflects the findings of the Sláintecare report and builds on the governance improvements of the 2019 Act but we must ensure that it results in better care, not just better paperwork. For Galway East, for our nurses, GPs, and carers, this Bill must ultimately support those on the front line and not just the balance sheet.

In the context of the contributions already made to this debate, it would be remiss of me not to mention the outstanding work our front-line workers do every day and sometimes under severe pressure. No one can predict when there will be an emergency or an outbreak. From experience and from my knowledge of how the HSE, particularly in the context of University Hospital Galway, Merlin Park and other hospitals in Galway, deals with these scenarios, I have to compliment and thank those workers. It is important to say that.

Cathal Crowe (Clare, Fianna Fail)
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I also wish to speak in support of this Bill. I will take up from where Deputy Roche left off. We all acknowledge the huge efforts of our front-line workers in every part of the country, and the Deputy is right to pay tribute to them. They work damn hard. Conditions for them all are not great. I have been in hospital myself in the past as a patient and visiting people. One would often see nurses having their lunch at the end of a trolley or a counter and running down the corridor to deal with patients. We need to keep an eye on their workplace welfare. They work so hard and go beyond the call of duty every time they report to work.

The Bill is about governance and improving accountability in the HSE. I have a particular bugbear, which I am sure is the same for everyone else here. The Minister for Health is also a constituency TD, as are the Taoiseach and the Tánaiste. Everyone here is accountable to their constituents. This is nothing against the Minister; it just reflects the systematic set-up of Governments over many years. If I ask a parliamentary question of the Minister for Health, it will probably be passed to the HSE. That is fine; I accept that. However, the HSE will not reply in the three or four days within which standard parliamentary questions are answered. If I asked a parliamentary question about a driving test or something that is not massively consequential for someone’s well-being, I will get a reply in three or four days. If I ask a parliamentary question about someone’s acute healthcare, however, I may not get a reply for three or four months. When parliamentary questions relating to health are diverted to the HSE for reply or when we are told to email reps@hse.ie, the same legal framework and lead-in period of four days if it is an oral parliamentary question or three days if it is a written question should apply, where possible. I understand that people may be on holiday, and we do not want to burden healthcare officials with filling out reams of paperwork in order to reply to questions from those within the body politic. I am not suggesting that. On basic matters, however, there needs to be a better turnaround. This is not the Minister’s fault, but she might be able to take action to address it.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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You are right.

Cathal Crowe (Clare, Fianna Fail)
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It is not just the Department of Health; it is also the Department of Transport. If we table parliamentary questions to that Department, they are forwarded to the National Transport Authority or Transport Infrastructure Ireland. A large number of agencies have been set up over many decades. The all-important stuff we try to do as TDs gets siphoned off in different directions, and it can sometimes take months to receive replies. I had a reply to a parliamentary question come back recently in respect of someone who has since passed on. Luckily, I was able to intercept the reply in my office and tell my staff not to send it out. It would have been the grossest insult to the family involved if the reply had gone out.

The Minister is a very good person. She is a good person to be leading the Department. I saw her at the University Hospital Limerick a few months ago. The gloves were off and the sleeves rolled up and she was down those corridors to see how it was functioning for better or for worse. I have every faith in her in the months ahead.

HIQA has reported to the Minister. There is something on her desk we would all love to see. I refer to the HIQA report on the future of healthcare in the mid-west region. It was being withheld until the arrival of the ESRI's report. It is due out in September, I think.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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It is not on my desk.

Cathal Crowe (Clare, Fianna Fail)
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Sorry, it is not on the Minister’s desk yet. I apologise. The report to the Minister is imminent and the Cabinet will have to consider it. The report is on emergency healthcare access in the mid-west region. From replies to parliamentary questions that I and others have tabled, I know that initially HIQA was supposed to report to the Minister and then to Cabinet. Now, however, she has rightly asked it to factor in the recent ESRI report into its report. The report from the ESRI suggests that we need 40% more acute beds in this country by 2040. It is right that those two reports should be considered together in order that we might view public healthcare in the overall context.

In 1962, President John F Kennedy spoke at Rice University in Texas. He told those present, some of them guffawed and others laughed, that he would get men on the moon by the end of that decade. That happened in 1969. When he made that speech, he did not really have a full vision of how that was to happen. It was a policy aim, and he told his officials and everyone else to make it happen. Someone in the Department of Health is going to have a moon-landing moment. They will have to have it sooner rather than later because if we keep kicking the can down the road when it comes to public healthcare in the mid-west, what is needed will never happen.

During her time in the Department of Health - and I hope she has a very long and fulfilled political career - will the Minister make a moon-landing decision in September and apply it public healthcare in the mid-west region. When my mother started out nursing in the region in the 1980s there was accident and emergency care in Ennis, Nenagh, St. John’s Hospital, Barrington’s Hospital and the regional hospital in Limerick. There were five accident and emergency departments for a population of 300,000. There is now one to a population of 500,000. Something has gone fundamentally wrong here. It has happened over many years and it has to be fixed. Regardless of who makes the decision, and I hope it will be the Minister, we should be under no illusions. That hospital will not be built in 12 or 24 months' time. Public infrastructure in this country takes a huge amount of time to build, but it has to start with a political decision. It has to start with someone in a leadership role saying “Enough”. The ESRI has reported this, HIQA has reported that and unfortunately many people have lost their lives in hospital too, which is a body of evidence in its own right. That needs to be the guiding principle and the beacon that I hope will lead the Minister to make the decision in the autumn to improve access to public healthcare in the region. She has been down to see it. I have every faith she will do the right thing but I ask her to please, take the political decision. She may well be the Taoiseach when the ribbon is cut, because these things do not happen quickly. Regardless of that, however, the political decision to do this now has to happen this autumn. I trust the Minister will make it.

Like others, I pay tribute to the many people who work in our healthcare system. An Garda Síochána recently bemoaned the appearance of billboards outside some Garda stations. It happened at Limerick Garda station on Henry Street about six months ago. Melbourne police department is now recruiting, and it parked up a truck and trailer trying to lure gardaí to the land down under.

When the Minister, her colleagues in government, the Ceann Comhairle and others with political leadership roles in this country are overseas, they should spread the message that Ireland is open to recruitment in the health sphere. There are a lot of jobs that we cannot fill with our own graduates.

We need to look at attracting our nurses back home. I mentioned the point in the Chamber some months ago and the INMO did not like it. There has to be some carrot and stick, albeit more carrot than stick. We cannot train up the best and brightest people to become nurses and doctors and accept that they will spend their first six or seven years after qualifying in a sunny part of southern Australia. We have to have them here. Maybe after fulfilling five or six years of public contracts, they can break away and leave the country but they owe it to this country. It is not popular to say it but we will need that to fix our problems.

I thank the Minister and offer her my continued best wishes.

Thomas Gould (Cork North-Central, Sinn Fein)
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There are 121 people in the HR department in the south west. The Minister talks about progressing this Bill, but I believe it is bluff and smoke and mirrors. It is trying to pretend that there will be proper accountability and value for money in the HSE. Even though 121 people are working in the HR department in the south west, €250,000 was paid to private consultants in 2023. Who brought this private form in and why was it brought in? Why is this work not being done by the staff there? They are capable and well able to do their jobs.

This is like so many other issues within the HSE. We cannot get answers or accountability. The HSE refuses to answer straightforward and simple questions. I asked who had made the decision to close SouthDoc in Blackpool in Cork. I received an answer through freedom of information that the head of primary care did not know who had sanctioned it. She did not know who made the decision. I then asked the head of the HSE in the south west but he did not know who had made the decision. I spent two months writing letters trying to find answers and I still cannot get one. The HSE is paying full whack to SouthDoc even though SouthDoc in Blackpool is closed. This is not me saying it. The figures I received from the Department say it. The people of the northside in Cork North-Central cannot get access to an out-of-hours service unless they drive across the city. The Minister is talking about accountability and transparency. These are the facts on the ground.

Turning to primary care centres and value for money, Fine Gael has wanted to privatise everything since coming to power. Over €20 million will be paid over the next 20 years for Ballincollig primary care centre, yet the State will not own it. We still have no primary care centres in Blarney, Mayfield and Glanmire. They have been hit by delay after delay. They have also been privately contracted. From what I can see, no primary care centres will be delivered in Cork unless it is by a private contractor.

I thank all the front-line workers - doctors, nurses, other medical staff, people in the canteen and cleaners - in every section of our hospitals. Fortunately, I survived sepsis and cancer in recent years and, touch wood, I will be able to keep going. The workers have done brilliant work. When someone seriously ill gets into the system, he or she will be taken care of but an uncle of mine died recently who suffered four years of pain. His name was John McCarthy. He is survived by his wife Noreen and his sons John, Mark and Stephen. He suffered in pain for four years. I wrote to the HSE and the Mercy hospital. One month before he died, I got correspondence telling me that John was not a priority and that his case was not severe. Four weeks later, he was dead. There needs to be accountability and transparency for John, his family and all the other people who, unfortunately, are failed by the HSE.

Peadar Tóibín (Meath West, Aontú)
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I welcome the fact that the Minister is looking to tie financial support for the HSE to its performance. It is something that I have made an argument for over the past number of years. I firmly believe that we need to reach a situation where the HSE is paid for the work it does for patients and the benefits it brings to patients. We would probably go further than this and tie funding for the HSE to the number of operations, treatments, consultations and engagements it has with patients. This will ensure that money would get to the front line and that taxpayers' money would not be lost in layers of administration, which happens in the HSE. The Government is fond of recruitment embargoes. A recruitment embargo in the administrative sector of the HSE for two years could be beneficial in reducing the level of administration in the HSE.

If we tied funding to services delivered, it would mean that theatres would not remain closed for months on end in some hospitals, as the hospital would get paid for the theatre being in use and having a throughput of patients. Therefore, it would be illogical to allow those theatres to remain closed.

There is a difficulty in terms of the HSE and funding. Billions of euro are being poured into the HSE but we are not getting the service to which we are entitled. All the talk in this Chamber is about more funding for health services but the Dáil needs to start focusing on how we get better results for the money we are investing in the HSE.

As the Minister will be aware, the IT system in the HSE is not fit for purpose. We see ourselves as a tech island, yet the technology levels in the HSE are not acceptable. Many people still have their documents in physical form and when those documents need to be shared, the physical documents need to be moved about for people. It means that we cannot deliver a proper system. Covid was an example of that because some people received their Covid shots on the basis of the nursing homes they were in while other people received them on the basis of their GPs. Some people were called for two Covid shots while others were not called for Covid shots. We all have bank account numbers at this stage and there are really important details of all our engagements with those banks kept on an IT system, and it works. The fact that we do not have this for the HSE is still a significant problem.

Accountability is very important. The Minister will not agree with me but sometimes the lack of accountability in the HSE comes from the top. I mentioned the issue of Simon Harris not admitting initially to signing the contracts for the national children's hospital. He has rowed back somewhat on that, which I welcome, but I am still not confident about what will happen with the National Maternity Hospital. I was given a bill of quantities that was being used for the National Maternity Hospital. It was given to me by an anonymous individual. I had a look at it and there were lots of gaps in it. There was very little detail in it. It looked like the bill of quantities that was used for the national children's hospital. It looked like it had the space necessary for a future contractor to wangle a heap more cash out of the State. I ask the Minister to look at that. I raised the matter with the Taoiseach, who did not deny the veracity of the document. He said he had no interest in reading it. He said it was not the Minister's job to look at this and that the finer details were down to staff in the Department, but that is not the case. We need ministerial accountability if we are going to sign off on such documents.

One of the most shocking replies to a parliamentary question I have received from the Department over the past number of years concerns the number of adverse incidents in hospitals. In the five-year period from 2018 up to and including 2022, there were 500,000 adverse incidents in hospitals. Many of these were of low significance and did not have a massive impact on the individuals, but there were 3,142 deaths as a result of adverse incidents. I will give an example of how this arises. I know a woman who lives a five-minute drive from Navan hospital. She worked all her life in Dunnes Stores and retired at the age of 66. A couple of months later, she had a stroke.

It took an hour and a half for the ambulance to get to her home. She was finally brought to the hospital. Two weeks later, she was being treated and was brought to the shower by two nurses. The hospital was so busy, one of the nurses was pulled away and the woman fell and hit her head on the floor of the shower unit and sustained a head injury. She was then brought up to Beaumont Hospital. Her name was very similar to somebody else's and she got the wrong blood transfusion as a result. She had significant internal organ failure. This woman worked all her life, did the best she could, paid her taxes and retired, and three separate adverse incidents shortly afterwards have left her debilitated to this day ten years later. That is what is happening and there is no accountability for it. The State paid €2.4 billion in compensation in a ten-year period, so it is not just costing us in lives and ill health, but in billions of euro in taxpayers' money. We need to really inject accountability into the system. I ask that accountability be one of the significant elements funding is determined by in future.

Last year, 115,000 people were so sick that they went to accident and emergency departments but had to turn around and leave without ever being seen by a doctor. That is an incredible statistic that shows the overcrowding that is happening in certain hospitals. The number of people who die before an ambulance reaches their homes is increasing significantly year on year. In 2019, 757 were dead before the ambulance came. That is going to happen and is just a natural part of the system, but this figure had increased to 1,000 people in 2021. This shows that a lot of ambulances are being tied up. We had 11 ambulances outside Drogheda hospital one night because of the overcrowding in the accident and emergency department. They were waiting to see if they could deliver their patients to the hospital. They could not and had to stay there. There was no ambulance available in Monaghan, Cavan, Louth or Meath for the whole night as a result.

I was the first person to raise insourcing in the Dáil. I spoke about how private companies were being created by consultants to funnel patients into the consultants’ businesses. A report showed that, in one year, €14 million had been paid out to some of these businesses. I was told by a consultant in the south of the country that there is no incentive to get rid of a waiting list, for the waiting list is the business model of these insourcing businesses. The Minister is going to have to get to grips with this issue. We cannot have that conflict of interest where a consultant operating on a public list is scheduling and creating rotas for people to work on those public lists but does it in a way that means there is a steady stream of business to the private business as well. That has to be challenged. I accept that it is on the Government’s agenda.

Another reply to a parliamentary question showed there were 300 private clinics operating on the grounds of public hospitals. That is quite significant. We have private patients being treated in private clinics operating in public hospitals with the use of public equipment. A different reply to a parliamentary question showed 300,000 public patients had gone through the NTPF since 2017. That is not what the fund was set up for. It was not set up for such a large quantity of patients to be dealt with in that fashion. Those numbers have ballooned in the last few years. If you take the NTPF, the private businesses operating in public hospitals and the insourcing that is happening, there is a significant level of privatisation of the public health system happening right before our eyes weekly and that has to be challenged as well.

Another reply to a parliamentary question we received showed 13,000 nurses had left Ireland in the last five years. That is an incredible figure. In 2022, over half the doctors who graduated left the country. Another reply indicated 51% of all undergraduates in medical schools in this State were from outside the EU. The reason for this is such students pay nearly €200,000 for their degrees over the five- or six-year period. The universities are dependent on those funds because they are short of funds, but the danger is that most of those individuals who are from outside the EU will want to work in their home countries by the time they graduate and will not be available to the GP system in this State. Thus, the Government talks about more spaces in the universities for GPs, but it is not translating necessarily into more GPs going through the university system to work in our health service. That has to change.

There is a major capacity issue with the psychiatric unit in Crosslanes in Drogheda at the moment. I am told people who are suicidal are being told to go home in taxis because there is not enough space to deal with them. I would love if the Minister’s Department would pay attention to that because, as she knows, that is a life and death situation affecting many families.

Michael Collins (Cork South-West, Independent Ireland Party)
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Today, we are presented with the Health (Amendment) Bill 2025. On the surface, the Bill promises reform, but let us be clear - this is not reform, but bureaucracy dressed up as progress. The Bill does not fix our broken health system. It merely rearranges the furniture in a house that is already on fire. It tinkers with the governance structures while ignoring the real crisis, which is the daily struggle of patients and front-line workers. The people do not need more layers of reporting or internal reviews but functioning hospitals, nurses who are empowered and not overworked, GPs who are supported and not sidelined, and care that is accessible, timely and humane.

This morning, my office got a call from an 89-year-old lady who was caring for her 55-year-old son who had a disability. She is unable to get home help. She had it until a number of weeks ago but the HSE has set up a pod system for home help in the Bandon area. The constituent is outside the pod system and, therefore, has no home help. It has been put out to private providers, but to date that has been unsuccessful. This lady is saving the State a lot of money by caring for her 55-year-old son yet the State is unable to provide her with assistance. She is 89 years of age. There is a severe lack of home helps in west Cork. A new computer system is being set up and the home helps are being expected to go online instead of doing what they are great at, which is looking after the people at home. A lot of them are retiring and walking away from the whole thing because it has got too complicated. It is obvious it is not working on the ground.

We have another family, which has a six-year-old boy who has been diagnosed with undescended testes. He has been on the waiting list to be seen in Cork University Hospital even though he is classed as urgent. He is in a lot of pain, which is causing him to fall quite a lot. He is not able to go out and play with his friends and this is causing him a lot of anxiety. His mother received a letter today asking if she wanted her son to remain on the waiting list.

We have a constituent who is in his mid-50s and caring for his elderly parents at home. They both have dementia. Recently, his mother was in hospital and, upon discharge, she required a wheelchair and commode at home. Her son made over 40 phone calls to the HSE about getting the equipment he was told would be supplied upon discharge. Eventually, he had to go to the HSE stores department and get the equipment. Communication with the HSE is extremely poor.

Friday saw the publication of the abortion figures for 2024. There were 10,852 abortions in Ireland, which is up 63% on 2019. The promise made during the 2018 referendum that abortion would be safe, legal and rare has well and truly been broken. The figure of 10,852 is the highest number of abortions we have ever seen. In my county of Cork, 957 babies lost their lives by abortion last year. The Government must think seriously about offering women with unplanned pregnancies greater supports and clearly-signposted alternatives to abortion. No woman should ever feel she has no option but to have an abortion.

True reform means more hospital beds. It means better pay and conditions for our healthcare staff. It means supporting carers who give so much and receive so little. It means a mental health strategy that does not just exist on paper and reaches into homes, schools and communities. Our vision is clear. It is oversight, transparency and fairness with policies rooted not in spin, but in service to patients, workers and families. Over the last number of weeks, I have raised a lot of serious issues here and I find there is very little progress on them. I am writing to the Department of Health and the Taoiseach and I am raising them with the Taoiseach. One is the situation we have with the nursing home in Bantry. There is an issue between a proposed purchaser, the receiver and HIQA. The bottom line is the people who are suffering most are the ones who are worried their nursing home will be closed down on them. There has been an enforcement order slapped on it by HIQA, giving two weeks, which I think will be up this weekend, for the receiver to appeal. In the meantime, there is an opportunity because the hospital has been brought up to a perfect standard. The staff there are doing their best to bring the hospital up to standard.

There is a possibility of 17 more beds for patients and that provision is desperately needed. I know of people in the Bantry catchment area - in Drimoleague and all around that area - who are being sent to nursing homes as far away as Kenmare. That causes awful stress for families. I put a question to the Minister of State, Deputy O'Donnell, recently, on which I am not sure he ever got back to me, to find out exactly what was wrong and asking that he intervene in some way or other to get this across the line. It is down to a paperwork exercise. There is no longer any issue with the nursing home. There is another one in Conna near Fermoy.

I also raised the issue of Perrott House. I hate to use the word "abuse" but abuse can come in different forms. We have seen what goes on in some nursing homes. Families have been told Perrott House has to be done up, and there is no issue with that, but they have never been told where their loved ones will go. Last week, a family member of mine asked me about this. He is delighted I am raising it continuously in the Dáil. Families feel they are not getting adequate support or advice as to what exactly is happening with places like Perrott House. They are finding out information bit by bit and they are worried and looking over their shoulders.

An issue that has been raised by several Deputies is the ambulance service. I have been fighting a long time for a better service. I know of cases where people have waited three, four, five or six hours for an ambulance. That is outrageous and bordering on a disaster situation for many people. I have sometimes advised people that the best thing to do is to take a chance on taking the person by car to get treatment. I spoke a year ago of someone having to wait eight hours in Bandon. It is not good enough. We need an ambulance service that people feel they can trust. People living in west Cork might have an ambulance coming from another county. How is an ambulance brought from another county into the deep end of west Cork to pick up somebody who is gravely ill?

It would be wrong of me to stand here and fault community hospitals. They are the gold stars of our health service. Anybody with a loved one in a community hospital, or who is familiar with the local community hospital, knows the excellent service these facilities provide. In my area, we have lots of community hospitals, including in Schull, Castletownbere, Dunmanway, Bandon and Kinsale. They are top-class facilities. However, the population is ageing and there is no extra bed in them, nor any extra beds planned over the coming years. How do we plan to tackle the crisis facing us in the next five, ten or 15 years? We have a growing population of elderly people who will need community hospital beds. Hospitals that had 20 or 30 beds in the 1960s and 1970s still have the same number now and the same number planned into the future. The Minister must take note of that. It is not a good situation.

I have spoken to a lot of nursing home operators about how they have to keep their facilities up to standard. The community hospitals at least have the State behind them in ensuring they are up to standard. Nursing homes have no such State backing and those costs must come out of the owners' coffers. In some cases, that may lead to the closure of nursing homes. It is a very serious concern. There must be supports to bridge the gap. The Minister has met Tadhg Daly of Nursing Homes Ireland several times, as have we. He has advised on the direction things need to go. They are not moving quickly enough. I have spoken to nursing home operators who are seriously concerned they will not be able to keep their doors open. In most cases, they are having to pass increased costs on to patients. That is unfair on patients and their loved ones.

We have fantastic medical care centres in a lot of places in the country. My worry is that, while they have 20 or 25 rooms, only three or four of those are in operation. Why is there no dental service back in operation in places like Schull, Skibbereen, Dunmanway and Castletownbere? We have fantastic medical centres in Schull and Castletownbere but no dental service. It was there when I was growing up in the seventies. Surely be to God it should be there in 2025. The dental service in Bantry is in operation only three days a week. Clonakilty has a five-days-a-week service and is now seeing to the whole of west Cork, with which it cannot cope. At one time, first, third and sixth class children were looked after by the service. Now, it is only sixth class pupils who get that service.

There are areas where services need to be improved and I ask the Minister to look at them. In the case of Perrott House and the nursing home in Bantry, people are finding themselves in crisis situations right now. They would appreciate if some help were given by the Minister.

Danny Healy-Rae (Kerry, Independent)
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I am glad to have an opportunity to speak about this Bill, which deals with very serious matters that affect every community, especially in Kerry. There are many failings and many issues. The Minister has said the HSE's annual service plan is to be replaced with an annual performance delivery plan. An issue I have encountered in this Chamber since I came up here is that, every budget time, we vote for X millions of euro to go to the HSE to provide health services for children, the elderly, people who have had accidents and everybody else who needs medical attention. We know about all of the failings of the system. It seems to me there is no real accountability for all the millions of euro given to the HSE. We, as elected Members, have no recourse to really challenge the executive as to what it is doing or has done with the money.

We see nurses going at full belt day and night in hospital wards. They are doing their level best but there never seems to be enough of them or other front-line staff. However, any number of millions of euro is provided for administrative staff. The Minister will correct me if I am wrong but it seems to me people are being appointed or reappointed to vacancies on the administrative side but when it comes to people on the working side, such as the nurse or someone else on the floor who needs to be replaced, the HSE are only allowing so many appointments. That is what we have been told is the reason we do not have as many nurses as we should.

There is an issue with Kenmare Community Hospital going back to when it opened in 2012 or 2013. It is located only 7 miles from my door and I am very proud that my father secured the funding for it. He fought hard and stuck it out to the bitter end until he got the funding. Sadly, not all the beds in the hospital are in use. We are told the problem is that the required number of staff cannot be obtained to operate all the beds that are idle upstairs. This community hospital services an area from Poulgorm Bridge, which is situated where one leaves the N22 to head towards Kilgarvan and Kenmare, all the way back to the county bounds in Lauragh and on to somewhere around Caherdaniel. It services all the families in that area in which somebody needs respite, but there is only one respite bed available while other beds lie empty.

We see the same with the community hospitals in Killarney and other places. We are waiting for the new community hospital to open in Killarney and to see to what use the old district hospital can be put. We are looking for a minor injuries unit and a primary care centre. We have been promised different things by the HSE at different times. We need finality on these issues sooner rather than later. Councillor Maura Healy-Rae is constantly raising this issue, as, indeed, are other local authority members from Killarney municipal district.

Things like that are very important. I remember when my father was on the Southern Health Board. The elected members on the Southern Health Board at the time visited hospitals and were involved in the running of the board. That is one of the questions. The Minister said there will be ten new members on the board. Will there be any elected members on the board? It is important there is.

On the old Southern Health Board – and it was the same with the Eastern Health Board and all the different health boards at the time – the elected members went around with the doctors and surgeons, where they interacted and found out what was wanting. They then contacted the Department of Health and worked together to address those issues. We need more of that because although many HSE officials are grand, more of them are not. They are not fulfilling the needs of the people. They are just not doing their job to achieve the outcomes we want for the people who deserve it.

People are living longer and have additional needs. We see all the problems that are coming along with autism and all of that. There seems to be any number of children presenting with autism. I wish we could find out whether anything is causing it. We need to help those people who present with autism. I feel for young parents who want the best for their child and want their child to be the best. It is a real ambition for them to want the best for their child. The time to be assessed is taking too long. We need to speed that up.

We are looking forward to the Minister taking a new look at the whole health system. It is a daunting request. I know that. Many Ministers have been blamed in the past. There are many intricate and different aspects we need to address.

Another issue we have is a lack of GPs at any time. If it were not for South Doc in the off periods, many people would be left unattended. We just do not have enough GPs. At weekends, accident and emergency departments fill up because there are no doctor services available. People are referred to the accident and emergency department where they have to wait long hours, including elderly people.

On the issue of elderly people, sometimes they have to leave their bed, including old men and women in their 80s, or maybe close to 90, to go to the accident and emergency department in Tralee. They end up sitting in a chair, or maybe on a trolley if they are after coming out of an ambulance, for hours before they are seen. That is not fair on people who have come out of their warm bed only to end up in a chair in the accident and emergency department. I am asking for that to be rectified.

I know the beds are there. It is the staff who are not there. We do not have enough staff. That is a real hurtful thing and I feel for people. I leave my phone on every night. I never turn it off because I often get a call at 12 o'clock or 1 o’clock at night from a family, whose elderly father or mother has been waiting in a chair to be seen from early the day before, telling me they will not have a bed again tonight. While these people are bedridden, as it is called, they get sicker and need attention. Where do they find themselves? They are put in a chair in the accident and emergency department. I am asking that a full stop be put to that.

There is another aspect giving me great concern. Long ago, when people got sick, some could be treated in the district hospital. People cannot get into the district hospital now unless they were in the regional hospital first. I cannot understand that and many others cannot understand it. I am asking the Minister to look at that because, more often than not, these people would be looked after in the district hospital in maybe one or two weeks and then they would be good enough to go home again for another spell. I know you are not going to make a young person out of them, but it would suffice. It would be more useful, make more sense and maybe stop the clogging up of our accident and emergency departments in the regional hospitals.

Many of the Deputies who spoke asked for all their wants to be met and to try to rectify everything. I am asking the Minister to do her best on these issues, especially for the older people who arrive in Tralee hospital after coming out of bed and may have to spend 24 hours in a chair waiting to be put into another bed. That is wrong. I also ask her to look at the issue of people not being able to get into the district hospital without going to the regional hospital first. Does the Minister know what often happens when there is no bed available for them? A taxi brings them home again. That is wrong. We have the beds. It is just a matter of more staff. I thank the Minister very much.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Deputy Healy-Rae has helpfully set out the difficulty with regard to hospital beds. Let us take Kerry hospital as an example. In the context of staff numbers, in the past five years, Kerry hospital has had an increase in staff of 43%. It has had a budgetary increase of 67% in the past five years also. To provide the breakdown of that staffing increase, Kerry hospital has had a 52% increase in medical staff; a 44% increase in nursing and midwifery staff; a 74% in patient and client care staff, who are the support staff; and a 43% increase in health and social care staff. Those are significant numbers.

Kerry hospital is perplexing me at the moment. In May, it was one of the best performers in hospital trolley management, which is a big issue in Kerry hospital because it has been historically poor in that regard. In May, there were 13 days on which there were zero patients on trolleys in Kerry hospital. There were three days on which one patient was on a trolley. May was, therefore, a good month. It shows there was bed capacity and management of the hospital in the round. The considerable extra staff meant there was good management of the emergency department. Something happened in June, however, and the figures were the complete opposite. This is the nuance of hospital-by-hospital level experience.

The Deputy set out exactly why this is so important. It is about the dignity and safety of patients who should not be waiting for 24 hours. They should not be waiting for more than six hours. Of those people who present, only 25% of them need to be admitted and managed in other pathways. This is only one particular example that happens to relate to Kerry because Deputy Healy-Rae was the last speaker. I could equally speak about Cork and the figures for that area. Although Deputy Healy-Rae was not in the Chamber when I was pulling the information together, with regard to Wexford, the constituency of the Ceann Comhairle, staffing numbers have increased by 21% over the past five years. There has been a 22% increase in medical staff and a 33% increase in nursing and midwifery staff. Wexford hospital is performing extraordinarily well with a much smaller increase in resources. It has low hospital trolley figures. Its culture is one of whole-of-hospital management. It is doing really well. It certainly needs more investment and support, but it is performing extremely well. I pulled the figures out for Waterford as Deputy Cullinane was present a minute ago. Waterford hospital has an average of zero people on hospital trolleys in 2024 and 2025. It has also had a 44% increase in staff, but with a different outcome compared to Kerry hospital.

If I take St. Vincent’s University Hospital, which is the closest model 4 hospital to me, it has had a 35% increase in staff and a 59% increase in budget. Yet, it has an inconsistent performance in its accident and emergency department and its management of delayed transfers of care. All of these particular local nuances matter. The Mater hospital, which I visited last week, has been good enough on its accident and emergency management. It is the rest of the hospital’s responsibility to support the accident and emergency department. A couple of weeks ago, however, it was one of the hospitals on a list of hospitals that were in considerable difficulties.

It had closed the Smithfield injury unit for the bank holiday weekend, which it has been paid to operate under the service level agreement. These are inconsistencies which are not acceptable and which we cannot stand over but they speak to the level of detail and nuance that is necessary to understand the complexity of health budgeting and how that is being translated to patient care on an individual basis.

While I appreciate this Bill does not transform the world, it does a couple of really important things that we need to happen. That includes in particular the corrective action plans, CAPs, that are necessary. The CEOs are now required to notify me or the Minister for Health of the overspend and to identify the detail of what caused the overspend and how it is proposed to avoid the overspend. The board can then review that, amend or approve proposals, agree on the cause, and agree on the actions that will eliminate or reduce overspend which it believes are practicable. None of that applies at present. There is a different level of detail in managing spend and overspend. It should not be the case that there are threats or assertions that a body cannot pay its pharmaceutical bill or its revenue bill and must close beds because all of those things are completely unacceptable, outrageous responses to a failure to manage a budget. In circumstances where bills for external consultants or legal advices outside of the State structure are still being paid or where, for example, there has not been evidence of non-pay savings over a three-year period, it is a bit like taking a dead cat and saying "Now, Minister, give me a big pile of money or else." We have to be serious about hospital management and about money being spent in a consistent and predictable way. We have to do that collectively and identify the instances where that is not happening.

There is unfortunately too much variance between hospitals and in how we think money should be spent. The budget has increased. In 2013, the health budget was €13.5 billion. It is now €25.8 billion. In a ten-year period, we have essentially doubled the health spend. We as a State cannot do that again. There was significant and necessary investment. We historically underinvested in health, particularly on the capital side. I thank every Deputy who has made the case for a large envelope to be given to the Department of Health and the HSE in the review framework, recognising the difficulty of managing that process overall, because of course all hospitals need water and energy security. Those things are also important but there needs to be significant capital investment. I appreciate the recognition of that. We cannot continue to grow the current budget the way it has been growing.

We have invested in people and hospitals. We must get the return for that investment. It is not acceptable for a hospital to make the case for an additional CT machine or any other diagnostic equipment in circumstances where that CT machine is not being used for all of the hours that Deputies and I expect it to be used. It is not acceptable to have CT machines or other diagnostic equipment which is not being used beyond 4.30 p.m., as is the case in some hospitals. I go in and ask what time the CT machine runs until and I am told it is maybe 8 p.m., maybe 5 p.m. or maybe 4.30 p.m. That is not okay and it is not okay for the State to be required, or have pressure placed on it, to put additional CT machines somewhere that one is not being used to the optimum capacity. Those are the savings and productivity necessary to deal with the sort of service we want to deliver to patients.

We have, together, a significant issue to manage, and which Deputies identified, with regard to insourcing. I believe it is not correct or moral for the State to continue a system which it knows is creating a barrier to achieving productivity in the public system. I am completely committed to a public health system funded by the State and delivered for public capacity, and to having that public work done in public hospitals. I recognise that there are historical contracts that enable consultants under certain contracts to do private activity in certain spheres. I recognise that that is so. On the other hand, I also see that 65% of consultants are now on the public-only consultant contract. We want public activity.

It was the correct set of decisions to take every step possible to reduce the waiting lists because that results in people getting pain relief, elective procedures and diagnostic tests that they need. Over the next 12 or 24 months, as we decide to do this, we have a real challenge in making sure that capacity is delivered in the hospital system. I would welcome the support and help of the health committee in particular in analysing the performance of hospitals in this way and making sure that we are winding down a structure we know is legitimate and lawful but is not what we want and not what we believe is the correct thing to do. I do not want to do it in a way that will cause waiting lists to spike, not because Deputies are going to correctly hold me to account for the waiting lists but because I do not want people to be in difficulties.

We will have to find the right way to bring down the activity that we do not believe serves the public interest in the medium to long term, that is, third-party insourcing and so on, and to increase productivity. Both are granular challenges which will be difficult and are complex. I need Deputies' insight, help and analysis and to use all of the tools of the Oireachtas to help to analyse the nuanced performance of hospitals that I have spoken of today. Deputy Conway-Walsh referred to Mayo in particular and I am interested in Mayo because it was one of the first hospitals I visited. It had very poor hospital trolley performance over the bank holiday weekend in early February, but it has been consistently difficult. It had a significant uplift both in resources and staff, but I am concerned about its weekend management. Not to be too unfair to Mayo, but the point is that there are different nuances in every hospital and we need to be honest about this.

This Bill is important because it helps to do one thing, that is, to be focused on corrective action. That is the sort of granular detail that we will need to improve financial performance in the health system.