Paul Coghlan (Fine Gael)
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I welcome the Minister for Health, Deputy Harris, to the House.

Simon Harris (Wicklow, Fine Gael)
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I congratulate the Leas-Chathaoirleach on his elevation to even higher office.

I am delighted to speak in the Seanad about my priorities for health and advancing the programme for partnership Government commitments in the first 100 days. I will be here for most of this debate which will allow me hear the priorities of Senators. My colleague, the Minister of State, Deputy Marcella Corcoran Kennedy, who is leading the public health promotion section of the Department, will join the debate later and will also be interested in the views expressed by Members.

Establishing the committee on the future of health care was one of the first commitments of the programme for Government. I am grateful for the cross-party and grouping co-operation which allowed it to be established without delay. The Leader of the House has already raised with me the eagerness of Seanad Members to make a contribution to the formulation of this ten-year vision. This is a contribution I would welcome. While it is out of my hands in the sense that it is a matter for the Oireachtas, I hope and trust a mechanism can be found to facilitate the involvement and engagement of Senators in creating a ten-year vision for health care.

This presents us with an historic opportunity to achieve something which has never happened before in health policy, namely a long-term consensus on its fundamental principles. When one talks about ten-year strategies and committees, one can see people rolling their eyes, saying, “Another committee, another strategy”. However, this has never been done before. We have never before set ourselves the challenge of getting every political party and Independent grouping to sign up to a programme setting out where we want the public health service to be in the next ten years, regardless of what happens in elections and politics. If we can reach this consensus together, it will give the public, health service staff and management the certainty that the direction of travel will not change, even if the Government does. When I speak to people on the front line of the health service, they tell me they are not fed up of reform but, instead, fed up of a little bit of reform here and there while never finishing the process. Part of the reason for this is because there has not been consensus. Health Ministers come and go, tweak the system but we never allow enough time for a certain direction of travel to be undertaken.

I recognise some concerns already expressed since the committee was established. First, people have pointed out the six-month timeframe is ambitious, which I accept. However, it is up to the committee members to make it work. Second, a key requirement to make the committee succeed is to achieve political, and indeed, societal consensus on the future of health care. I could not agree more with this objective. It will be a significant first if we can achieve it. Finally, when talking about committees and reports, it is important the process just does not create another report to go on a shelf but actually leads to something tangible which we can all get behind, regardless of future governments or elections.Again, I am fully in agreement with that view, and the Department will provide every support to the committee in its important work. I intend to second somebody from the Department of Health to provide support to the committee in carrying out its work.

The central objective of the new Government, as reflected in the programme for partnership Government, is to use our now strengthening economy to make life better for people. During the general election I very clearly heard people stating it is grand the economy is back on track and that it might be improving in some ways but asking what we will do about a range of public services. One of those which all of us involved in various electoral contests heard very clearly was the importance of reinvesting in the health service. The Government's objective, and my objective as Minister for Health, must be about improving the public health service on which people depend. It is a health service which really matters to families and communities and on which we and our families will depend at some stage in our lives.

We all know the health service faces many challenges. However, I am pleased to state as Minister for Health that I am in the fortunate position, because of the work of the people, to preside over a period of reinvestment in the health service. We saw this last week with the revised Estimate of €500 million for the health service. This will help stabilise health service finances in 2016, and the HSE has already stated it will put the health service on a sustainable footing. It also gives me an opportunity to address some immediate pressures facing patients as well as meeting programme for Government commitments in the first 100 days.

These commitments include enabling me to put in place a winter initiative to manage emergency department overcrowding. Work is under way on this initiative and I met the emergency department task force, which is jointly chaired by the Irish Nurses and Midwives Organisation and the head of the HSE. At the meeting I asked for input and ideas. I asked what worked and did not work last year in hospitals and what new measures we can try. I am very pleased that the funding I have secured for the winter initiative is more than the budget for the winter initiative last year. This year we have €40 million for a winter initiative compared with €33 million last year. I extend the invitation to Senators for ideas, input and any suggestions they think will help make our emergency departments more manageable, particularly during the winter period when we see a spike in attendances. I would very much like to hear them.

It is very important to me that the initiative focuses not just on acute hospitals but also on effective integration between primary care, social care and acute hospital services. We must stop talking about the issues and challenges facing our hospitals as though they are just problems in our hospitals. I note Senator Dolan's commitment with regard to disability work. Part of the issue is when people who do not necessarily need to be in hospital, or would not have needed to be in hospital, find themselves in an emergency department because they could not access a service in primary care or social care. Had they been able to access this, they may not have needed to turn up in an emergency department at the weekend, or had the support been in place in primary care or social care, they could have left the acute hospital when they were ready to do so, rather than finding themselves in the uncomfortable position of occupying a hospital bed when they would much rather be at home in their community with their family. We cannot just talk about acute hospitals on their own. This is why we do not have a Minister of State for primary care, because the Minister for Health is not just the Minister for acute hospitals but also the Minister for all the health service, which very much involves primary care and social care.

Another integral part of the initiative I am able to announce as a result of the extra funding is increasing resources for home care services. As a result of an extra €40 million for home care above and beyond what was planned in the budget, we are not only able to maintain home care and transitional care services at 2015 levels, but also, for the first time in quite a period, we are able to increase them. The programme for Government acknowledges the need to improve our services to older citizens, and the provision of additional home care services and transitional care services will assist more older people to leave acute hospitals when they are clinically ready to do so. This will allow patients awaiting admission in emergency departments to be admitted in a more efficient manner. This initiative will also help older people and people with disabilities to remain independent at home and to continue to have active lives in their communities for as long as possible.

I hope the Seanad notes that in terms of the future direction of health care in the ten-year strategy, one of the specific terms of references is how to ensure the effective delivery of primary care. Deputy Kelleher in the other House likes to remind me of the very valid point that when Dr. Rory O'Hanlon was Minister for Health in 1987, when I was one, he used to talk about the delivery of primary care. We are still talking about it. My colleague, Senator Reilly, started this process. We must realise the primary care is not just about buildings in the community; it is about being able to avail of more services in the community. This is why I think it is an important body of work to do.

To do this, we must recognise that we need to build up general practitioner, GP, capacity to respond to patients' needs and to respond to the expansion of chronic disease management in general practice. Recently, I met the NAGP and the IMO to discuss this. Our GPs deserve and need a new contract. We have not had a brand new contract in 44 years. Patients in Ireland value their relationship with their GP and the State also needs to value this relationship. As with any contract negotiation, the State needs to decide what it needs and what extra, additional or changed services it requires as part of a new contract.

I am very pleased that as part of the additional funding I have secured, I will be able to restore all the funding to the mental health budget. As Senators know, due to time related savings, which is a very bureaucratic phrase, some of the money meant to be spent in the mental health area this year was not going to be spent and would go into the base for next year. The additional funding I have secured for our health service means I am in a position to restore the €12 million that had been diverted from mental health services. We will, under the Minister of State, Deputy Helen McEntee, be in a position to spend on mental health services the full €35 million which was ring-fenced for them. The Minister of State will develop a plan this year.

We will also be able to invest further in disability services. My colleague, the Minister of State, Deputy McGrath, is working on this area. We have an additional €3 million for school leavers. An important area is where people with a disability, who are turning 17 or 18 and are leaving school will go next. As a country, we have not dealt with this well and we need to do it much better. The extra €3 million will provide assistance. As part of the additional funding for disability, there will be more money for emergency placements and for bringing disability facilities and residential services up to HIQA and national standards, which is important.

I wish to speak briefly about the need to improve waiting lists and waiting times, with a particular focus on those waiting the longest. It is fair to say that as a direct result of the years of economic recession, we are seeing unacceptably high waiting lists in this country. We will be reactivating or revving up the National Treatment Purchase Fund, NTPF. The programme for Government commits to providing €15 million funding to the NTPF for an initiative targeted at those waiting the longest. That funding will come from a continuing investment of €50 million per year to reduce waiting lists. I met representatives of the NTPF yesterday and asked them what they can do with €15 million, how many patients it will take off a list, how the organisation will decide who to take off lists and what it could do with more than €15 million. We are having a discussion about how best the Department of Health can spend the €50 million that has been pledged in the programme for Government in terms of waiting list initiatives. This year, we are planning a specific dedicated waiting list initiative through the NTPF, focused on endoscopy. I expect this to mean the service will be in a position to carry out at least 1,200 endoscopy procedures and to clear the lists of those waiting 12 months or longer. This is an important issue and it needs to be addressed. I expect to be in a position formally to bring the Seanad details of this quite soon.

I acknowledge the health service has been changing, and it would be wrong not to acknowledge where success has happened. We must challenge ourselves. At what point did we decide it was acceptable for the political and media norm to be that we only ever talk about the health service in the negative? This does a huge disservice not just to the Government of the day but to the 105,000 people who work in the health service. Every day good things happen in the health service. It is rightly our job to challenge things that do not go well and to highlight problems - absolutely - but I want to acknowledge the good work carried out in difficult circumstances by front-line staff in recent years. Life expectancy in Ireland has increased by two and a half years since 2004 and is now above the EU average. We have seen a decrease in the average length of stay in hospitals and significant progress in reducing tobacco consumption. It is fair to say that Senator Reilly in his time as Minister for Health continued the good work of previous Governments in driving this agenda, which has Ireland leading Europe in terms of tackling tobacco consumption. Progress has been made in many health areas, including how we deal with cancer patients and cardiac situations, and it is important to recognise this progress, along with recognising those who work so hard on the front line.

There is clearly much more to do, but I believe there exists an opportunity to make realistic and achievable improvements in patient care and therefore make a difference to people's lives. As well as the shorter-term initiatives I have outlined, I am determined that we progress major investment projects, such as the national children's hospital and a new national maternity hospital. I was in the House last week speaking about this. We must look at how we keep our population healthier through the national obesity strategy and the new national cancer strategy.

I want to be very clear. I stand here as Minister for Health knowing that I alone will not fix the health service and that while the Oireachtas is very diverse, it need not be divided on every issue.If we are honest with each other, there is a great deal we agree on across the Oireachtas in terms of the direction of travel for the public health service, although I acknowledge that we sometimes like to extenuate our differences for political reasons. However, there will always be issues on which we do not agree. If ever there was a unique opportunity to put in place a ten-year vision, it is now because we have a minority Government and we have no monopoly on wisdom or mandate. I am very much in the hands of both the Seanad and the Dáil in terms of how we can work collectively together and I look forward to working with Senators on all sides of the House.

Keith Swanick (Fianna Fail)
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I welcome the Minister to the House to discuss important issues regarding the health system. As a GP based in rural Ireland, I would like to outline some of the issues in primary care, which is a crucial aspect of our health sector. I commend the Minister for his support of the ten-year consensus on health care. It is a hugely promising step for the Government, which will refocus discussions on health reform in this House and the Lower House on patient care rather than political gains.As a GP, I also commend the Minister for his recognition of the role of general practice. International studies demonstrate that the strength of a country's primary care system is associated with improved population health outcomes, regardless of per capitahealth spend and percentage of elderly patients. Furthermore, the World Health Organization, WHO, has reported that increased availability of primary health care is associated with higher patient satisfaction and reduced aggregate health care spending, and orientation towards a specialist-based system enforces inequality in access.

The time has come for all stakeholders to work together in a pragmatic and solution-driven approach to develop a ten-year plan to reform health care. I welcome Senator Colm Burke's comment regarding Senators being members of the ten-year committee. There is a need for better integration between primary and secondary care. This approach is supported by international evidence that it will deliver efficiency and better patient outcomes. Every €1 spent on primary care saves €5 elsewhere. This model works in Kilkenny, with the success of the local area integrated care committee and acute medical assessment unit. Kilkenny provides an example of what is possible for integration between primary and secondary care resulting in shorter patient waiting times, and giving GPs greater access to diagnostics. That will prevent the patient ending up in the wrong place at the wrong time. Patients often self-refer to accident and emergency departments, for example.

We have a current manpower crisis in general practice. A total of 157 GPs are trained per year, but we are currently exporting half of these highly-trained professionals. An Irish College of General Practitioners survey of trainees and newly qualified GPs in 2014 found that only 37.5% of GP trainees were definitely planning to stay and work in Ireland and only 43% saw themselves as a principal in a GP practice or partner in a group practice. An option for the remainder would be as employees in salaried posts. In the current climate, however, few existing practices have the finances to do this. While training more GPs is necessary, until an environment that will encourage those who are trained to stay is created, we cannot begin to solve this looming manpower crisis. A further concern is the ageing demographic of the current GP workforce. A report commissioned by the National Association of General Practitioners, NAGP, in 2015, by LHM Casey McGrath, found that more than 900 GPs - close to one third of the current workforce - expressed an intention to retire or emigrate in the following three to five years.

General practice currently carries out 22 million consultations per year with a greater than 95% satisfaction rating. This is expected to increase to 35 million annually in the next three to five years. The projected number of GPs needed to meet this demand is approximately 4,000. Currently, approximately 2,400 GPs have GMS contracts but with the projected retirements in the next few years, we stand to have only half the required numbers. However, we regularly hear from GPs who have emigrated to Australia, New Zealand and Canada. They consistently highlight that the major difference between our health care system and theirs is their timely access to diagnostics such as X-rays, scans, physiotherapy, counselling and expert opinion, the difference it makes to their working day and the benefit to their patients, which cannot be overestimated. In recent years, the State has rightly built primary care centres. However, this is not all about bricks and mortar. It is important that activity takes place within these centres to keep patients out of the secondary care system.

Ultimately, many of the challenges faced by GPs boil down to the terms and conditions of our working lives, which are dictated, as the Minister said, by an ancient contract between the State and the HSE. I hope he will confirm in due course that the NAGP will be invited to negotiate a new contract on behalf of its members. I believe he had constructive meeting with the association's representatives last week and I welcome his commitment to further engage with them in the coming weeks. The organisation has made significant gains in progressing key issues for GPs since its relaunch in 2013.

With regard to the Supplementary Estimate for health, Fianna Fáil welcomes the allocation of an additional €500 million with €40 million for home care services, €31 million for disabilities, €20 million ring-fenced for mental health services and €40 million for the new winter initiative. Should the Oireachtas health committee have extensive hearings with the Department and the HSE as to what is required to meet both the demographic demand and unmet need in order that all areas of proposed expenditure can be fully examined and scrutinised? In particular, the HSE should be invited to make a submission to the committee similar to that which was sent to the Department last August in order that health expenditure requirements can be extensively debated and analysed in advance of the budget in October.

James Reilly (Fine Gael)
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I congratulate the Leas-Chathaoirleach on his recent election to the post and I also congratulate the Cathaoirleach, who is not present, on his appointment because this is my first opportunity to do so publicly. I also congratulate, Senator Buttimer, the new Leader of the House and, indeed, all new Senators.

There is much I would like to say but I agree with everything that Senator Swanick said, much of which I have said in the past. I also am delighted to have heard the Minister speak in the manner he did. It is important that as we celebrate the centenary of 1916, which started a process that led to our independence, we remember what the Proclamation said about equality and treating all our citizens equally. One of the most pressing needs around equality is the right to health care and access to health care when one needs it, not when one can afford it. That has been at the core of what we have sought to do. The ten-year plan and the cross-party committee will decide what we want. Many of agree on the what but the how and the when cause divisions. We want a fair health service that treats everybody equally and is there for them when they need it.

The points I wish to make I have made in the past. I always had a mantra that the patient should be seen at the lowest level of complexity that is safe, timely, efficient and as near to home as possible. The nearest place to home is usually the GP's surgery. We need primary care centres to deliver the excellence of care that GPs can provide in excellent surroundings and that sends a message. I agree more access is needed to diagnostics but it also needs to be ensured people are working to their level of competence and that GPs are not seeing patients that nurses could see, nurses are not seeing patients other paramedics should see and consultants should not be examining patients who could be dealt with within the primary care system. There is a huge opportunity with a new cadre of nurses coming through who are interested and energised and want to provide different services and who are well capable of learning those skillsets.

No part of the health service is isolated.Senator Swanick addressed this in his comments. One cannot fix what is happening in accident and emergency units unless one fixes what is happening in primary care, which equally is dependent on what is available in the community, and the full circle is completed by rehabilitation.

Senator Swanick talked about elderly patients. I am very concerned about the fact that there has been a movement towards a medical model in nursing homes which was arrived at by the need to address burdens on families and society and concerns surrounding the safety of elderly people living on their own, as opposed to a service and a place where we address their needs and help them to get the best out of life as they inevitably grow more frail. That is something that we must continually keep readdressing.

I was struck also by the Minister's comments regarding disability. Senator John Dolan would be the first to say that people with a disability often ask, "Why am I here? I am not sick; I have a disability." It is an entirely different problem. We must address this big issue, which has always been a huge tension between the excitement of investing more in cardiac bypass and stenting versus longer-term investment in education on exercise, obesity, alcohol and tobacco. That dynamic is always there and is one that is very difficult for politicians to address. I have been critical of politicians on this island, in Europe and at the UN for being more likely to go for the big bang of the new cardiac unit rather than the slightly softer matter of more PE in schools, exercise and education so that people realise one can prevent many illnesses. It is no longer a threat in the western world to die from infections; the big threat is from chronic illness and non-communicable diseases. The broader issues surrounding that are influenced by child care, and we must have a vision in that regard too. I believe the Government has started on that route in making child care more affordable, giving every child an equal chance in life. Again, this is the big problem for us. We all know the things we want, we all speak to them, but we must acknowledge that funding is finite and that if we invest over here, we cannot invest as much over there. I therefore return to the argument about the new CAT scanner versus a new public health initiative.

Do I have a few more minutes? I have about one minute.

Paul Coghlan (Fine Gael)
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The Senator has half a minute.

James Reilly (Fine Gael)
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I congratulate the Minister on his appointment and wish him well and will be as supportive as I can possibly be of him. I encourage him to pursue the issue of a patient safety authority urgently. It was to be advertised before I left office and then, suddenly, it all changed into something else. We still have no patient advocacy agency in this country, and we need one. I often said that I often felt when I was Minister for Health that I was actually the Minister for ill-health because it was all about disease, illness and sickness and there was no emphasis on keeping people well and encouraging men and others to go to see their doctors early when there is something wrong.

I will finish by wishing the Minister and the committee well but echoing very strongly the request of my colleague, Senator Burke, that there be Seanad involvement. We miss out hugely if we do not have that.

Victor Boyhan (Independent)
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I will be very brief. I will not even be one minute. Firstly, I congratulate the Minister on his appointment and thank him for yet again coming into the Seanad.

There is clearly not much mention of the National Treatment Purchase Fund in the programme for Government. In the past it has demonstrated itself as being a very able, efficient and very focused group. Under this new Government arrangement it was somewhat tapered and called the special delivery unit within the Department of Health. It was a sort of stand-alone operation in Tara House on Tara Street. I do not know whether it has now been subsumed altogether into the Department itself, but there is room to explore and consider the capacity of the National Treatment Purchase Fund to access blocks of really good competitive deals in both the private and public sectors. Let us not fear the private sector and the synergies between the private and the public sectors. What people want is fast treatment, and the person who has been waiting the longest needs to come first. That is the issue. I would therefore like the Minister at some stage or other, not necessarily today, during one of his trips to this Chamber, to elaborate on where he sees the role and the potential for expansion of the National Treatment Purchase Fund.

Colm Burke (Fine Gael)
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I welcome the Minister to the House. I am delighted that he is here with us dealing with the health programme, in particular the need for a ten-year development plan for health. It is extremely important.

One of the things that concerns me regarding the whole health care area is why every issue that comes up in the media seems to be very negative in its content, whereas there are a lot of positive things, to which the Minister referred earlier. It is interesting how the HSE report was made available and laid before this House in the last two weeks, yet very little coverage was given to it. I remember being at a meeting not so long ago at which people were saying the health system was crumbling. I asked them what particular aspect was crumbling but the debate went on.

I started looking at the figures regarding what exactly the health service is doing. I raised the attendance at outpatient clinics in Irish hospitals last week. There were 3.3 million attendances which, over a five-day week - most of these outpatient clinics operate five days a week - works out at 63,000 people per week attending outpatient clinics in Irish hospitals, or 12,500 per day, which is a huge number. If one then considers accident and emergency units, it works out at approximately 23,000 people a week attending accident and emergency units. The question is how we work towards first of all making the services that are being provided more efficient, but also, particularly regarding accident and emergency units, how we work towards reducing those numbers so that services are available outside the hospital system.

My colleague, Senator Swanick, raised very important points regarding the issue of GPs and the support for them, and it is also important to realise that GPs over the last number of years have suffered unfairly under the cuts. I remember meeting a number of GPs over the last 12 months who identified that they had suffered cuts of up to 40%, and I am not exaggerating. As a result they find that they cannot provide the same level of service that they want to provide to their patients. One very simple example was given to me. If someone comes into a surgery and needs three stitches in his or her arm, the pack for doing that costs €30. The GP is only entitled to claim €26 outside of the time that he or she puts into providing the care, so the easiest option is to refer the person to an accident and emergency unit. That is just one example of what I am talking about, namely, the inadequate support given to our general practitioners.

I agree with Senator Swanick about the National Association of General Practitioners. All of the medical unions should be involved in negotiations regarding the contract for GPs because this is not a contract for 12 months or two years but a contract that would hopefully be in place for a long time, probably five, ten or 15 years. Therefore, it is important that all of the people involved in this area of providing medical care are involved as regards what that contract should contain.

We face a number of major challenges, and I think the Minister is aware of them, and he has highlighted them already. A simple example given at a presentation by GPs that I attended is that there are approximately 600,000 people over 65 years of age in Ireland. Within 14 years that will be 1 million. A very interesting figure that the GPs brought up, however, is that 51% of all hospital beds are occupied by over 65s. If one works out that ratio, the number of additional beds we would technically require over the next 14 years is quite substantial unless we can improve a number of other areas to make sure we have fewer people having to go into hospital and that a lot of the care that they require can be dealt with outside of the hospital setting. The budget for the HSE last year was €13.895 billion, €3.621 billion of which went to non-statutory agencies.In addition to that €13.895 billion, a huge amount is spent on private health care such that Ireland is now the second highest spender on health care per head of population in the OECD. Are we getting value in real terms? Could we deliver a better service with the money being spent? I believe we could.

Another issue we need to consider and which should be part of the health plan - though many may say it should not - is medical education. We are spending about €90 million per year on medical education. Within 12 months, 60% of that investment has gone out of the country. We need to look at how we can keep our own people within the health service in Ireland and if they want to go abroad for a period, we should at least be able to get them back. This is affecting smaller hospitals in particular. In such hospitals outside Dublin, Cork, Limerick and Galway, the major centres of population, up to 70% of the medical practitioners are non-Irish. They are providing a good service but we should have a system in place that encourages Irish people to stay in Irish hospitals.

Paul Coghlan (Fine Gael)
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I call Senator Rose Conway-Walsh. The Senator has six minutes.

Rose Conway Walsh (Sinn Fein)
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I may not use the six minutes. I thank the Minister for attending. I will be really positive. I thank the Government for its investment in Áras Deirbhle nursing home in Belmullet because for many years there was no investment in that nursing home. This is hugely important in the context of what I am going to say.

In light of the negative impact on rural areas of centralising and privatising health care in Ireland, Britain and many other countries, will the Minister consider a proposal to provide as many health services as possible in rural and urban settings where the larger hospitals are situated many miles from acute specialist hospitals? Sinn Féin and I have long believed that a new approach is necessary to overcome the challenges met by people living away from these centres in accessing health care. This growing problem is not confined to remote rural areas, although the lack of transport, the absence of a good road network and the cost involved in accessing the most basic services is greater in these areas, including the place where I live in Erris, County Mayo.

There is a really good strategy, Developing Community Hospitals, is use in Scotland, so there is no need for us to reinvent the wheel. The Minister may be familiar with Belmullet hospital and the fact that, under the then Fianna Fáil Government, half of the beds there were closed in 2010. We led a very active campaign, Senator Mulherin with testify to this, to try to keep those beds open. However, the then Government insisted on closing them. We are left with an infrastructure of quite a large hospital that could be used as a centre for the delivery of the services we need. Will the Minister consider a pilot project to develop a multidisciplinary health service facility at the hospital in Belmullet and have a cost-benefit analysis carried out in order to deliver this? We could lead the way in terms of examining whether this might be a method of tackling the shortfall in the provision of services between the centres of excellence and the acute centres. We could look at the possibility of a community casualty unit to prevent people having to travel elsewhere to have minor injuries treated. We could examine the development of electronic health records in order that people's patient information could be available, provided proper broadband services were available. We could also revisit the whole development in technology which never happened but which was promised under the Primary Care strategy. The Minister will recall the pilot projects established in the context of Primary Care. The major problem with those projects was that proper resources were never provided in respect of them. Putting a sign saying "Primary Care" above a door does not make a facility a primary care centre. Investment is needed. The electronic potential identified within those centres could now be used not only for primary care but also in the development of these multidisciplinary health service facilities. We could test this model in Belmullet in order to discover if it will work. Many safe and effective services could be delivered at local level using this model. We could have an integrated patient transport policy included in these hospitals. My direct question to the Minister is whether he would be willing to look at it and whether he would be willing to work with us in the community of Erris in Belmullet to test this model in order to establish whether it would work in other areas of the country also.

Mr. Simon Stevens, head of the NHS in England, realises there are many shortcomings in the centralisation and privatisation of health services. The way in which our health system has developed has left us in a situation with which none of us agree whereby one's treatment is based on where one lives. Whether a person lives or dies can come down to where he or she lives. People in areas such as that in which I live are at a major disadvantage in trying to access services. I remind the Minister that patients from Belmullet seeking to access the most basic services currently being delivered in Galway are obliged to make a six-hour round trip. Some people may have two, three or four appointments in one week. That is not the way to treat some of our most vulnerable people, namely, those who are ill and who require to access health services.

I ask the Minister to examine the Cuban model of delivery, which is very interesting. Even in terms of cost, it delivers an excellent health care service to a population of 11 million for less than it costs to deliver the services at Beaumont Hospital.

Will the Minister to comment on the ESRI report on the possibility of the delivery of universal health care, particularly as that has long been our policy? Universal health care has often been ridiculed on the basis of the argument to the effect that we cannot afford it. We have always said we could afford it and it is interesting to have the evidence to back that up.

I look forward to working with the Minister and I hope he will have an open-door policy in terms of addressing all of the issues to which I refer. I ask him to consider the impact on the health service of the policies of previous Governments and how that has militated against people living in rural Ireland in particular.

Paul Coghlan (Fine Gael)
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The Senator did very well. I call Senator Michelle Mulherin who has six minutes.

Michelle Mulherin (Fine Gael)
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I welcome the Minister and I wish him well. I also welcome his statement on the future of health care. While ten years seems a long time, what is significant is that he referred to bringing all sides on board and to obtaining different views on how we might achieve a more desirable health care system for everybody. This will require dialogue and that dialogue will take place in the context of an increasing demand on our health services. People are living longer and are coping with chronic health conditions. With advances in medicines, there are new drugs, new treatments for cancer and other life-threatening illnesses and diseases and, periodically, the whole debate to the effect that the State is required to fund new drugs is played out in public. The pharmaceutical companies are trying to get the top dollar while the State has to watch its budget. These are all realities and all the time we are talking about human beings.

It is worth remembering that, even as we try to deliver it, health care must be for everybody, regardless of a person's finances or what he or she can afford. If one is sick or dying, one does not have any options. It is at this time one is really vulnerable. If our State is worth anything, it must continue to strive to find ways to make that health care a reality for all citizens. I know the Minister is committed to that. I welcome the convening of the new health care committee. I support Senator Colm Burke's suggestion that Senators be included among the membership of that committee in order that both the Upper and Lower Houses - across the board in terms of parties - will be represented on it.I welcome this opportunity to get down to the nuts and bolts of the debate and tease out the issues.

I ask the Minister to intervene in a pressing issue that has arisen in Ballina district hospital, County Mayo, namely, the escalation of an ongoing dispute between WestDoc, which provides the hospital with an out-of-hours general practitioner service, and general practitioners who provide the service during normal hours. These services provide 24-hour cover and allow the hospital to function. I have been informed by staff of a threat to withdraw general practitioner services from the hospital in the coming days. This would result in the closure of the hospital, which is difficult to believe. The staff who contacted me are very concerned about patient care.

Ballina district hospital is a step-down facility with a large number of elderly, frail patients. It provides a top-class service, as everyone who uses its services will attest. People are delighted with the care and attention they receive. The hospital's closure would lead to 59 patients being transported by ambulance to Castlebar general hospital. Staff are also fearful for their jobs. While discussions are ongoing, the dispute appears to be escalating and a threat of withdrawal of service has issued to the Health Service Executive. I ask the Minister to ensure all obstacles are overcome and the parties move towards finding an immediate solution to the dispute.

I commend the general practitioners who provide a very good service to the hospital. I also commend hospital management with whom I worked closely to have all the beds in the facility re-opened. In 2011, when the previous Government was elected, the number of beds in the hospital had declined to 40 and it was feared that there would be further bed closures. Working with the Minister and Health Service Executive, I and managers at the hospital fought long and hard to secure the re-opening of beds and the expansion and renovation of the hospital. In conjunction with the Mayo Roscommon Hospice Foundation, Ballina district hospital provides hospice suites for the first time.

A great deal of good work has been done at the hospital and it is a matter of grave concern that it may close. Such a scenario would be unacceptable and would have knock-on effects. Mayo general hospital, like all hospitals with an emergency department, suffers from the problem of requiring patients to wait on trolleys. Ballina district hospital and hospitals in Swinford and Belmullet, which also provide step-down beds, provide a lifeline to Castlebar general hospital by relieving pressure on its emergency department. I would appreciate if the Minister would revert to me on this extremely urgent matter. The parties must sit around a table and knock out a solution in the interests of health care in the region.

John Dolan (Independent)
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The Government must adhere to the timeline for ratifying the United Nations Convention on the Rights of Persons with Disabilities by the end of this year. Work is being done on the legal and legislative changes required for ratification. In parallel, implementation planning is needed for the urgent restoration of practical measures such as home supports, personal assistance, neurorehabilitation services and therapies, and so forth. Previous speakers referred to other measures and many more come to mind. The mobility allowance is dangling by a thread and the motorised transport grant was abolished. Budget 2017, which will be introduced in four months, will indicate whether there is a willingness and an ambition to move beyond words in terms of the importance of the inclusion of people with disabilities.

Not to put a tooth in it, the question people are asking is whether the long-running crisis in disability and mental health will continue to be viewed as acceptable. These areas of health have not been adequately addressed for decades. Austerity measures have brought a vicious and continuing harvest of poverty, exclusion and loss of hope to people with disabilities and their families. The restoration of services that have been lost is the immediate priority and we must proceed on a programmatic basis thereafter.

The ten-year plan announced by the Minister is very welcome and I will make a couple of points on some of the relevant issues and tensions. Every year, we have what are described as the "new disabled". At least 50,000 people will become disabled or require disability or mental health services this year. Disability is, therefore, a societal issue. We do not have disabled people and the rest of us because disability can and will come to everyone's door. Reference was made to an increase of 2.5 years in longevity in the past 12 years, which is a significant improvement. While mortality rates have declined significantly in the past 20 years, morbidity rates have increased. The ten-year plan is extremely important because we should have been planning decades ago. Let us start to address demographic changes, such as longer lifespans and an increase in the number of people living with disabilities and other conditions that reduce their capacity. People with disabilities and their families have been paying the price for the failure to plan.

As people move out of institutions, others, often young men and women, are moving into nursing homes and other institutions. Some health programmes receive statutory support, while others are provided on an administrative basis, for example, personal assistance, home help services and so forth. This has allowed these services to be filed away for the past decade.

Health has always been the default service provider for people with disabilities. When people require education, employment activation, accessible transport, housing and so on, the matter is regarded as a health issue because disability is involved. However, they are issues for the relevant Department, whether education, housing or transport. I ask all Senators to think about this matter because the Department of Health has always been at the short end of the problem. Other Departments have primary responsibility within their remits for the lives of people with disabilities and their families. It is long past time that they faced up to that.

The nature of disability is changing. At one time, the narrative was that there were people with disabilities and able people. That is no longer the case. We are all on the slippery slope. As a result of improvements in health and social provision, many people have what I describe as disabling conditions such as those of an episodic nature. We must reconsider our approach to these issues, which will mean ensuring that Departments other than the Department of Health share the burden. Enabling measures are required to keep people at work and ensure young people move from education into training and employment. Budget 2017 is the first critical step to be worked on.

How did the 50,000 people who will become disabled this year view last year's budget? Most will have asked whether their income had improved or they or their families were better off as a result. This year, however, these same people will view the budget from the perspective of having a disability and will ask whether they will be able to remain in employment, secure a job or continue to function as a parent, look after elderly parents or engage in the community.

I have three requests. First, the ten-year plan must strongly factor in the areas of disability and mental health and find ways to draw in community organisations and groups working in these areas. Second, budget 2017 must restore services.Third, we must focus on community living and participation.

Other Departments and public bodies must get their act together and not leave everything to do with disabled people to the Department of Health.

Maura Hopkins (Fine Gael)
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I thank the Minister, Deputy Harris, for addressing us. I welcome the Minister of State, Deputy Corcoran Kennedy, to the House for the debate.

Like my colleagues, I support the setting up of a cross-party health committee which will have a longer-term focus with regard to health policy over the next ten years. That is welcome. During the recession health budgets were hit but now that we are in a better economic position it is important that we direct our resources appropriately towards the fairer delivery of services for our people.

I would like to refer to many issues within the health service but I will focus on the area of stroke care. The suddenness of a stroke can be very difficult for patients, families and carers. The effects of a stroke range from very mild difficulties such as hand weakness to more complex challenges such as speech difficulties, sight loss or paralysis on one side of the body. As an occupational therapist who has specifically worked with stroke patients for the past eight years I have become deeply frustrated when, following a stroke, many of our patients are unable to gain access to specialist rehabilitation in a timely manner. There is such potential for these individuals to improve given the right access to services.

An audit report on stroke services carried out by the Health Service Executive, HSE, and the Irish Heart Foundation published in January this year found that the death rate from stroke has dropped from 19% to 14% since the last audit was carried out in 2008. Some 8% of stroke patients are being discharged to nursing homes compared with 15% in 2008. That marks a substantial reduction, which is most welcome.

The Minister, Deputy Harris, rightly said there are good developments every day within our health service and those changes are very much driven by the HSE national stroke programme currently led by Professor Joe Harbison, who has shown great leadership in terms of the reorganisation of acute stroke services. We have improved the position from one stroke unit to 21. We have ensured that we have approximately 250 medical doctors trained in thrombolysis or clot-busting treatment. That means real improvements are being made in the initial stages following a stroke.

However, stroke remains Ireland's biggest killer after cancer and heart disease. Our stroke patients must be treated with the same level of urgency as that of cancer and heart disease. The key finding of the audit was that a very high proportion of survivors suffer needless disability, and I listened attentively to Senator Dolan's contribution, because of a lack of rehabilitation services once they have been treated in hospital for a stroke. With medical advances we must have better and more timely access to rehabilitation services. It is important to consider rehabilitation services within the context of community services and hospital services for those over and under 65 years of age.

The audit also shows that only about half of patients are admitted to a stroke unit at any one time during their hospital stay. In 2016, treatment in a stroke unit is the most basic requirement. All of the clinical evidence supports the benefit to stroke patients and improves their outcomes and their recovery.

For patients under the age of 65, the position is of even more concern. Those patients find it extremely difficult to get access to inpatient rehabilitation services because the only one we have is the national rehabilitation service in Dún Laoghaire. Many of our patients are waiting months. We need to make sure that our multidisciplinary teams are properly resourced.

One of our major challenges in terms of rehabilitation is the delivery of more units. I ask the Minister of State to ensure that the specialist rehabilitation unit planned for Roscommon hospital is progressed as quickly as possible. It is essential that the project team comprising hospital, clinical and estates personnel is assembled as quickly as possible, and I ask the Minister of State to ensure that happens without delay. We must ensure that we are providing proper services for the people of the west, who find themselves in a very difficult position where they require rehabilitation.

In terms of the early supported discharge services, I ask that there would be a greater focus on community care and properly resourcing our early supported discharge teams.

Michelle Mulherin (Fine Gael)
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I welcome the Minister of State, Deputy Corcoran Kennedy, to the House. The next speaker is Senator Nash who has six minutes.

Gerald Nash (Labour)
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I am pleased to contribute to this important debate. I first want to wish my colleague, the Minister of State, Deputy Corcoran Kennedy, every success in her portfolio. In the previous Oireachtas we both had different roles but I very much enjoyed our engagement in terms of my role as Minister of State with responsibility for business and employment and her role as the very successful Chairman of the Joint Committee on Jobs, Enterprise and Innovation. I extend my congratulations also to the Minister, Deputy Harris, on his appointment. It is not overstating the case to say that we as a society very much depend on their success as respective Ministers in their portfolios, so there is no extra pressure.

For some time I have stated privately and publicly that the future direction of our national health service requires that we have a long-term, consensus-driven strategy and approach to our service that has a genuine role for all stakeholders in the process. That means everybody across society, not just those of us who are privileged to sit in this House and the Lower House. The success of this proposition and the proposed ten-year programme in regard to health services requires all of us to be honest with one another. It requires an honest Government but it also requires an honest Opposition. We need to start with a vision of the kind of health service we want. It flows from that that we must be absolutely clear about how we plan for that and how we resource it. We need to have an honest discussion.

The provision of first-class health care comes at a cost. It is very costly but it is something that is worth paying for. Treatment in acute medical settings is particularly expensive and the operation of our emergency departments is, by definition, very costly. Those of us who do have and will have the need to use our acute hospital services deserve to be treated in a timely and effective manner and provided with the best possible treatment by staff who are supported and valued in hospitals that are accountable and managed by people with the right skillsets and who understand that it is the patient, the citizen, who should be at the heart of health care service provision. They should also accept that their jobs, and the way in which they manage their jobs in hospitals, should be open to the closest of scrutiny.

We are also familiar with the problems experienced in our overcrowded emergency departments across the country. I am acutely aware of the long-standing problems experienced in Our Lady of Lourdes Hospital in Drogheda, my home town, in my constituency.I have been party to many efforts, particularly in recent years, to address that hospital's multifaceted overcrowding problems.

We need to step back and take a clear-headed look at this situation. Many of the problems experienced by emergency departments, and the reason for the bottlenecks in appointments, outpatient services, surgeries and so on in acute hospitals, can be traced back to the lack of prioritisation of the provision of integrated primary care services and of the notion of prevention being at the heart of the life of a healthy society. Remarkably, Ireland has the only EU health service that does not offer universal coverage for primary care. We have a public hospital system that is largely fed by a private primary care system. This is the perverse way in which the health system has evolved organically since the foundation of the State.

Many sneered at the idea that we would provide free GP care to young children and those aged over 70 years. It was dismissed by some as a political stunt, but it was the start of an ambition to provide such a service to all of our citizens in a move towards a new national community health service. My party's vision for a new integrated primary care service involves the proper integration of GP services, advanced nursing practitioners and allied health professionals and staff being active in community settings treating and managing patients away from expensive hospitals.

If we believe that the pressure on hospitals is enormous now, what will it be like in the years to 2020 and 2030, when it is anticipated that there will be a 40% increase in the incidence of chronic disease in Ireland? To avoid this apocalyptic scenario, we must develop dozens of new community-based clinical programmes that target the most prevalent and complex chronic diseases so that people can get consistent access to treatment and prevention strategies without needing to visit hospitals. This approach would have an empowering effect on patients, liberating them from an excessive reliance on the acute hospital setting.

We cannot afford not to make these step changes in the delivery of services. It is important that we put the primary care vision and the integration of services at the heart of everything that we do in our vision for a health service over the coming years. We can build a consensus on this approach.

Martin Conway (Fine Gael)
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Cuirim fáilte roimh an Aire Stáit go dtí an Teach. I apologise for not being present for the earlier part of the debate. Unfortunately, I had to honour a commitment. I welcome the Minister of State, Deputy Corcoran Kennedy, to the House. I have known her for a long time and know of her passion and commitment to public service. She has hit the ground running in what is an interesting, challenging, fruitful and rewarding portfolio. There will be tangible successes as a result of the personal commitment that she brings to everything she does. She worked on the justice committee in the previous Oireachtas, so I saw that at first hand. This is an exciting prospect.

It is appropriate that we debate health in the Seanad's first weeks. I welcome that a new conversation is developing. I have always adopted a positive approach in politics, even in the most difficult of circumstances. If we engage, be positive and seek consensus, we can achieve much. If we divide, we will be conquered by forces outside. If we unite, we can conquer.

I was heartened by the commitment in the programme for Government to an agreed ten-year plan for health. The Minister for Health, Deputy Harris's first public comments after his appointment were in that vein. He wanted agreement and to set up an all-party Oireachtas committee that would devise the strategy for the next decade. This is appropriate, as health is not a political football, but a political issue. For too long, it has been a political football. All sides in the Oireachtas are to blame. People have seen the vulnerability of the health services and used it as a political football to gain traction in opinion polls, notoriety and votes. That is not an appropriate approach to health and the millions of people who depend on the health service.

We spend per capitamuch less on health than many other countries, for example, the Netherlands, Germany, etc. People claim that it is not a question of finances, only of how the resources are spent within the service, but I contend that it will remain a financial matter until such time as we realise that we cannot have first-class health services if we continue giving tax cuts in budgets. That is a difficult political decision to make. It is easy to knock 0.5% or 1% off various tax rates and doing so puts more money in people's pockets, which everyone likes and aspires to, but it means that there must be some give elsewhere. I would prefer no tax cuts and instead to see that money going into the health service in order to restore much of what has been removed in recent years.

We in this House have a role to play in the formulation of the ten-year policy strategy. I am unsure as to whether the select committee is being set up by the Minister to formulate that strategy, but I hope not. Rather, I hope that it is a joint Oireachtas committee. Some Senators have vast experience in this area. Senators Swanick and Reilly are GPs and Senators Freeman and Dolan have experience implementing health services and dealing with related issues, for example, mental health, persons with disabilities, etc. These people are in the House. They want to serve, make a contribution, engage and be part of the formulation of a ten-year strategy. No one expects everything to happen instantly - it happens incrementally - but the best way of ensuring that we have a health service that we can stand over and be proud of some day in the future is by agreement, consensus and pulling the various strands and expertise together.

The situation with accident and emergency services in the mid-west where I am from can only be described as diabolical. Reconfiguration happened even though the facilities were not in place to handle it. The 24-hour accident and emergency units in Nenagh and Ennis hospitals were closed and their services consolidated in Limerick, but there were no facilities in Limerick. The service is collapsing. Consolidation and reconfiguration should not have happened until such time as the new emergency department unit had been built and opened. I am glad that we will have a state-of-the-art emergency department in University Hospital Limerick in 2017, but the reconfiguration put the cart before the horse. It was bizarre.

The medical profession-----

Michelle Mulherin (Fine Gael)
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Time, Senator.

Martin Conway (Fine Gael)
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I will conclude now.

Michelle Mulherin (Fine Gael)
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I am sorry, but the Senator is over time.

Martin Conway (Fine Gael)
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This is an important point. The medical profession and all stakeholders have responsibilities. There are many anecdotal examples of GPs referring people unnecessarily to accident and emergency units. The ten-year plan that the committee is being formed to establish and develop needs to engage with all stakeholders and, where possible, should have their unanimous agreement.

Michelle Mulherin (Fine Gael)
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I have to call the Minister at 6.40 p.m. and, therefore, I will try to get in as many Members as possible. I ask them to be brief.

Brian Ó Domhnaill (Fianna Fail)
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I congratulate the Minister of State on her appointment to the health promotion brief. It is an important brief, which can play a part in reducing the spend on health, depending on what policy is articulated. We have had a good discussion. The spend on health is approaching €14 billion from the public purse with an additional €5 billion provided by the VHI and other private sources, giving a total of almost €20 billion. The health sector has been debated in both Houses and by commentators over the past ten years, in particular, as people live longer and our demographics change. There is more disease and there is a need for prevention, treatment and cure. As a result, there is a cost to the Exchequer and private health insurance companies, which must be met. The sector faces major challenges but a ten-year vision is the correct way to approach them. I believe we need a 20-year vision in this country and across Europe. We should not stop at ten years but look much further ahead than that, taking on board new treatments and so on.

A number of areas need to be targeted. One is the cost of drugs and the patenting arrangements and how that can be reduced. Elderly care and home help hours, in particular, must be addressed. Demand exceeded supply by 10% at the end of 2015 and that will not improve this year given home help hours have been cut again. The average cost of home help is €75 per week. The alternative is for the elderly to participate in the fair deal scheme and obtain long-term private or public residential care. The public cost averages €1,390 per week while the private cost averages €893 per week. When that is compared to the cost of home help, it does not make sense. The Department's strategy seems to support increased spending on the fair deal scheme. More money has been allocated to the scheme this year and for the home help service. That is only one example of how resources are not being targeted efficiently and effectively.

The Department and the HSE have spoken a great deal about targeting efficiencies across the sector but that is not happening. There are no financial oversight or performance-related auditing and accounting practices to provide value for money and more effective outcomes for the patient. The approach is, therefore, not patient-centred. It is about going into hospitals and cutting costs. Until the system changes from a block grant to hospitals to money following the patient, patient care will not be at the centre. For example, Letterkenny General Hospital should get a block grant based on last year's performance not on this year's. That does not make economic sense. I am examining this from a financial point of view in respect of allocating resources more efficiently and effectively. Reference was made to the OECD report on spending on the health sector in this country. It found that our spend is higher than the average but our outcomes are lower than the average. We must consider our ten-year vision in that context.

That are many other issues but other Members are offering. I would very much like the opportunity to have an open-ended debate on health with contributors speaking for an extended time because every Member has something to offer. Our spokesperson, Senator Swanick, made the case for primary care and I agree wholeheartedly with him.

Maire Devine (Sinn Fein)
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I wish to share time with Senator Ó Donnghaile. We could form a multidisciplinary team in the House. We have GPs, mental health advocates, registered nurses, addiction and disability advocates among us. I ask the Minster to please include us on the health committee.

I welcome the Minister of State. Some would commiserate with her on what is perceived as a poisoned chalice but, unfortunately, the health system has been fatal for patients I have been involved with, given the savage cuts that took place during the years of austerity. Hopefully, we will turn that around and make a great plan for the next generation and the generation after that, which will most need it.

I would like to address inequality. Inequality in health is the most shocking form of inequality. The health committee will convene and make a blueprint for the sector. I hope there will be a frank and open discussion in order that we try to come to a consensus on what is best for people and the next generations. We must realise that we will have to pay for it and it will cost more. The population is increasing and we are living longer and, therefore, our needs will increase. Health is the basis of every single facet of our lifetimes.

I will push for universal health care. We need to look into this but many countries have it as a right where health care is free at the point of delivery and is based on need alone. I work in the health service and we are hanging by a thread, which is in danger of wearing away. We are over-burdened and it is chaotic. I will, hopefully, bring forward Sinn Féin's vision from our health policy document, which has been costed and analysed. It will take an additional €3.6 billion to get where we need to have universal health care for all.

Is the Minister of State aware of the second annual report of the national health care quality reporting system, which was published recently? It was reported on in The Sunday Business Post.There are significant variations in patient survival following a heart attack or stroke across the State while the mortality rate in small hospitals is almost 17%, well above the average of 6%. This rate is across all seven hospitals in the report. Perhaps the Minister of State could comment on that.

Michelle Mulherin (Fine Gael)
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Unfortunately, due to the order of the House, there is no time left for other Members who indicated. I call on the Minister of State to give her concluding statement.

Marcella Corcoran Kennedy (Offaly, Fine Gael)
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I thank those Senators who generously congratulated me on my new role as Minister of State with responsibility for public health promotion. As this is my first time in the Twenty-fifth Seanad, I extend my sincere congratulations to every Member. I am looking forward to working positively and constructively with them in the years to come. Members will note the optimism in the term, “years to come”. In politics, one needs to be positive and optimistic.

I am pleased to have heard most of the excellent contributions from across the Seanad and the Dáil regarding the committee on the future of health care and the health service. The committee will look carefully at the future of our health care service. I welcome the establishment of the committee, a key commitment in the programme for the partnership Government. Universal health care is not just a policy to implement or change for the sake of change. It is a direction and a journey towards a better and fairer health service for all of our citizens. Given the year that is in it, it behoves us to follow through on the ideal of cherishing all of the children of the nation equally and to create a vision for a universal single-tier service where patients are treated on the basis of health need rather than on ability to pay. While this task is challenging, this committee is a great opportunity to bring us further on the road to universal health care.

I have taken note of the questions from the last two speakers and will refer them to the Minister for Health, Deputy Harris, for a direct response. I also noted the comments about the committee being a joint committee in which Senators would have an opportunity to participate. I will ensure the Minister is directly advised of that. The Department will be happy to assist and advise the Houses of the Oireachtas as appropriate. I look forward to the outcomes of the committee’s work and wish it well in its deliberations.

Michelle Mulherin (Fine Gael)
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When is it proposed to sit again?

Colm Burke (Fine Gael)
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At 10.30 a.m. tomorrow.