David Cullinane (Waterford, Sinn Fein)
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I move:

That Dáil Éireann: notes that: — it is widely accepted that the Government has chosen to underfund the Health Service in Budget 2024;

— comments made by the Minister for Health, Stephen Donnelly TD, recorded in the Irish Times on Thursday, 12th October, 2023, stating "it is entirely likely that a supplementary budget will be required next year";

— comments made by the Chief Executive Officer of the Health Service Executive (HSE) to the Oireachtas Joint Committee on Health on 27th September, 2023, stating that there will likely be a Health Service income and expenditure deficit of "somewhere in the region of about €1.4 billion or €1.5 billion" in 2023; and

— comments made by the Secretary General of the Department of Health to the Oireachtas Joint Committee on Health on 27th September, 2023, stating that "there has definitely been underfunding of Existing Levels of Service (ELS), absolutely. That is a problem"; further notes that: — the Government have allocated only €708 million for ELS funding in 2024 for the Health Service, which is less than half of the shortfall identified for 2023 before even covering other cost pressures in 2024, such as carryover, demographics, and pay;

— the Government has not allocated additional capital funding to the HSE to deliver the promised and needed 1,500 acute inpatient hospital beds, which are not included in the National Development Plan funding; and

— the new children's hospital will require a significant additional allocation of funding due to the Government's mismanagement of the project, which will add further cost pressures on the HSE's budget; condemns the Taoiseach, the Tánaiste, the Leader of the Green Party, and the Government as a whole for: — their reckless decision to underfund the Health Service in Budget 2024;

— embedding an overreliance on outsourcing, agency staffing, management consultancy, and overtime, which has increased costs, hollowed out the Health Service, and burned out the workforce;

— their failure to reform the healthcare system and deliver a single integrated financial management system in the HSE, to invest in digital transformation and to put in place more effective management of waiting lists;

— ignoring warnings from the HSE and the Department of Health that the budget for 2023 and 2024 does not cover the true cost of running the HSE; and

— ignoring warnings from healthcare trade unions and patient advocacy organisations of the potentially catastrophic consequences of dramatically underfunding the HSE for workers and patients; considers that the Government's budgetary decisions for 2024: — will have a severe impact on frontline services, clinical programmes, national strategies, access to new medicines, tackling waiting lists, and dealing with manifold crises across Emergency Departments, Child and Adolescent Mental Health Services, and Children's Disability Services;

— have already led to cuts in frontline services with 7,000 unfunded approved posts in the HSE being cut, and a recruitment freeze being put in place on vital frontline Health Service roles, such as non-training scheme doctors, healthcare assistants, and home help workers;

— will have serious consequences for the HSE's ability to meet the already weak targets set out in the Minister for Health's Waiting List Action Plan, which is behind profile and unlikely to hit targets by year-end for a second year in a row; and

— will result in hospital managers and doctors making tough decisions on what services to provide, what services to cut, and which patients will not receive the care they need; and calls on the Government to: — immediately increase the funding allocation for the Department of Health for 2024 to:

— adequately cover existing levels of service and cost pressures such as inflation, demographic changes, demand increases, and pay increases; and

— provide for new developments funding to advance vital projects across hospital bed capacity, community care reform, and taking further steps towards universal healthcare and reducing the cost of healthcare such as raising the medical card threshold and reducing the Drugs Payment Scheme threshold;

— urgently bring forward a supplementary budget for 2023 to reverse the recruitment freeze on essential frontline posts as the HSE faces into an extremely tough winter without adequate resources to deliver the quality and quantity of care to avoid thousands of patients languishing on trolleys and exposed to unnecessary risk of delayed care and hospital-acquired infections; and

— put in place a time-bound plan for ending the HSE's reliance on expensive outsourcing, agency staffing, management consultancy, and private healthcare.

It is hard to take seriously the Minister’s amendment to the motion I have just proposed. It is blatantly wrong to claim in the second line of the amendment that "the health additional allocation for Budget 2024 is nearly €2 billion". That is not correct. There was some €808 million of additional core expenditure. There was then one-off funding of €1.032 billion which the Minister knows includes Covid-19 expenditure, Ukraine money, waiting list initiatives and so on. Almost all of that was there last year as non-recurring expenditure, with €750 million for Covid-19 alone. When the Minister says there is an additional €2 billion of spending on health in this budget, it is more spin coming from a Government which has deliberately underfunded the health service for next year.

The head of the HSE, Bernard Gloster, and the head of the Department of Health, Robert Watt, appeared before the Joint Committee on Health today. They confirmed that they sought €2 billion of additional core current expenditure, at a minimum, and they received €707 million. They both accepted that the shortfall is in the region of €1.3 billion. The CEO of the HSE reiterated clearly and publicly today that the health service is not properly funded for next year and that he was given inadequate funding. He went on, astoundingly, to repeat what he had said previously, which is that he has been asked to write up a national service plan within which he has to build in a deficit of potentially up to €1.3 billion. Essentially, we will have a national service plan which is a work of fiction. All of that is because of a very deliberate decision that the Minister and his colleagues have made, essentially not to fund the health service properly.

The Minister in his countermotion fails to address any of the consequences of the decision he and his colleagues have taken. The Minister was very quick over the course of this year to talk of 1,500 new beds coming on stream. These are rapid-build beds and we are hearing that hundreds of those will be coming on stream in 2024. Let us see what happens but I would be astounded if any of those beds are delivered in 2024, and still no funding has been allocated for them.

We also know that for the first time in many years the head of the HSE was forced to put in place a recruitment embargo in many areas of the health service, including the front line. That was not even done during the darkest days of the troika. This recruitment freeze includes non-training junior doctors, some home helps and healthcare assistants, clerical staff and so on.

I have spoken to many hospital managers over the course of the past couple of days. Already the consequences of this decision are being laid bare. In my own constituency and that of the Minister of State, Deputy Butler, I spoke to the manager of University Hospital Waterford. The Minister and I, and the Minister of State, Deputy Butler, have praised the work done by the hospital to ensure there are no patients on trolleys. One of the reasons there are no patients on trolleys in that hospital is because a medical ward was opened: medical ward 6, which has 35 beds. The Minister might be surprised to learn that most of the staff who are there to keep that ward open are agency staff in are what are called "unfunded posts" which they were hoping to have funded as part, perhaps, of those 7,000 posts which have now been scrapped. This manager now tells me that he has to make a tough decision on whether to close that ward, with the consequence of having patients on trolleys again, or to take staff from elsewhere, including cardiac care services and other services. We are seeing across many hospitals that managers are being asked to make very tough decisions.

The reality is that one cannot have a recruitment freeze and say that it does not bite. One cannot shelve plans to build beds and say that it does not bite. We had 130 patients on hospital trolleys in Limerick yesterday, which shows the madness of the Government's position. It is clear from what we have heard again today from the heads of the HSE and the Department that the health service is not adequately funded. The question the Minister has to answer is whether the HSE will cut more to deal with that deficit or if the Government write the cheque in any event at the end of next year.

If the latter is the case, he has made an absolute farce of himself, the budgetary process, the Department of Health and the HSE. I ask the Minister to answer the question he has not yet answered. Where are those 1,500 beds and when will they be funded? I will make one final point. The Minister has still not answered questions that have been put to him by advocate organisations. He put in place a national stroke strategy. How much additional funding, or any funding, has it got for next year? Zero. It has got zero funding because of the decision he and his colleagues made not to properly fund the health service. If he does not think that will have consequences, he should not be in the job he is in.

Pearse Doherty (Donegal, Sinn Fein)
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Hear, hear.

I could not agree more with the sentiments of my colleague Deputy Cullinane. He has spoken to those on the front line right across the State, to understand the consequences of the Government's decision to deliberately underfund health. Those consequences are real. It will be heard in the stories that will unfold over the course of the next number of months. These are real patients, real people, including children, who will languish on trolleys and who will go without the treatment in a timely manner because the Minister has decided on this approach. I have been finance spokesperson for 13 years and have responded to 14 budgets. Never in my life, two weeks after the budget being announced, has there been universal agreement that the Government has deliberately underfunded health. This is not underfunding to the tune of a couple of million or tens of millions, but €1.3 billion according to the CEO of the HSE. That is the reality of it. He is saying he will deliver a service plan to the Minister that will state that the HSE will have to go over budget next year by €1.3 billion. Why is this? It is because the Minister and his Cabinet colleagues decided to cook the books when it came to health. The Minister decided deliberately not to provide the additional resources that were required just to stand still and to leave the chaos we have in the health system at the same level next year as it is this year. He did not even do that. He has made the announcement over and over again. Where are the 1,500 beds? When are they going to come on stream because he has funded none of them?

He has talked about national programmes yet they cannot be funded. We talked about attention deficit hyperactivity disorder, ADHD, clinics that have been announced two years ago. How are they going to be funded? He has cut health to the bone as regards what is needed and the consequences are real. Does he think he can say there is now a recruitment embargo, that thousands of posts that were supposed to come on line, will not come on line, and that there will be no consequences? The consequences will be these people in my constituency in a hospital that is already in crisis, and a situation where the GP of nearly every person has written to the Minister, and 11 consultants refer to service collapse, while the Minister has decided to underfund that service. It is absolutely shameful at a time when the Government announces a budget of €14 billion that the Minister does this to the most vulnerable people. It is patients in their 80s and 90s, in my constituency and elsewhere, who will be languishing on a trolley or on a chair because the support is not there. The beds are not being funded. It is a disgrace and the Minister needs to change course.

Rose Conway-Walsh (Mayo, Sinn Fein)
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There are more than 880,000 patients on hospital waiting lists. Records are being broken every year for the number of patients left on trolleys. Average waiting times in some emergency departments have reached over 27 hours. Some 9,000 people every month leave emergency departments without even being seen. These figures do not do justice to the hardship and turmoil this has caused patients and staff. Mayo University Hospital has one of the worse ambulance turnaround times in the State. Half of all the ambulances there are taking more than an hour to reach patients. This is being driven by the lack of capacity as well as the lack of home help and community beds. There were 22 people lined along corridors on just one night in July in Mayo University Hospital. Numerous times this year, the hospital has put out warnings about visiting the emergency department due to overcrowding. Some 10,027 people are waiting to see a consultant at Mayo University Hospital and 1,365 patients are still waiting for surgical procedures.

Despite the scale of the crisis, the Government decided to stop investing in health and people keep asking why this is. They cannot make sense of it. The head of the HSE said unless he makes cuts, there will be a guaranteed deficit in the health budget. The people of Mayo are absolutely shocked to see the Government throw in the towel on health. When access to healthcare is getting harder and harder, the Government chooses to stop investing.

There are two long-awaited projects in Ballina and Belmullet in County Mayo that cannot be abandoned. These projects are desperately needed and must go ahead. The real impact on people is sometimes lost in the debate. I have been trying to help a woman of 62 to access neurological care for over a year. Her family wrote to the Minister before the budget. She went to her GP with memory loss in June 2022. Despite the fear and the anguish of her family, she was left waiting for months. Her condition deteriorated rapidly. She eventually was sent to Dublin for two weeks. It took almost a year to get a diagnosis of dementia syndrome. Since then, she has struggled to get access to any form of treatment and now she is told by neurology in Galway that the waiting time for urgent cases is ten to 14 months. That is for urgent cases; I hate to think of the time if she was not an urgent case. The Government has abandoned this woman and her family just as they have abandoned so many other people in Mayo and across the State. There is no point in Government Deputies coming to the House to give out about it; they are part of the problem.

Réada Cronin (Kildare North, Sinn Fein)
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It is quite clear that the Government has washed its hands of health in the same was it washed its hands of housing. This is why I have constituents across north Kildare who cannot afford it but who are pushing themselves financially to pay for private health insurance after they have paid their taxes including USC, and PRSI, not because they have notions but because they want to stay alive. Elderly constituents or people with health conditions tell me they scrimp and save to afford the private health insurance so they can get a fast appointment for a colonoscopy, an MRI, or a CT scan. That is no exaggeration; it is the reality of the health service on the Minister's watch. I have spoken to management in Naas General Hospital and they are very concerned following this budget for 2024 and the underfunding within it. I remember around 20 years ago when I moved to Kildare, a new hospital was proposed for Naas but there has not been a budge about that since. We love our hospital and we value our hospital staff who work in it. We want and need our services in the community in north Kildare so people are not forced off to Dublin. We are due to get an endoscopy unit in 2033. This is 20 years later than initially stated. How does the Minister expect people in north Kildare to hold on with rectal bleeding or unresolved indigestion for another ten years? We are a hardy lot in north Kildare, but we are not that good.

Elderly people in particular are terrified to go to the accident and emergency in Naas or to be taken there. Up to the end of May last year, 1,269 patients in the general population left the emergency department at Naas General Hospital without being seen at all and that compares with 903 in the same five-month period the previous year. Trolley figures as heard on KFM Radio Kildare are horrendous when they are announced every day.

Before I finish, over the past couple of weeks constituents of mine in north Kildare have been contacting me about different health issues but I was struck by how concerned they were about hospitals in Gaza. I ask the Minister on behalf of these constituents and on my own behalf as well, as a human being, to use his position as Minister for Health to push for fuel, medial aid and protection for hospitals in Gaza to stop newborn babies and people on life support dying, to keep them in fuel to keep their incubators going, and to use his position at Cabinet to push for a cease-fire in Gaza so that fuel and medical aid can get into these hospitals without delay.

David Cullinane (Waterford, Sinn Fein)
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Hear, hear.

Mark Ward (Dublin Mid West, Sinn Fein)
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I want to speak about an email I received from a constituent this morning. It reads as follows:

Hi Mark

Just want to touch base with you with a situation I experienced while in A and E in Tallaght hospital due to mental health issues on Sunday with my 17yr old Son. We went into Tallaght hospital by Ambulance on Sunday due to his suicidal thoughts and psychotic outbursts, they left us waiting 9 hours before he walked out of the hospital. Now he won't go back to the hospital to see the CAMHS doctor that he needs to see as he thinks he will be waiting hours again. The mental health service is disgraceful for people, I'm at my wits end trying to get him the help he needs.

This is not a unique situation. I receive emails like this all the time. If this 17-year-old boy had a cut on the outside of his head he would more than likely have been cared for, but because he had an issue going on inside rather than outside his head, he was left waiting indefinitely. Imagine the mental anguish this boy was suffering while he was waiting for those nine hours. Due to the Government's mismanagement of mental health services, this situation will happen more often. The reality is that people have gone to accident and emergency departments, left without getting mental health services, and have never been able to return.

I also want to talk about another constituent of mine. I spoke to her daughter this morning who informed me that her 64-year-old mother was left waiting on an ambulance for an hour and half with a suspected stroke. Her mother has a history of aneurysm and she then spent 76 hours on a trolley in Tallaght Hospital waiting for admission to the stroke ward. Her mother also has Alzheimer’s. Here we have a 64-year-old woman with Alzheimer’s and a history of aneurysms, left waiting for three days and three nights on a trolley to get admitted to a stroke ward. Situations like this did not happen overnight. The current Minister for Health and three former Ministers for Health sit around the Cabinet table. Years of mismanagement and a lack of political will has led to a crisis like this. Due to the Minister's decision this year to chronically underfund health, things are just going to get worse.

I do not usually speak about the personal situations of people. I got permission today from these patients to speak on their behalf. I usually speak about statistics and policies. This happens every day. There is not a Deputy sitting beside me who does not receive emails similar to this every day. Something needs to change. The Minister needs to resource health.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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The situation we have in health and the reckless underfunding of the health budget this year will have an effect the length and breadth of the country, nowhere more so than in my constituency of Sligo-Leitrim. As we know, the hospitals all along the western seaboard from Donegal to Limerick and including Sligo are those that have some of the highest rates of people waiting on trolleys to be seen. This is because there is nowhere else for them to go. The promised beds that were supposed to be provided in these hospitals have not been put in place. The Minister's budget does nothing to put them in place.

We also have a recruitment freeze affecting people who want to join the HSE. They want to work in it and be part of it. They want to contribute to their society and community. This week I was contacted by a young man who had been successful in a recruitment process for the HSE. In September he received email confirmation that he had been successful in his interview and was being offered a position. He was also asked when he could start. In early October he received another email with a recruitment pack. He was contacted three times with regard to a start date. He prepared to get started in the job he was about to take up in the HSE. He gave notice in the job he was doing. He received two emails two hours apart. One asked when he could start and the other told him his job could not proceed due to the cuts. He was told there was a ban on recruitment and he could not go forward. This is the situation not only for this particular individual - we will call him John - who contacted me in the Sligo and Leitrim area, but for people throughout the entire country.

We have people who want to work in the HSE. We have people who want the long-term stability of having a job and a future and being able to provide for their community and work for their people. The Government is denying them this opportunity simply because it believes in its ideology that private is better. It wants to push people into private medicine rather than providing public services. This is the experience of the public. The Minister can shake his head as much as he likes but this is the reality that people face on a daily basis.

People come to us with individual criticisms and situations. They are the symptoms of a broken system which the Minister presides over. This system needs to be fixed. Having a budget in which the Minister underfunds the HSE and does not bring extra money to it in a situation where it is already in crisis tells me that he is not serious about doing the job he is in the position to do and that he wants to destroy the health system for some other agenda, whatever it may be. This is the only conclusion that the majority of people can come to.

Martin Browne (Tipperary, Sinn Fein)
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At a time when trolley numbers at University Hospital Limerick, UHL, regularly achieve record figures it is beyond belief that funding for the HSE is becoming what some at the health committee meeting today described as "constrained". In this scenario "constrained" suggests that the scenes of absolute chaos we have seen at UHL or any other hospital with overcrowding pressures will not improve. The improvement in services throughout the region that we were promised when reconfiguration was first mooted was never delivered. Now, after years of incompetence, the Minister appears to have given up at the cost of patients.

When the situation became so bad that the Minister's spin no longer worked, more of a role was given to the medical assessment units in Nenagh, Ennis and St. John's Hospital. The fact remains that the impact of this is not being realised. Now we have been left in a situation whereby, unbelievably, the Minister has underfunded the health service and the room to address this situation has become as confined as the areas in which people are languishing on trolleys. They have been spiralling into the waiting areas in UHL to the despair of the staff.

To define what underfunding in this scenario means, we just have to imagine the scenes at UHL spiralling further out of control. Will the Minister tell me what effect underfunding will have on the capacity in UHL? What impact will underfunding have on the ability of the units in Nenagh, Ennis and St. John's Hospital to have any impact on trolley numbers? What impact will the recruitment freeze have on the provision of any adequate level of community care in north Tipperary? These are questions that need immediate and clear answers because we are speaking about people's lives.

Existing levels of service are clearly inadequate. If the Minister is not providing enough to cover existing levels of service he is clearly going backwards. I am calling on the Minister to step back from the brink and increase the funding allocation to adequately cover existing levels of service and cost pressures, to provide for new developments, to provide funding to advance vital projects for hospital bed capacity, to engage in community care reform, and to bring forward a supplementary budget to reverse the recruitment freeze on essential front-line posts, especially as we head into the winter, which we know will be tough on patients and staff alike. This has never been more urgent.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following: "notes that:

— the Government has allocated €22.5 billion to the health budget for 2024;

— the health additional allocation for Budget 2024 is nearly €2 billion;

— this includes an increase of €808 million in core current funding, €1,032 million in non-core current funding and an additional €120 million in capital funding; and

— Budget 2024 includes funding for Covid-19 vaccinations, testing and tracing, waiting list initiatives, urgent and emergency care initiatives, Ukrainian supports, staffing for new acute beds, intensive care beds, community beds and surgical hubs, investment in our healthcare workforce including in advanced practice and new training posts, mental health and social inclusion measures, and cyber and digital capabilities;

further notes that the Government has focused on increasing capacity:

— in the last three years the Government has added 22,000 healthcare workers (net), including 6,700 extra nurses and midwives, 3,100 additional health and social care professionals, 2,500 extra doctors and dentists;

— hospital bed capacity has increased by over 1,000 beds during the same period;

— ICU/crucial care bed capacity has increased by 25 per cent;

— a national network of Enhanced Community Care Network teams is being rolled out, enabling patients to be treated outside of hospitals and closer to home; and

— six new surgical hubs are being progressed with the first due to open within months;

acknowledges that:

— funding has been allocated to clinical strategies and improving access;

— hospital waiting lists fell in 2022 for the first time since 2015;

— the total number of patients removed from waiting lists during the first eight months of the year is higher than target, with over 150,000 more patients removed from waiting lists compared to the same period last year;

— a record 22 million hours of home care are forecast to be delivered this year, up from 17.48 million in 2019;

— important progress for patients has been made in the rollout of national clinical strategies including in cancer care, maternity care, trauma care, palliative care, critical care, dementia care, mental health services, older persons services, health and wellbeing programmes, social inclusion, screening services, and in our National Ambulance Service;

— new services have been introduced in areas including diabetes, stroke, obesity, fertility and genetics; and

— unprecedented investment has gone into women's healthcare with the opening of new menopause clinics, fertility hubs, specialist endometriosis centres, and same day see-and-treat gynaecology clinics all over the country;

recognises that costs have been reduced to patients in line with universal healthcare:

— inpatient hospital charges have been abolished, saving people up to €800 a year;

— free contraception has been rolled out to women up to the age of 30;

— 2023 will see half a million more adults and children have access to free General Practice care;

— state-funded In-vitro fertilisation has been introduced for the first time; and

— the maximum amount that people now pay on their monthly medicines bill has been cut from €124 to €80 per month since this Government entered office; and

further recognises that:

— significant reforms are underway and will continue to ensure strong productivity in provision of health services;

— there has been an unprecedented shift in patient care from the hospital to the community sector, including via 96 new primary care teams, national networks of Chronic Disease Management, older persons and community intervention teams, and a national network of new primary care centres;

— Ireland is now a leading country globally in advanced practice for nursing;

— the introduction of the new public-only consultant contract facilitates extended working hours, and this helps with patient flow and ensures more senior decision makers are available to patients after hours and at weekends;

— significant progress has been made in the roll-out of phase 1 and phase 2 of the safe staffing framework to all hospitals, with 56 million allocated for implementation since 2020;

— investment in Emergency Department (ED) avoidance measures including expansion of injury unit services and National Ambulance Service protocols are providing alternative pathways to EDs to patients; and

— roll-out of a new productivity platform provides, for the first time, detailed productivity information in the acute sector.".

Our goal is for everyone to have high-quality affordable healthcare when they need it through a public healthcare service. There is a long road to travel, and we know this, but we are well on the road to making our ambition a reality. Investment did need to grow. For years we had one of the lowest levels of hospital consultants and hospital beds in western Europe. We did not build new hospitals. We had too few GPs and out-of-date computer systems. There has been too much reliance on hospitals and too little investment in community care.

Too little was invested in keeping people healthy. Costs for too many patients have been too high. Too many people have waited too long for care. Too many patients are still waiting on trolleys. Too little has been known about which hospitals and which services are thriving and which are struggling to see enough patients. This is changing. While Ireland still spends less per person on healthcare than most other western European countries, funding has dramatically increased. We have cut costs for patients, abolished hospital charges, introduced free contraception, reduced monthly medicines bills, provided free GP care to another 500,000 people and rolled out free IVF.

We have built a lot more physical infrastructure with a record number of extra hospital beds, intensive care beds and primary care centres. Having not opened a new hospital in 25 years we are now progressing five new hospitals at the same time. We have hired a large number of extra healthcare workers, including thousands more doctors, nurses and health and social care professionals. We are increasing college and training places. We are becoming a world leader in advanced nursing and midwifery practice and in our approach to safe staffing in our hospitals. For every two GPs who retire, three to six new GPs enter practice.

We are fundamentally reforming how and where patients are cared for. An entire new community-based health service, with thousands of additional healthcare workers, has been put in place in just three years. More than 150 new clinical teams have been set up throughout the country in primary care, older persons services and chronic disease management. A large number of consultants have now taken up the public-only contract. This is a vital step in removing the distorting effect of private income from public hospitals. A new productivity platform is being introduced in every hospital. This means we can find those doing the best and learn from them. It also means we can identify those that are struggling and support them in treating more patients.

These reforms and this new capacity are beginning to work. Last year the waiting lists fell for the first time since 2015. So far this year our healthcare workers have removed 150,000 more patients from the waiting lists by providing them with treatment than was achieved last year. Not only are our healthcare workers removing more patients from waiting lists this year than last year, but so far this year they are 50,000 patients ahead of target. They deserve great credit for this. Our waiting lists are now one half of what they are in Northern Ireland. This has not always been the case.

More and more people are receiving the care they need in their own community. Our healthcare workers are delivering a revolution in women’s healthcare. This includes opening new menopause clinics, fertility hubs, specialist endometriosis centres and same-day gynaecology clinics. New services are becoming available in areas such as diabetes, stroke, dementia, neurorehabilitation, genetics and obesity. Existing services are being expanded in cancer care, maternity care, gynaecology, trauma, home care, mental health, palliative care, cardiology, ambulance services and more. They are making a difference every day throughout the country.

Some of our services are not delivering at the level that we all want and that patients must get. I fully accept the calls being made on the other side of the House in terms of individual patients not getting the care they need. It is what we spend every day in this House, on both sides, trying to fix and make better. These very serious and real concerns, issues and challenges take up most of the public debate. The good work going on, and there is a great deal of it, does not get a look in. The truth is our healthcare workers are making progress, and working damn hard in every part of this country to make this progress happen on behalf of patients. In every part of the country, healthcare workers are rolling out new services, taking patients off the waiting lists and providing fantastic care to millions of people all the time.

The national conversation about this year’s health spending is similar. Most of our health services are being delivered on budget. The main area that is not is the hospitals. This is mainly because many more patients are turning up than were forecast and medicines and other supplies are costing more than was forecast. This is happening in Ireland and across Europe. Let us take a doctor, a nurse and a radiographer working in one of our hospitals. The medicines and supplies needed to treat patients have become much more expensive. For every ten patients these healthcare workers have been funded to treat, 11 have turned up. What have these staff done? They have treated all 11 patients, as they should. How have they done this? They have done it by working longer hours, running more scans and using more medicines. To do all this, they are spending more money than they have been allocated. However, some of the terms being used to describe these staff and their spending of this additional money include a "runaway health service", in need of a "massive bailout", with spending like "a flesh-eating bug", that is "out of control" an "omnishambles", a "runaway train" and a "black hole".

David Cullinane (Waterford, Sinn Fein)
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Those are Fine Gael policies.

Stephen Donnelly (Wicklow, Fianna Fail)
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This is what our doctors, our nurses and all our healthcare professionals are hearing-----

David Cullinane (Waterford, Sinn Fein)
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I could not agree more.

Stephen Donnelly (Wicklow, Fianna Fail)
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----about their efforts to provide the services, treat the extra patients and spend the extra money. We all know there are productivity gains to be had, but at least two thirds of the additional spending this year is because our healthcare workers are rightly treating more patients who are showing up, and are doing so at a time when medicines and supplies have become more expensive. Turning to next year, it is difficult to forecast what is going to happen in terms of prices and patient demand. A post-Covid surge may recede, leading to a very different level of patients presenting. Prices may well also correct. Either way, €1.1 billion of next year’s €2 billion health budget is allocated to supporting existing service levels.

David Cullinane (Waterford, Sinn Fein)
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Not all core.

Stephen Donnelly (Wicklow, Fianna Fail)
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The remaining €900 million includes funding for: Covid; waiting list initiatives; urgent and emergency care measures; Ukrainian supports; staffing for new hospital beds, intensive care beds, community beds and surgical hubs; investment in our workforce, including in advanced practice and new training posts; mental health and social inclusion measures; and new cyber, digital and physical infrastructure capabilities. The budget includes provision for ongoing recruitment of hospital consultants, who will be working on the continued roll-out of services across numerous clinical areas. We are also fully rolling out safe staffing in every hospital, including in every accident and emergency department.

At the same time, we are going to continue to increase productivity. More patients will be treated in the community. More advanced practice nurses will be trained. The new financial management system will be accelerated. More consultants will move to the public-only contract. Productivity information, for the first time, will become central to how services are managed. Patient flow will continue to be improved and reliance on overtime and agency provision will be reduced.

I am commissioning a study on the future costs of healthcare so we can all have a commonly agreed position for how much it will be likely to cost, year by year, in the years to come to get to the goal we are all agreed on, which is universal healthcare. I refer to the vital idea in our Republic that every man, woman and child can get the care they need when they need it, regardless of how much money they earn or how much money a child's parents can access. This is the concept of a public healthcare service that we can all be proud of.

Johnny Guirke (Meath West, Sinn Fein)
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The underfunding of our healthcare services in budget 2024 will impact our front-line services, including in my county of Meath at Navan hospital. It is undeniable that the Government's decision to underfund the health service is reckless given the existing challenges faced by our healthcare system. The embargo imposed on recruitment for essential front-line posts will result in a shortage of healthcare professionals, leaving hospitals like Navan struggling to deliver the quality of care our patients need and deserve.

Turning to GPs, we have one GP in County Meath for every 3,500 people. On one hand, we are asking hospitals to do something about people waiting on hospital trolleys. On the other, hospitals are being told they will have to lay off one third of agency staff. Regarding the embargo on administrative staff, these do extremely valuable work, which hospitals could not operate without, whether they are accessing medical records, signing in or tracking patients. This is leaving staff in a precarious position. In some cases, morale is low because of the workload they are already under. All this together can only lead to a winter of discontent and people waiting longer for care.

The underfunding also poses a direct threat to our home help services across the country. In County Meath, we already have hundreds of people waiting on home help services. Where people have been approved for home help, there is nobody to undertake the work. These services are a lifeline for many vulnerable people, providing vital assistance and support in their own homes. The embargo on recruitment will mean that there are fewer healthcare assistants available to provide in-home care, which will mean many patients will be left without the help they desperately need.

In County Meath, there is already a lack of home care and support for people with neurodisabilities to enable them to live in their own communities. This lack of neurodisability services is appalling. It is because the community healthcare organisations, CHOs, are not adequately funded, leading to people with disabilities being left behind. It is time for this Government to prioritise health.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I have serious concerns about the underfunding of our health service. We were told today that it is to the tune of €1.3 billion. We must also factor in the additional capital funding needed for the much-promised 1,500 acute additional hospital beds and the growing cost of the national children's hospital ,both of which have not been allocated extra funding in the budget. Such a significant underfunding of our health services will impact on the delivery of much-needed services in Laois and Offaly. It will impede the required expansion in the number of step-down beds for patients being discharged from acute hospitals such as Portlaoise. It will also restrict the HSE's ability to advance the provision of primary care centres and local health centres in towns like Portarlington, Rathdowney and Mountrath, as well as Portlaoise, which is a town heading towards having a population of 30,000 people and still does not have a primary care centre.

The midlands will struggle and will not get the required resources to fund already underfunded and underperforming dental services for schoolchildren and the now-collapsed dental treatment scheme for adults. Simply throwing money at the HSE is not what is being proposed here. This is not the solution in itself. Funding, however, is necessary. This must, however, be accompanied by radical reform. We are calling for a supplementary budget for 2023 just to maintain existing services and reverse the recruitment freeze on the essential front-line posts, and not those posts with people who are standing about, required to keep the services going. We want a time-bound plan to be put in place to end the HSE's reliance on expensive outsourcing and private healthcare. This includes ending our over-reliance on outsourcing, agency staff, management consultancy and huge overtime costs.

I saw the Minister shaking his head earlier, but I heard a Deputy from his party speaking eloquently on local radio this morning about these issues and saying exactly what I have just said. We need to support our front-line workers, increase staff numbers and fill the gaps in essential services.

Donnchadh Ó Laoghaire (Cork South Central, Sinn Fein)
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I am very worried about what we are going to see this winter and in the coming years. This debate is not academic. We should not forget how profound are the impacts of underfunding, bad policy and mismanagement.

There are people out there tonight who will pay a heavy price for that. Underfunding will result in more sick and vulnerable people waiting on trolleys in crowded corridors. Underfunding will mean people with a whole variety of conditions having to wait and wait for their procedure while they are debilitated in pain at home with their life on hold. Underfunding will mean more elderly people and pensioners in their eighties being forced to wait on hospital chairs for days while waiting to even get a trolley. That is the truth of it. Ní cinneadh é seo gan tionchar. Beidh tionchar trom aige seo ar dhaoine.

It should not be discounted the chilling impact that the Minister's policies will have on our medical professionals abroad who are thinking of coming home. So much has been said about nurses and doctors in Australia and in the Middle East. We now have the farcical situation where even if they wanted to come home there might not be a position for them. There are 86,000 people on waiting lists in Cork. I have little faith that this figure will come down when we see the raft of cancellations: 954 in the Mercy University Hospital in one quarter; 419 in the South Infirmary Victoria Hospital; and figures not available for Cork University Hospital, CUH. The latter is a crucial centre for the region and has very ambitious plans for the coming years in the form of: a regional paediatric centre; the CUH cancer centre; and a 24-7 arterial emergency vascular service. How can it and other hospitals pursue that ambition and how can it proceed to recruit staff when this is what the Government budget has allowed? Record cancellations of appointments is shifting the burden onto the ever-growing waiting lists.

Pa Daly (Kerry, Sinn Fein)
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I support this motion. I condemn the Government, the Taoiseach, the Tánaiste and the leader of the Green Party for their reckless decision to underfund the health service in budget 2024. I have listened to what the Minister has said and it all sounds great. All the while, a new community hospital is opening up in Killarney that will not provide one extra bed because the other beds are being closed. I have heard what the Minister said in respect of GPs entering practice but how many of them are going to be working full time? In rural Ireland it is very difficult to get a locum never mind a GP. Where is the minor injuries clinic that is so needed in County Kerry?

I support the call for the Government to increase the funding allocation for the Department of Health, particularly as existing levels of service are diminishing by the day. As of today University Hospital Kerry, UHK, has 23 people waiting on trolleys, which is on a par with much larger hospitals in the cities. According to the National Treatment Purchase Fund and as reported by Radio Kerry, some 11,000 people are on waiting lists in the county. There are currently 50 whole-time equivalent clerical vacancies in a hospital which has been traditionally under-resourced. This will directly impact on patient care. There is no rheumatology secretary. There is a similar lack of staff in cardiology. New referrals are going to have to be sent to Cork. Respiratory pulmonary function tests will also not be able to take place in UHK. Serious problems will arise. It is time to deal with this now, lift the embargo and introduce a supplementary budget as soon as possible.

Johnny Mythen (Wexford, Sinn Fein)
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The Minister will be aware of the huge underfunding of the health sector in budget 2024 starting at €1.3 billion as already mentioned. In reality, the follow-on from this means there will be no additional services this year or into 2024 and there will be no moneys for future strategies. The health service is already creaking at the seams. Due to these cuts, the system has instantaneously experienced cuts to front-line services, with the loss of 7,000 unfunded posts, and a recruitment ban in respect of some front-line posts. I put it to the Minister that there are 600,000 people on some form of waiting list as we speak. There are 10,000 children with disabilities who have been waiting more than 12 months to see either a consultant, a speech therapist, an occupational therapist or a psychiatrist. More than 5,500 children are waiting for assessments of need. There are 700 vacancies in this sector alone, with a 64% vacancy in children's disability network teams. In my constituency, CHO 4 is the third most affected area in the country, with 1,424 children waiting for contact from their disability network teams. Wexford General Hospital was promised 69 new beds but I suppose they too will be collateral budgetary damage.

The underfunding of health has the direct result of placing enormous pressure on the workforce and is putting staff and patients at risk. This will have a knock-on effect in just about every service across the country. The term "crisis" has become synonymous with this Government. Here we are again with a worsening health crisis. Just this week in Wexford, the Ford

Counselling and Psychotherapy Centre had to give notice of its closure on 30 November next. This comes as a great shock to all the people in Wexford and to the families they have helped over the past 30 years. Imagine the shock and trauma these clients are currently going through. Will the Minister tell me and everyone else what people are to do? Inadequate guaranteed annual funding has been cited as the main reason for the closure. Now there will be even less money.

Never mind moving forward, our health system will hardly be able to keep standing still. The people of Ireland deserve to be looked after far better. Their health and well-being should be our foremost priorities. The Government must immediately increase the funding allocation for the Department of Health for 2024 before it becomes a case of "Physician, heal thyself". I hope all Deputies will support this motion.

Duncan Smith (Dublin Fingal, Labour)
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I thank Deputy Cullinane and Sinn Féin for bringing forward this motion. The Minister provided a few quotes as to what our front-line workers were hearing. When he is summing up, perhaps he could say where those quotes come from. I do not believe they came from the proposers of the motion. They are not from me and I do not believe they will come from the Deputies who will speak after me. It is important to say where those quotes are coming from.

David Cullinane (Waterford, Sinn Fein)
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From Fine Gael colleagues maybe.

Stephen Donnelly (Wicklow, Fianna Fail)
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They are not from within the House. The suggestion was not that they were from within the House.

Duncan Smith (Dublin Fingal, Labour)
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I have watched it on screen. I say this in the context of a debate of this nature when many of us, including the Minister, are trying to be serious about this very concerning budget. At a meeting of the Joint Committee on Health earlier, we heard from Bernard Gloster, CEO of the HSE, and Robert Watt, the Secretary General of the Department of Health. While both were coming at it from slightly different angles, they told the same story, which is what we have known for more than two weeks and which was brought into sharp focus with the landmark interview Mr. Gloster did on the Sunday before last when he said that the health service is underfunded.

The Minister, as he did earlier and as is done in the countermotion, can list off elements of the health service that are being funded. We can contest this and we can contest that. We can go around the houses. We can debate for hours, but these are the uncontested figures, namely, the €1.5 billion deficit by the end of the year and a further deficit of €1.2 billion. We are in a more acute space with this health crisis than we have ever been in before.

We cannot be surprised that people want to leave the system. This Government has let workers down. The recruitment freeze that was announced will impact not just on the grades that are the subject of it. We are aware that our staff work as part of a team and as part of a chain. As a result, if we do not have healthcare systems and if we do not hire enough non-consultant hospital doctors, it will impact on nurses, on other healthcare assistants, on consultants, and on all aspects of our health service. There is no getting around that. No amount of debate we have had either in this House, in the committee or on the airwaves has got away from the fact that as a result of this budget harm will be caused.

As it currently stands there almost 900,000 people on waiting lists. Today, 559 people are lying on trolleys in our hospitals. Again, this is another day of normalised crisis in the way in which we refer to our trolley count. It is incredible we do not even blink an eye at the figure of 559 in our trolley crisis and that it does not even make the news on any particular day. Yesterday, 130 patients were waiting on trolleys in University Hospital Limerick. It was another record-breaking day for that hospital. That is absolutely outrageous. It is in this context that Bernard Gloster said he will do his best to protect, namely: access to accident and emergency departments; ensuring they are adequately funded; and keeping the waiting lists down. If the health service is underfunded to stand still, if these areas of our health service - access and waiting lists or acute services - are the ones that are not being protected as matters stands and if Bernard Gloster is going to have to direct more of his funds there, then we really are facing a very concerning 2024.

Regarding last week, the whole approach to health and this charge we are putting across, there is a feeling that this Government has thrown in the towel. The crisis has just gotten too big and inflation, unforeseen demand and the cost of running our healthcare system, seen as a triple reasoning, have just beaten this Government. Health is different. It is different from any other Department. It is demand led. We are all supportive and want to see savings made where they can be. We want to see a more accountable HSE. We want to see it being better run. We also know that there are 5.1 million people in the country. People are presenting to accident and emergency departments, to their GP services and to their primary care centres because they are unwell and sick and because they need care. This Government and this health budget have left many people in the country afraid of presenting to their health service. The national strategies, which Bernard Gloster says he will be unable to protect given the funding allocation for next year, are going to be starved of funding because the budget just will not be there. By not providing adequate funding, these strategies will not simply stand still; they will actually go backwards.

I will reiterate the point I have made a number of times over the past two weeks: the response the Minister for Public Expenditure, National Development Plan Delivery and Reform gave about re-examining the health budget clearly is not sinking in. We have to re-examine it, as this motion calls for. We have to re-examine it urgently. We cannot go down to the wire in December for an emergency supplementary budget. That is not good practice. It is not going to do us any good going into 2024 if we have another year of budgetary crisis. This Government has no problem going last-minute on health. We saw it last week with the section 39 dispute when negotiations went until 3 a.m. on the morning of what would have been a historic strike in our care sector. This Government is not afraid to wind the clock down, much to the concern of vulnerable and sick people all over the country.

At least 4,000 people will be impacted by the Government's decision not to secure funding for new developments in any of the clinical programmes in the health service. That is going to mean real consequences for patients across a wide variety of areas. The Irish Pharmaceutical Healthcare Association estimates that over 1,000 cancer patients are going to be impacted by the lack of funding. I do not accept that we do not have the money for this. I accept that this Government has made choices and that these choices are going to harm people. The Irish Cancer Society has made it abundantly clear that there is a real risk that cancer outcomes could decline in the years ahead due to the Government's health budget. It is simply not good enough that the Government could not find the €20 million needed to invest in a cancer strategy. Cancer touches almost everyone's life in some way, either directly or through a close friend or family member. Nobody could stand here and honestly say that the funding of our cancer service is something that should have been left behind.

When looking at our clinical strategies, we are looking at the likes of stroke or sepsis, which I spoke about last week. Some 15,000 people contract sepsis in Ireland every year. It is one of our biggest killers, with the Royal College of Surgeons saying that sepsis can be a contributing factor in up to 60% of all hospital deaths. The Government's own sepsis strategy says it is down around 25% to 30% but those are still huge numbers. Mental health funding has also taken a hit. Over the last two weeks, I have heard from a number of my constituents and from organisations all over the country who have expressed their worry about the lack of mental health services funding going into the new year. Ministers are patting themselves on the back this week for a slight increase in some services but that is not what the services on the ground are reporting back to me and my colleagues. A total of 44% of Irish people surveyed had difficulty receiving treatment for mental health issues, compared to the EU average of 25%. In a country that has a shameful history of dealing with people with mental illness and mental health, it is no surprise that our percentages are so high and so out of whack with the EU average. That is all the more reason we need to double down and ensure that, when it comes to mental health and mental illness funding, organisations and the HSE can plan for years ahead and have certainty of funding. That, again, has been taken away.

Along with proper funding for our health service, we also need proactive action so we do not find ourselves in this position again next year. Last week, the Tánaiste said in response to my party's leader, Deputy Bacik, that there would be a need for a deep dive to examine spending on the health service. It is 2023. It is long past the time to have a deep dive. The excuse that there was unforeseen demand does not wash. Our health service should be at the forefront of all our State agencies and Departments, working cross-departmentally to ensure we are seeing what demand is going to be, that we are working with population projections and growth projections. It is simply not good enough to throw the hands up in the air and say that inflation, unforeseen demand and a runaway budget is the cause of this. This is the fault of this Government. This Government has made choices with this budget. These choices are going to harm patient outcomes, sick people are going to get sicker and very sick people could end up dying. That is the legacy of budget 2024 in health.

Róisín Shortall (Dublin North West, Social Democrats)
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At the outset, I want to say that last week when we were debating this issue, the reportage concerned me a bit. There was reportage in The Irish Timesthat I was first being charitable to the Minister for Health and then that I was not actually being charitable but was being uncharitable to him.

Paul Murphy (Dublin South West, RISE)
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I saw that.

Róisín Shortall (Dublin North West, Social Democrats)
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The fact of the matter is that I was not being either; nor was I trying to be either.

Stephen Donnelly (Wicklow, Fianna Fail)
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I agree, Deputy.

Róisín Shortall (Dublin North West, Social Democrats)
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It is quite infuriating when debates are reduced to the level of personality clashes or something from the past. It is quite annoying. The point I was making, and I thought I had made it quite strongly, was that the Minister is not the only person responsible for the health budget, that the health budget and its adequacy is the responsibility of the entire Government, from the Taoiseach down. We need to bear that in mind and those people need to bear responsibility for what is happening to the health budget next year. I also made the point quite strongly that it is not only an issue at a political level. There is also a mindset in some Departments that is anti public service in terms of ensuring we have properly functioning public health services. There is a kind of begrudgery about that, with some people thinking we could not possibly spend money to have a properly functioning public health service even though every other country in Europe has that. I just wanted to clarify that. I do not engage in personal animosity. I am not interested in that.

I listened to what the Minister said earlier about the achievements over the last couple of years. I do not doubt any of that. In the main, we have all been on the same page. There is an agreed policy there and a very important reform programme. The challenge for us as a country, as a Government and as a political system and all the administration associated with that, is to implement this. After Covid, even though there was glacial progress made for a few years, in the last couple of years progress was beginning to be made and the Minister made that point. The Minister used the term that things were beginning to work. There was a momentum there. There is momentum this year but the big danger now is that unless we actually fund that necessary reform programme, that momentum will be lost. Confidence will be lost as well. For many years, staff in the health service did not have confidence in the ability of the Government of the day to actually reform the service. They chose in many cases to go abroad to systems that work, where they get satisfaction and where they can meet the needs of patients. Gradually, we were starting to convince people that with Sláintecare, there is a reform programme and it is being funded.

I have already given the Minister credit for progress that was made last year in starting to remove cost as a barrier. We need to do a whole lot more next year. Progress was also beginning to be made on shifting activity out of hospitals to the community. We were beginning to make progress on that. The big concern now is that that will come to a standstill and the momentum will be lost because reform costs money and there is not money, it would seem, to continue that kind of reform within the health service.

I listened this morning at the Joint Committee on Health to the Secretary General of the Department of Health talking about the importance of reform and reorienting the health service, getting better value for money, moving to a new model of care and a lower-cost model of care.

All of that sounds grand. If that is what we are aiming to do, why are we not funding it this year and why are we putting the progress of the past year or two at risk? That is the risk involved in this. The progress that has been made will be put at risk and things will be set back by some time.

It is one thing to say we need to move to a lower cost model of care, which is what Sláintecare is, but the funding that is provided for next year will not allow us to do that. If we are trying to get activity out of hospitals and into the community, we cannot stop funding the hospitals. The alternative community facilities and staff must be funded and then the activity can be moved. It is not something that can be done overnight with a click of the fingers. It must be planned and, for a certain period, there will be an element of funding of dual schemes. That is the reality and unless that principle is recognised, we simply will not achieve the delivery of Sláintecare.

The CEO of the HSE absolutely gets this and recognises it fully. He repeated today what he said on radio last Sunday week, which is that unless there is additional funding, there will not be enough money to fund the health service properly next year. He could not be clearer that there is not enough money to do it. There are three main standout areas in which there was unexpected expense. There was health inflation, over which the HSE has no control. As an example, the CEO referred to the energy bill, for which the HSE signed a new contract during the year. The increase in the cost of that contract was 85%. There is nothing he or the HSE could do about this; that is a reality. Food costs are also very high. The other area of increased expense arose from the unexpected demand. The Minister spoke about this earlier, saying that where ten patients are expected to come in the door, 11 are arriving. It is right that the 11 are treated. There were 70,000 additional areas of activity within the health service last year. That is a good thing and people should not be penalised for delivering it. The only way to make progress in working through and reducing waiting lists is by increasing productivity and treating more people. We should not be penalising the HSE for doing that.

It was said clearly by both senior people who attended the committee meeting today that the big problem with overruns is in the acute sector. There are, in essence, 22 privately run hospitals in the form of the section 38 hospitals. I do not know how the system operates but it seems to be a black hole. We do not know how much a hip operation costs in hospital A compared with hospital B. We do not know why some hospitals operate on a 24-7 basis and some of the big hospitals do not, with people downing tools at 4 p.m. in some cases. We also do not know about productivity of consultants and what oversight there is in that regard. This morning, I queried the oversight of the operation of the big hospitals. I was told the reporting is not to the HSE or the Department of Health but to the hospital groups. I know from data I sought not so long ago on clinical directors that the reporting used to be to the HSE before it changed to the hospital groups. What is the governance and oversight of the hospital groups? In time, this process will change, which we hope to see at some point next year, but there are big questions to be asked about accountability in regard to the operation of the voluntary hospitals.

I repeat a point I made last week. There are also big questions to be asked about the reason we have not until recently started to implement an integrated financial management system. Why on earth has the biggest organisation in the country not had such a system? We do not know where money is being spent and where staff are located. This goes back to the historical underfunding of the health service over many years. Why do we not have a fully implemented digital health strategy? A plan for such was refused and knocked back by the Department of Public Expenditure, National Development Plan Delivery and Reform when it was presented to it in 2018. The Department said the plan must wait until the opening of the national children's hospital. Why do we not have multi-annual funding? Responsibility must be taken at Government level and by the Department of Public Expenditure, National Development Plan Delivery and Reform.

I understand there will be a Supplementary Estimate within the next three weeks. That provision absolutely will have to go into the base for next year and be included in a Revised Estimate for the HSE and for health provision generally next year. If that is not done, it will be a huge failure on the part of the Government. There is an opportunity for the Minister to do something of real consequence in totally reforming the health service by correcting the underfunding for next year.

Paul Murphy (Dublin South West, RISE)
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We have the worst hospital waiting lists in Europe, with more than 1.1 million people on some form of waiting list for healthcare. Incredibly, this is more than one in five of the population. Today, 563 people are on trolleys in hospitals throughout the country, with a record being shamefully broken at University Hospital Limerick when 130 people were waiting for admission there on Monday morning. We have 2.9 hospital beds per 1,000 people in this country, which is a little more than half the EU average of 5.3 beds. We have an unprecedentedly large budget surplus but, two weeks ago, the Government proposed a budget for a worse healthcare service. That is the blunt, shocking reality. A a time of plenty, the Government proposes a budget that will result in longer waiting lists, more people on trolleys, not delivering the beds that were previously promised and a recruitment freeze that will have devastating effects. I could quote a lot of people to back that up but most significant is what the CEO of the HSE has correctly been saying, namely, the simple reality that the funding to the health system is not adequate. He spoke about built-in deficits, which is the first time in my memory that this will be the case for service plans. It is quite incredible and it will have real-life impacts on ordinary people.

Dr. Rachel McNamara, chair of the non-consultant hospital doctor, NCHD, committee, of the Irish Medical Organisation, IMO, has stated:

This recruitment freeze flies in the face of safe staffing levels. It will add to the chaos in a system which already does not have enough doctors to deliver safe patient care, where many teams across the country are not fully staffed and where NCHDs are still working illegal and unsafe hours.

This situation points very directly away from Sláintecare, towards the delivery of which we are supposedly driving. This confirms for me that everyone signing up for Sláintecare is just a convenient political trick. We are told everyone has agreed on what will be done but the reality of the two- or even three-tier health service in this country continues and is actually deepened by the policies of the Government. Everyone gets to claim to support the model that looks a little like a national health service while the existing service continues in the opposite direction.

The question is why the Government decided to do this.

The superficial reason presented is that the Minister for Public Expenditure, National Development Plan Delivery and Reform, Deputy Donohoe, wants to keep the Department of Health and its Minister on a tight leash. This is the idea that he does not have control over the budget and the Department of public expenditure is not going to give it enough money, so he will have to come back asking for more at short notice and it will give him only a little more when needed in order that he will not run away with himself.

Even if that were true, although I do not think it is a very deep analysis of what is happening here, it would be quite an incredible step for the Government or the Minister, Deputy Donohoe, to take. It would be punishing patients and our health service, and proposing and passing a budget that will mean a worse health service, to rein in a profligate Minister. If the rest of the Government does not have confidence in the Minister for Health, they should act to remove him, rather than undermine and destroy our health service.

I think the deeper reason is that it suits the mainstream narrative of Fianna Fáil and Fine Gael to go along with the idea the health service is some sort of black hole. Every year, in every budget, we hear there is more money for health than ever before and that it is the largest budget for health. Of course it is the largest budget for health; we have such a thing at the moment, particularly in medical costs, as inflation, and we have population growth. To stand still, the health budget needs to get bigger. The cheapest way to deliver high-quality healthcare, however, is with a public, one-tier health service. That is the cheapest, best quality and best value-for-money way to do it, and it is the Government’s undermining of a quality public health service that is creating inefficiencies. If we get rid of direct employment, we will have to pay more for agency staff. If we outsource all our catering, cleaning and everything else, we will pay more than we will by doing it directly and inhouse.

Similarly, we do not develop capacity within the hospitals and then we export people and continue to promote a private health service through the National Treatment Purchase Fund. At a time when our health service is creaking and is going to get worse as a result of political decisions, the private hospital sector is making big profits. Last year, Larry Goodman's Blackrock Clinic reported a doubling of profits, to €14.5 million on revenues of almost €160 million. A fundamental cause of the crisis in health is the fact people make profit from it, and the answer is a national health service.

Mick Barry (Cork North Central, Solidarity)
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I want to focus my contribution on the issue of the home help service. It was reported in the press at the weekend that the HSE had written to private home care providers directing that the home help package be reduced from one hour to 45 minutes. This cutback means, in effect, that home help workers throughout the country will have to call to the homes of elderly and vulnerable people, help get them out of bed, wash them, dress them, feed them and have them ready to go within 45 minutes. I would like to see the Minister work for a day as a home help provider and try to do that. I would like to see Mr. Bernard Gloster try to do likewise. It might not be impossible for an experienced home help worker to do it, but even in that instance it could be done only in a rush, squeezing the space and time for conversation, for listening and for a rounded, humane relationship. Cutting home help to 45 minutes is a big cutback, at 25%. It is mean and nasty and it will impact negatively on some of the oldest and most vulnerable people in our society. It will also impact negatively on low-paid, women workers whose contribution to our health service and society has been undervalued for years. This cutback should be reversed.

Mr. Gloster is correct when he says the funding allocated to the HSE in budget 2024 is inadequate, that the shortfall for 2024 will be in the region of €1.4 billion or €1.5 billion and that the combined deficit for this year and next year could be as high as €2.7 billion. A government that underfunds our health service to this degree does not deserve to stay in office. The fiasco of this situation, and what it could mean for people over the course of this winter, seriously increases the likelihood of the Government being given its marching orders by the electorate come the general election.

Seán Canney (Galway East, Independent)
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I welcome the opportunity to speak on this important subject. A huge debate is going on between the HSE and the Government as to whether there is enough money in the health budget to deal with services over the next 12 months. That is an unfortunate position in which to find ourselves at a time when the country has plenty of money, but I do not mean the Minister should go along and spend that unwisely or throw it at the system. Nevertheless, engagement needs to happen between the Health Service Executive and the Minister in respect of how best to use the public money that has been given to it.

We have heard suggestions there is no accountability in health, with money just spent and no responsibility or whatever. I do not know whether this is part of a plan to bring the HSE to task in respect of its funding, its spending of that funding and the outcomes it has for it, but it is unfortunate that this is going on in the public domain, where there is a debate as to whether there is sufficient money while, at the same time, some people are worried about how they are going to get through the winter.

The Minister of State, Deputy Naughton, who is sitting in the Chamber, is from Galway and will know what the emergency department in Galway will be like this winter. People will say there is not enough money to deal with it, and this is what will be going on. The handling of this financial arrangement with the HSE has been done in a very mediocre way and we need to make sure people will act professionally and try to set out what the allocated money is for, what is supposed to be achieved, what the outcome will be and how any shortfall will be made up. We need to be responsible, mature and cognisant of the fact older people and others who are waiting for services such as operations have been on waiting lists for two or two and a half years. They will be waiting for operations and other services and all they are hearing about is whether there is enough money in the budget. This should have been sorted out long before budget day. I cannot believe it was let drift into the public domain without there being a reasonable plan for the people of this country.

This is against the backdrop of there being very good aspects of the health service. Last week, in my constituency, €30 million worth of infrastructure was opened. The Minister of State, Deputy Butler, was there. The problem, however, is that that positive is being spoiled or dampened down by this public row that is going on, and I cannot believe it is going on. We have the infrastructure, but we need to get more staff and make sure everything is working properly. We need the X-ray facility that has been long promised for Tuam. It was financed by the then Minister for Health, Deputy Harris, in 2017 and still it has not been delivered. That is the kind of stuff we should be concentrating on.

We probably have €1.5 billion worth of investment to put into University Hospital Galway and we need to do it. We have the plans to do it, we have Government support to do it, but we need to put a plan in place to deliver it so we have a place where people can work properly and be proud to work rather than working out of prefabs and everything involved with that. This is an unfortunate debate we have to have, all because there has been an amateur approach to the whole budget for health this year. I do not know who to blame for that, and I do not want to be blaming anyone. I want to see it rectified. Genuinely, the bottom line on this is we need the Government and HSE go into a room, close the door, sit down and come out with a plan as to how services will be delivered this year rather than this being something that lingers on. Staff are saying to me how come things have got to where they are. In Tuam, County Galway recently, one of the officials was talking about all of the people employed in the disability sector, and the staff shouted at him that if he halved that figure, he would be nearer the truth. That does not look right, it does not feel right and it is not what is needed if we are trying to deliver a health service with confidence. The Government and the HSE need to do a bit of growing up to make sure we deliver the service and concentrate on what we have to do rather than concentrating on budgets in public.

Matt Shanahan (Waterford, Independent)
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I thank Sinn Féin for the opportunity to debate further the issues in our health service, which at this stage are legion. The planned HSE funding freeze is worrying. I am inclined to agree with my esteemed colleague, Deputy Canney, that the rationale is that Government is trying to put some manners on runaway HSE budgets. Anybody who has spent any time working in or around the healthcare industry knows we have a lot of inefficiencies. It leads to a lot of needless waste. That is yet to be tackled and is something we need to pay particular attention to. Like Deputy Canney, I worry about the message to workers, patients, families and those on long-term waiting lists. We are potentially causing people needless anxiety. I point out and have said recently in the House that we have a large number of no-shows for planned elective work in hospitals, for whatever reason. It runs anywhere from 15% to 30%. If we were to create an initiative around that, we would certainly manage to bite deeper and faster into the extensive waiting lists around the country and not spend a lot more money.

I will also speak about the problems of unstructured downsizing, which is where you take one metric and apply it to all hospitals, in particular in the acute hospital space. The Minister of State, Deputy Butler, will remember that around 2012, the Government created a cost-cutting measure in all hospitals in the country. University Hospital Waterford was the only model 4 hospital in the country that was under budget. One hospital in Dublin was more than 20% over. Everybody took a 7% cut in their budget. We were penalised because we did not overspend. Again, the problem is that if you cut in a broad way and it is non-selective and non-targeted, you will affect the hospitals lower down the food chain. Hospitals like ours in Waterford and University Hospital Limerick in particular will suffer most in terms of the model 4 configuration.

The Minister spoke about his productivity platform, or maybe it is a Department initiative, and about rewarding efficiency. I have said many times in this House that the acute model 4 hospital in Waterford is the most efficient emergency department in the country and the most efficient in terms of trolley count. When it came to doling out €650 million of capital spend this year for the nine model 4 hospitals, it was given to the other eight and University Hospital Waterford got nothing. This is despite the fact that it has pending permission secured for a laboratory build and for a vertical overhead. The Minister of State and I were on calls more than a year ago when these were being discussed and we were told they were approved. Yet they did not get done. We were told about an additional bed block, which looks to be gone now, along with the additional emergency beds. I pointed out to the Taoiseach this morning that we have two emergency department consultants approved since last March and these appointments have been sitting with South/South West Hospital Group, have not been approved, and have not been sent on to the consultant applications advisory committee, CAAC. Why is that? We are telling people on the one hand they are great, they are doing a great job, we are clapping them on the back, and we want to reward them, while on the other hand, there is no sign of that reward coming.

I made another point, of which the Minister of State is probably aware, which is that Waterford incurred significant patient charges consumables for the closure of Wexford emergency department. To my understanding, there has yet been no payment from Ireland East Hospital Group to reimburse Waterford's operations budget.

I will speak to digitisation. A number of years ago I did some work with a company, which was very successful in digital health right across America and western Europe. It is an Irish-based company. I asked the gentleman concerned why he was not looking at Ireland. He told me he had two representatives on the road for two years in Ireland. They had lots of meetings and positive reaction but did not sell a single system. He just gave it up and got out. Enterprise Ireland is still bringing that company around and introducing it to foreign customers in exposés throughout Europe and it still has not sold into Ireland. We are not able to do it. I say that what gets measured gets managed. Deputy Troy, Deputy Naughten and I are bringing an expert group on digitisation into the audiovisual room in November. I encourage anybody here to come along and hear what has to be said. This is how we might potentially supercharge our health system and introduce the real measurement efficiencies that will drive future service plans. Until we do that, we will keep going round in circles. We will not manage because we cannot measure and we will hurt the systems, which at this moment are the most efficient and the ones that need the most support but are not getting it.

Danny Healy-Rae (Kerry, Independent)
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I am glad to have the chance to address the Ministers of State this evening and highlight a few things I am concerned about. I will start with the recruitment freeze on home helps. Things were bad enough with the home help situation in County Kerry before this. I am asking for that to be dealt with positively. A new problem is arising with fair deal in that the HSE is refusing to sanction people for it, even though they are living alone, are in their mid-80s, have serious health problems and cannot manage in their homes alone. The HSE has refused in at least six instances to sign off and say people were entitled to go forward for fair deal. That is terrible. Elderly people in their 80s are being refused fair deal. I cannot understand it. Are they short of money or what, coming up to the end of the year?

I am asking again for a minor injuries unit for Killarney, either on the site of the old district hospital or the St. Columbanus Home, both of which are shortly merging into the new community hospital in Killarney, and we are thankful for it.

We also have to deal with the lack of GPs. Refugees are arriving into our country at the rate of 200 each day. It is as manifest in Kerry and Killarney as much as everywhere else. There will have to be more GPs to deal with those people. It is only fair we provide them and they will have to be got somewhere. There is more pressure now on our accident and emergency departments because the doctors cannot manage. Even SouthDoc after hours is under tremendous pressure. Where do people finish up only in the accident and emergency department in University Hospital Kerry in Tralee?

Another issue is section 39 workers. Some kind of deal has been arrived at but is not finalised yet. I am calling for complete parity of pay and conditions. There is no other way about it. They are entitled because they are doing the same work as HSE workers. They are trained and skilled staff.

I also want to raise the issue of St. Mary of the Angels. It is not taking in any new residents. It is closing down by stealth because anyone who dies, which has happened today, sadly, is not being replaced. This site is a wonderful place and campus. There are so many facilities there. I am asking for single units to be built on the campus of St. Mary of the Angels for people who need this residential care.

That is the way to get around the decongregation model the Government wants to arrive at.

Michael Collins (Cork South West, Independent)
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The question is where the money is going to. The funny thing was nobody except the Rural Independent Group was opposed to where the children's hospital went. We told Deputies it was in the wrong place and was running over budget. They voted us down and told us we were all mad and off our heads. Look at it now: it is a hoover of the highest order and there is not a head rolling anywhere. Some people are looking for a pat on the back for running a hospital completely and crazily over budget with no accountability. No other country in the world would accept this but good old Ireland has. Why did Fianna Fáil, Fine Gael and Sinn Féin approve where it was going? Let none of them look at us and tell us we were in the wrong. We said "No, hang on lads". As few resources as we have, we got the right experts in to tell us it would run crazily over budget and was built in the wrong place, both of which are true. Fianna Fáil, Fine Gael and the lads are all giving pats on the back. Somebody is making a fortune and that is why somebody else is suffering. Who is suffering? The people who deliver home help services will have to suffer because of the Government’s incompetence. They will have their hour cut to 45 minutes. Will the person doing 30 minutes be cut down to 15 minutes? Will new people be brought on board? It was announced last week that new people will not be brought on board. There is an embargo in relation to home helps.

I have a big issue with the stroke unit in Bantry General Hospital. From within the hospital they are pleading with us. The Minister was down recently and said he had no money for the stroke unit. That is a shocking situation because that money has been promised by Fianna Fáil and Fine Gael election after election, but with no delivery. The catchment is from Clonakilty, Skibbereen and Bandon to Castletownbere and all the way out to the Mizen Peninsula and the Sheep’s Head Peninsula. They need a proper, new, structured stroke unit, the same as the people of Dublin and Ireland needed a children's hospital, but we will not get it. We are put on the long finger because health has run over its budget and nobody here is putting up their hand saying they or somebody made a mistake. There are layers of management. Surely they can find where all the money is gone. Surely somebody can find where the millions and millions have gone. Are we gone into billions? It is an astonishing situation. It is farcical, and no head will roll.

I have been on to the Minister of State, Deputy Butler, recently about the nursing home situation. That is part of the health budget as well. It is sad to think a nursing home in Belgooly that once had 68 patients proud to be there will have nobody tomorrow. The Government stood idly by. I accept I got correspondence from the Minister of State but it was continuously defending HIQA’s decision. She could have stepped in. The HSE has to have a procedure in place to step in and take over the running of that nursing home. It is not fewer nursing homes we want in west Cork, but more. She did not step in; she kept hiding behind HIQA.

There is no worry about Deputy O’Donoghue’s area tomorrow morning. There will be 140 or 150 people in corridors around UHL, but when Belgooly needed help, Fianna Fáil, Fine Gael and the Green Party turned their back on it and 48 patients were thrown out of that hospital. I met families who told me what was done to them. It was scandalous beyond belief that the Government stood idly by, hiding behind HIQA, instead of the HSE stepping in and taking over the running of that once brilliant nursing home. It is scandalous the way the health budget has been run. The Ministers would want to wake up, get out of those seats and let someone in who can run the show.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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Time is up. We are going over to the-----

Mary Butler (Waterford, Fianna Fail)
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You should read the HIQA report in relation to that nursing home.

Michael Collins (Cork South West, Independent)
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I read it and I read it intensely, start to finish. You should have stepped in immediately when you knew those irregularities were there. You should have stood by the people of Belgooly, rather than turning your back and telling them to get out. That is what was told to them-----

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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Unfortunately, Deputy Collins, the time is up.

Michael Collins (Cork South West, Independent)
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-----and the staff. It is scandalous the way the staff were treated there.

Mary Butler (Waterford, Fianna Fail)
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I will never compromise on standards.

Michael Collins (Cork South West, Independent)
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Nobody stood by the staff. Aperee Living is a scandal and you stood idly by instead of kicking them out.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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Deputy Collins, please.

Mary Butler (Waterford, Fianna Fail)
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I will never compromise on standards when residents are not being treated properly.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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Deputy Collins, please.

Michael Collins (Cork South West, Independent)
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I have to answer the Minister of State. She should have stood by the people and did not. The beds are empty tomorrow morning.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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Resume your seat, please.

Michael Collins (Cork South West, Independent)
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Remember that. That is all that matters to the people of west Cork.

Mary Butler (Waterford, Fianna Fail)
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I will never compromise on standards.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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Sorry, Minister of State. We will not have a conversation across the Chamber, please. There are other people waiting.

Michael Collins (Cork South West, Independent)
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I have to fight for my people.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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There are other people coming in. The Deputy is a minute over time.

Michael Collins (Cork South West, Independent)
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Sorry. She is over time too.

Mary Butler (Waterford, Fianna Fail)
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I will never compromise on standards, a Chathaoirleach Gníomhach.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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We are moving to the Independent Group. Deputies McNamara, Harkin and Connolly are sharing.

Marian Harkin (Sligo-Leitrim, Independent)
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I thank Sinn Féin for tabling the motion, which highlights that the expected budget deficit in health for 2024 will be in the region of €1.4 billion to €1.5 billion. I listened to the Minister, Deputy Stephen Donnelly, explain that many of the cost overruns in the health service were caused by the fact doctors are treating more patients than allocated or expected. He spoke about the higher cost of drugs. If that is the case, surely he and the Minister for Finance knew we faced this deficit. According to the Minister, Deputy Donnelly, it is not a question of waste but of higher costs. It is not inefficiency; it is efficiency and treating more patients. Why could he not persuade the Minister for Finance he needed the extra funding to cover existing levels of service adequately?

From what we are hearing, it is likely there will be cutbacks. I am especially concerned by reports that the HSE wrote to private home help service providers about two weeks ago. The Minister of State is shaking her head. I am delighted to see that because I do not want any cutbacks in home help services. I hope the fact the Minister of State is shaking her head means that cutbacks will not happen. It would be madness if they did. It would mean that more elderly people would end up in hospital accidentally, would have to stay longer and could not leave because they would not have a proper home care package in place. They might have to go to a nursing home, so it makes no sense for those people or the State that there would be an intervention like that.

I will wait to hear from the Minister of State, but I am pleased with the signals.

Whenever I get the opportunity to speak on health, I want to emphasise that the five hospitals with the highest numbers on trolleys are all along the Atlantic coast. We have already heard and know that Limerick always tops that list, but it is followed by Cork, Sligo University Hospital, Letterkenny and Galway. I looked at the September 2020 figures and compared them to September 2022 and September 2021. I found the same five hospitals had the highest numbers of patients on trolleys. While Limerick always has the highest numbers, Sligo, while often in third or fourth place, is the second worst consistently for a very simple reason. It has far fewer acute beds than any of the other hospitals. That means the situation in Sligo is worse.

Michael McNamara (Clare, Independent)
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I would like to ask the two Government representatives if either of them heard Marie McMahon from the mid-west hospital action group on "Morning Ireland" saying that people were afraid to go to hospital. I do not know whether that is news to them, but it is not news to me because it is something I, my family, neighbours and friends have lived for quite some time.

A very close elderly relative of mine who is in a nursing home had a fall and an ambulance was called to bring her to Limerick. I stopped it and was told I could not do that, to which I said that I would stop it and would stand in the way, sign whatever I had to sign and go to whatever court I had to go to in order to explain the situation. My relative was very thankful. She was afraid to be brought to hospital. She was very happy in the excellent HSE-run facility she was in. She did not want to go to hospital and I did not want her to go there. She was brought elsewhere and I still stand over that decision.

My wife and I have a young son who is not seriously ill, but requires hospitalisation on occasion. We have decided that if he needs urgent hospitalisation, once we hit Birdhill we will take our chances and will not go to Limerick but rather in the opposite direction. Lives will be lost because people are afraid to go to hospital in Limerick. Lives are being lost due to the fact people do not go to hospital in Limerick because it is unfit for purpose. Today, there are 130 people on trolleys. I hate people who say, "Shame on you", but it is an indictment of this Government.

I raised this issue with the Tánaiste, Deputy Micheál Martin, month after month, and all he had to say was that it was nothing to do with him and it is not his job to run hospitals. He is right; it is not his job to run hospitals. However, it is his job to resource hospitals within the limits of the resources available in a budget. We have a lot of money, and we need to make sure there is a management team in place which can spend that money. Instead, he turned a blind eye to the situation.

The Taoiseach, Deputy Varadkar, was a little bit better. In fairness, he could not have been even a little bit worse than the Tánaiste because both call themselves republicans. They are not republicans. If they believed in republicanism, they would ensure there was some parody of healthcare across the State rather than the massive disparity between the healthcare that is available. People complain about it, but it is so much better along the east coast than it is along the west coast, as my colleague has alluded to. People are celebrating 100 years of the Free State, rather than 100 years of a republic. Sinn Féin will say, of course, that we do not have a republic at all. I hope it will do a better job. I have my doubts sometimes, but it could not do a worse job in health than has been done by this Government.

Somebody somewhere needs to adequately resource the health service. If the problem is not resources, as the Government has said, the problem is the management team. There is a problem and nobody is doing anything about it. It needs to be addressed. When pressed on the matter, the Minister, Deputy Stephen Donnelly, said there have been 2,000 new posts in Limerick since the Government took office. That is not the case. After the obfuscation, I asked a question and found out the figure is a third less. He needs to correct the record on that. More important, the problem in Limerick needs to be tackled.

Catherine Connolly (Galway West, Independent)
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Once again I want to thank Sinn Féin for giving us the opportunity to speak about health. There are many times when one could be given to despair making the same speeches over and over. Today, I confirm what my colleagues have said. The west of Ireland is the worst, with the exception of Cork hospital. Limerick hospital has the highest number of patients on trolleys. The hospital in Galway has 44 patients on trolleys, 36 in the accident and emergency department and eight hidden away on wards. I have made the same speeches over and over.

I have a letter from consultant orthopaedic surgeons addressed to the Minister. Mr. Fergus Byrne wrote the letter in March 2019. He told us that he could not stand over the situation which was becoming unbearable, and that there was a catastrophic waiting list of 2,000 patients which was beyond management and so on. I read the letter into the record at the time.

When we spoke about the hospital system in Galway, I foolishly relaxed because the options appraisal said a brand new hospital in Merlin Park would be built. Fast forward to 2023, and nothing has happened. There was another options appraisal which decided to build and keep building on the site of the regional hospital. That is exactly what happened. When I asked the person in charge about this, the person said we despaired. There was no money coming for a hospital in Merlin Park. The site comprises 150 acres.

The Ministers of State know that what we have now is a jigsaw without a picture. There are many pieces. In Merlin Park there will be a surgical hub and an elective hospital, which are welcome. There is no overall plan. On the congested regional site, we are building ad nauseam. Nobody really knows what is happening there. I have a history of the accident and emergency department which I do not have time to read out.

The former Minister for Health, who is now the Taoiseach, said in 2014 that a new building was the only solution to the problems in UHG. It is 2023 and we are still waiting, not for a new hospital because that has gone off the agenda, which is absolutely wrong, but rather a new accident and emergency department. That became something else with maternity and children's services. None of that has happened. In the meantime, a temporary accident and emergency department was added to the hospital.

I welcome some of the progress that has been made on Sláintecare. However, it is an obscenity to have people on trolleys. How many people in the Departments of Finance or Public Expenditure, National Development Plan Delivery and Reform have spent any time on a trolley? I would like them to tell us that. How many Ministers have spent time on trolleys? The average times in Galway are one, two, three or four days. We know that worsens mortality and morbidity rates among patients.

The NTPF was established in 2002, 21 years ago. That is usually the age of reason when we learn to be reasonable. Some 21 years later, we are still funding the private healthcare sector and helping hospitals to make a profit. We are doing that inside and outside of the country, as well as in the North. That was supposed to be a temporary measure. When we are not doing that, we are allowing waiting lists to build. The very doctors who are not seeing public patients on public lists are now seeing them on a private list, sometimes in public hospitals and at other times in private hospitals.

It was brought to my attention recently that somebody with unbearable pain who required a hip replacement was on a public waiting list and had to borrow €12,000 from his family to have an operation done by the very same consultant who could not do it when he was on the public waiting list. I could go on. It is very difficult.

I would be happy to work with the Ministers of State if I could see some commitment to a public health system with access for all. However, the hypocrisy in the Departments of Finance and Public Expenditure, National Development Plan Delivery and Reform and the Government regarding this is very difficult. We constantly fund the private system, including private radiology. The exact same thing is happening with primary care. We are privatising the primary care system.

Violet-Anne Wynne (Clare, Independent)
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Under this Government, UHL has broken yet another record. There were 130 people on trolleys there yesterday, the highest number in the history of the State. That will be the legacy of the Minister for Health and Colette Callan, as CEO of the UL Hospitals Group. The people of the mid-west are dying at the feet of the Government and nothing is being done.

Since 19 September, there have been more than 100 patients on trolleys in UHL every single day. There are 62 more patients on trolleys in the one hospital covering Clare, Limerick and north Tipperary than the three hospitals in County Cork combined. That is interesting.

The Minister for Health has lost the confidence of the staff in UHL and student doctors and nurses who cannot get their hands on visas to get to Australia quick enough. He has, quite rightly, lost the confidence of my constituents who have been abandoned and left to die by the Government. In this House, I have begged the Minister to take action and reinstate Ennis accident and emergency department. I am now demanding that he heeds my calls and those of the INMO and directs the HSE to outsource all elective procedures due to take place at UHL for the foreseeable future to private hospitals, in view of the potential for a high-risk event due to severe overcrowding and a surge in infection, and we are only in October.

Every single day that the Government sits on its hands and refuses to take significant action at UHL, the Minister for Health, the Taoiseach and their Government colleagues have blood on their hands. The blood of my constituents, who have been left to die without dignity in corridors, who have been sent home from an overcrowded accident and emergency department with suicidal ideation, or who timed out before the ambulance even reached them in rural Clare, is on their hands. If it was the Minister of State's mother, father or child, is there any stone she would leave unturned? We were promised a centre of excellence, but now we have a centre of chaos.

Mary Butler (Waterford, Fianna Fail)
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The previous speaker mentioned a person by name who is not in a position to defend themselves in the House. I want that noted on the record. I think it is very unfair to name individuals.

I want to thank everyone. I echo the opening remarks of my colleague the Minister, Deputy Stephen Donnelly, by thanking Members for their contributions to this important motion on the funding of our health service.

There should be no doubt that investment in social care, mental health and older person services is a substantial priority for the Government. The budget for older persons has risen from €1.97 billion in 2020 to just over €2.6 billion next year. This represents the largest allocation ever for older person services, and an overall increase of one third since 2020. Every day, a wide range of core services continue to be provided for older people across the country, including home support, day care, community supports in partnership with voluntary groups, intermediate care, as well as long-stay residential care when remaining at home is no longer feasible. In budget 2024 I secured an increase of €35.5 million for the nursing home support scheme, or the fair deal as it is known, to support nursing homes in maintaining services. I also announced the establishment of a dedicated new €10 million fund to support private and voluntary nursing homes with HIQA regulations and compliance measures. The details are currently being worked on.

The provision of home support has received much media attention in the last week. Improving access to home support is a priority for the me and the Government. Since budget 2021 we have provided an additional €228 million in funding. In 2023, the overall home care budget is €723 million. The HSE national service plan target has risen from 17.9 million home support hours in 2019 to an expected 21.5 million hours in 2023. This is more than has ever been delivered before. This year, we are ahead of target in the number of home support hours provided, with an increase of 571,000 hours delivered up to the end of August in comparison to the same period last year. Our target is 21.5 million hours of home support delivered this year, which we are fully funded to do. Any talk of cuts to home support hours is simply untrue.

Mick Barry (Cork North Central, Solidarity)
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Is the Minister of State saying that the letter was not sent? "Yes" or "No" will do.

Mary Butler (Waterford, Fianna Fail)
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The Deputy can ask me after this. Today I met Mr. Joseph Musgrave from Home and Community Care Ireland and we spoke about home support. The provision to the private sector at the moment is a core rate of €31 per hour, up to a maximum of €34 per hour. The service level agreement made with the HSE and the private sector involves the delivery of 30-minute and 60-minute sessions. There is no concept of 45-minute sessions. Notwithstanding these improvements, there is currently a funded waiting list of approximately 2,800 people who are receiving home support but not the maximum hours advised. This can be due to a shortage of workers at certain times such as weekends. The remaining approximately 3,000 new applicants have funding approval but are waiting for supports.

Some 300 new employment permits have been issued to home care workers from outside the EEA-EU this year. I would like to pay tribute to our home support workers who deliver specialised, quality and essential care to approximately 53,000 people every day, often working split shifts, unsocial hours and weekends. All our home support workers - they are not home helps - have a minimum level 5 QQI qualification and work really hard every day.

Dementia continues to be a priority for me and the Government. In budget 2024 I announced that a minimum of 18% of all new home support hours are now ring-fenced for people with dementia. I have also secured €300,000 new funding for weekend activity clubs for people with young onset dementia. I worked with the Alzheimer Society of Ireland on this.

Budget 2024 also increased the provision of transitional care funding by €4.6 million for next year. Already this year, 8,000 people have used transitional care funding to help them to move from an acute hospital setting to a nursing home.

Hildegarde Naughton (Galway West, Fine Gael)
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I welcome this opportunity to address the House on the funding for the health service in 2024. This was discussed in the House last week, and I would like to reiterate the Government’s commitment to ensuring our health services are well funded. The €22.5 billion health budget for 2024 is the biggest ever and will facilitate the continued delivery of quality affordable healthcare services. Deputies have referenced funding for waiting lists and emergency departments but it is important to point out that the emergency department action plan is fully funded, as is the waiting list action plan.

I also reiterate that funding to maintain existing services has been provided to meet inflation and rising patient demand. Resources are in place to hire 2,000 staff in addition to those who are already in place and are providing vital services in our communities. Provision has been made for the opening and staffing of six new surgical hubs across the country, including in my own constituency in Galway. The demand for healthcare has increased and continues to rise due to our ageing population and pent-up demand for services which arose as a result of Covid-19. As I have previously said, it will be necessary to achieve cost savings where we can and ensure taxpayer’s money is spent as efficiently as possible. I have every confidence that the Department of Health and the HSE will ensure this happens in 2024 and future years.

As Minister of State with responsibility for public health, well-being and the national drugs strategy, I believe some of the best use of public money in our health service can be seen in spending on programmes that emphasise prevention. One way to avoid the onset of medical conditions is through the promotion of healthy lifestyles. The Healthy Ireland framework, backed by the Healthy Ireland fund, is designed to counteract and prevent negative health outcomes as a result of smoking, alcohol, poor diet and physical inactivity. It also addresses the wider social and environmental factors which impact on health and well-being.

We have gradually increased investment in the Healthy Ireland fund since 2017. In 2023, it was just over €14 million. An additional €2.3 million will be allocated in 2024, bringing the total to €16.5 million for this important initiative. An additional €300,000 has been allocated to facilitate the recruitment of four community food and nutrition workers, which will bring the national complement to 19. These workers are a vital support to local communities in developing responses to food poverty and insecurity. Some €1 million will be provided for the further development of outdoor exercise facilities including GAA walking trails and facilities to support outdoor swimming. Some 22,000 people are expected to engage with HSE anti-smoking services in 2024. A quarter of these people will require medical intervention and supports. A total of €1.82 million is being provided to assist these people in kicking the habit.

The development of a new national sexual health strategy is continuing. The budget for free home sexually transmitted infection testing kits will increase by €700,000. We will also increase funding for our national HIV pre-exposure prophylaxis programme, PrEP, to help to fund additional staff and increase access to PrEP medication.

As part of our response to tackling gambling addiction, some €500,000 will be provided in 2024 to develop supports for the estimated 130,000 people with problems in this area. In the last two years alone, funding for our drug and alcohol services has increased by almost €10 million. Core funding for our drug and alcohol task forces and section 39 organisations has increased.

For the first time, €1.5 million in funding for drug and alcohol education and awareness programmes has been provided. In 2024, we are going to deliver new dual diagnosis hubs, which will support the recovery of young people with drug dependency and mental health issues. There is also dedicated funding for services after people embark on their road to recovery to support their integration into everyday life.

In conclusion, I acknowledge the hard work and dedication of all the workers and professionals in our healthcare system. I thank them for the care they provide to people who are often at their most vulnerable.

Maurice Quinlivan (Limerick City, Sinn Fein)
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On Monday, 130 people were on trolleys in UHL, which is a national scandal. We have had figures close to that before. We had 124 in May and 124 in September. Earlier I heard the Minister, Deputy Stephen Donnelly, talk about media reports. I was surprised he did not mention media reports in such a disastrous week for Limerick. I want to put on the record some media reports. A headline on the Live 95 FM website stated, "A record-breaking 130 patients are on trolleys at University Hospital Limerick." The Sunday Worldstated, "Chaotic scenes inside University Hospital Limerick as a record 130 patients languish on trolleys. 'There is no dignity here, that was lost a long time ago'." The Irish Daily Mailstated, "Rush for Covid jab as public bid to keep out of choked hospitals." A Breaking News headline stated "People 'terrified' of attending Limerick hospital due to overcrowding." The Journal stated, "University Limerick Hospital group issues apology over record-breaking overcrowding levels." The Limerick Poststated, "Safe care 'impossible' in dangerous Limerick hospital working environment." Those are some of the media reports in the last 24 hours; I did not record the rest of them.

The Government has clearly given up on University Hospital Limerick and abandoned the people of the mid-west, as I have said on the record before. A total of 18,012 people lingered on trolleys last year. These are not just statistics. These are people we know. They are family members, relations or neighbours of ours. Those 18,012 people were assessed and in need of a bed, but there was no bed available for them. This year it will be worse; it will be more than 20,000 people based on the figures at the moment. October has been the worst month ever and the month is not finished yet. The Minister has given up and has abandoned the mid-west region. There is no plan to get us out of the mess we are in.

Studies show that for every 82 patients who wait for more than six hours, there is one associated death and that happens in Limerick all the time. I was in the hospital recently. It is chaotic and overcrowded. It goes back to the merger and losing of St. John's and the hospitals in Ennis and Nenagh. We were promised a centre of excellence and we got a disaster.

Sorca Clarke (Longford-Westmeath, Sinn Fein)
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Budget 2024 did nothing to relieve the sense of catastrophe that is growing in the health service, which is not only breaking the will of the staff, but it is also breaking the will of vulnerable people in need of medical care. Based on the countermotion the Government put forward, one thing is very clear. Fianna Fáil and Fine Gael will continue to throw out predictable lines, ignoring the tough decisions that management needs to make, ignoring the impact on staff and ignoring its role in this growing omnishambles. Government needs to be very honest with people when it comes to funding our health service because of that level of vulnerability. I say this for a very specific reason. I asked a parliamentary question of the Minister for Health on 17 October about the number of paediatric nursing posts that should be in an accident and emergency department. I was told there is no standardised systemic approach. However, there is a programme signed off on by the trauma steering group in December 2022 that sets a very specific number of trained and educated paediatric nurses who should be in an emergency department.

I refer to the impact of budget 2024 on the Regional Hospital Mullingar. I have been inundated with calls, not just from patients but from staff who are working in that hospital. They need to know what impact the recruitment freeze and the directive to reduce those unfunded posts and agency staff will have on that hospital. They need to know if beds will close and how services that are reliant on those agency staff will be impacted. When it comes to the staffing, they also need to know if the new MRI unit, which the community has fundraised for years to deliver, will be impacted. They need to know about the development of respiratory and cardiac day service, the capital development around theatre and ICU development, the development of a paediatric day unit and the resourcing of that absolutely vital paediatric diabetes service there.

I have raised this issue in this House previously when it got to the point that that service was on the verge of closing. Last week that same service had to tell the parent of a seven-year-old boy that he will not be getting an insulin pump and that he will not even be considered for one until next year at the earliest. That team has minimal staff and meets huge demands from across the midlands. That child is now injecting himself into his bottom and into his legs up to seven times a day to allow his tummy to heal from the number of injections. With the indulgence of the Cathaoirleach Gníomhach, I want to put on record what that mother, whom I spoke to before coming in here, said. She said, "I'm very concerned that the children in Mullingar and surrounding areas are suffering as a direct failure of the HSE to provide appropriate supports to this team. I'm very concerned that if we have to go to another hospital, we'll go to the back of the list, but at least there will be a list. I cannot listen to Minister Donnelly and other health officials saying how they are trying their best anymore. They are failing our children."

David Cullinane (Waterford, Sinn Fein)
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I thank all the speakers who contributed to this debate. The three Ministers who spoke did their best to put a gloss on what was a disastrous budget for health for 2024. However, the facts expose the budget in health as the emperor with no clothes. It is very clear to anybody who is looking at what is happening in our health service and for the budget next year that the health service is underfunded and it will have dire consequences for patients. If the Government does not provide enough money for the health service to stand still, then the health service will go backwards. The Government, at best, is trying to pretend it has provided enough money for the health service to stand still.

At the Oireachtas Joint Committee on Health today, the head of the Department of Health talked about consolidating - that next year was the year to consolidate. It is not possible to consolidate the health service if it is not even provided with enough money to stand still. However, what is a certainty is that the Government did not provide the additional funding, which is needed to advance healthcare, to move forward and to deal with the 1 million people on some form of health waiting list, those on acute waiting lists, diagnostics and the community, and with the fact that we have far too many patients on hospital trolleys. Children with spina bifida and scoliosis have been waiting far too long for treatment. All of the challenges we have in the healthcare system, and there are many, simply will not be dealt with.

I agree with one thing the Minister for Health said in his contribution. He mentioned some of the negative comments which have been attributed to the health service. He conceded they were not made by people in this Chamber. It may have been some media commentators or others; I am not sure who he was talking about. However, the reason he had to say that is that some in government tried to shift the blame away from the three heads of Government, who signed off on a budget to deliberately and consciously underfund the health service, and onto what has been described as a runaway train that is the HSE and health spending.

I would certainly not pretend that we cannot achieve efficiencies in healthcare. Time and again I have given chapter and verse, pointing out that outsourcing, agency spend and spending more of taxpayers' money on subsidising private healthcare, which have been allowed to skyrocket over decades of mismanagement of public money when it comes to healthcare, is one of the reasons we have the problems we have now.

I asked the head of the HSE today even if we were to achieve the efficiencies he is seeking to achieve next year, whether we would still be running a very significant deficit. He confirmed that we would. He agreed with the point I put to him that he has been put in an impossible position of being asked to write a national service plan for next year which is essentially a work of fiction because he is being asked to build into it a deficit of about €1.3 billion. That is not a way to fund the health service. What we actually need to be doing is providing multi-annual funding to the health service, to all of our clinical programmes, to our national strategies at our hospitals, and to primary and community care to deliver the services they need to deliver.

The head of the HSE made the point today, and it was picked up by many in the media, that because we have people who are getting sick and because of where they get treated, we simply cannot cope with that in the future. We have to make sure that more people are treated at home or in the community. Of course, that is the case. That was the whole tenet of Sláintecare. However, there was not a single cent of additional investment of any substance in primary and community care for next year. The Government has agreed to, at best, stand still but not even stand still because it has not provided enough money even to do that. That is not my problem; that is the Government's fault - the fault of the three parties in government.

I cannot support the Government amendment. It falls even on its own false information, as I pointed out in my opening contribution, in bigging up the additional investment which has not actually been made. The Government and the three heads of Government need to take responsibility for their absolute failure to fund the health service properly. I have no doubt that as the days, weeks and months go by, for the rest of this year and next year, patients and those who work on the front line in healthcare will feel the consequences of that disastrous decision. Again, I support the motion we have put forward.

David Cullinane (Waterford, Sinn Fein)
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Vótáil.

Pádraig O'Sullivan (Cork North Central, Fianna Fail)
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The division is deferred until the weekly division time tomorrow evening.