The purpose of this motion is to ascertain the purpose of the budgetary Estimate last year and to consider how it has been implemented.  If we consider the statements of the Minister for Health and other Ministers last year in the context of the formulation of the budget, they accepted there were challenging and difficult times ahead.  At the time, we highlighted that we were very concerned about the budgetary process, the number of leaks and the intimidatory statements made by Ministers to their colleagues that Armageddon would arrive if they did not get their way at Cabinet.

It is clear now, seven months on from that budget, that much of what was said in terms of the health Estimate was a tissue of lies.  It has transpired the health budget was based on false premises.  For example, the programme for government stated the restructuring of the HSE was a priority.  This was to be one of the first acts of the Minister for Health.  He was like Wyatt Earp going down to the OK corral, looking for a fight.  He found the board of the HSE and summarily dismissed it and replaced it with an interim board.  We asked at the time what was the purpose of dismissing the board and the Minister replied that he wanted to be a hands-on Minister, one who would roll up his sleeves and take charge of everything.  Unfortunately, we are still waiting to see that legislation on governance of the HSE come to the Dáil.

This lack has created huge difficulties and there is now paralysis in the HSE and the Department of Health.  Nobody is quite sure who is in charge.  The Minister says he is in charge and is responsible, but he has abdicated his responsibilities.  The CEO, Cathal Magee, was before an Oireachtas committee recently and he outlined clearly that there is no way the HSE will achieve the savings outlined in the budget last year.  Therefore, the savings outlined last year were just figments of imagination.  This has transpired to be the case and the service is already running at a budget deficit of over €280 million.  Huge changes will be required and catastrophic damage will be done to services if the Department is to come in on target.  We have highlighted this every month since February and have pointed out that the budgetary figures provided last year were not achievable.  Later this year, we will see huge damage to services.  We will see the closure of operating theatres and the downgrading of wards.  The CEO, Cathal Magee, said at the Oireachtas committee that the HSE could envision the potential closure of hospitals to bring the HSE in on budget.  This motion notes that the health Estimate in budget 2012 was misleading, given the fact that it was based on assumptions and targets that were not deliverable by the Minister for Health.

Another key area in which there was a promise of huge savings was in reference pricing and generic drug substitution and figures were provided for these savings.  However, nothing has happened and no effort has been made to bring forward legislation to enable generic drug pricing and reference pricing.  This again was a stated priority in the budget, in order to bring about the savings required to bring the HSE in on target.  Clearly, this is another priority on which the Government has failed.  It has failed to ensure it had a budget over which it can stand.  The Government also proposed to make significant savings in the area of private health insurance and planned to charge people the full cost of public beds.  However, there has been no enabling legislation and no change.  By failing in these two areas the health budget will be down €200 million. 

The Government committed in the House last year to ensuring the HSE would have an adequate budget to deliver services, but what will happen now is that we will have fire brigade action from September onwards.  It will be a slash and burn policy, all because the Government was incapable of delivering on the priorities and policies outlined by the Ministers for Health and Finance in the budget last December.

It is now July and the HSE remains in a state of flux.  The CEO is the Accounting Officer, the Minister claims he is in charge and the board is made up primarily of people appointed from the Department of Health.  The Department says the HSE is responsible, but the CEO is the Accounting Officer, with the board.  This state of affairs has caused damage and dislocation, particularly with regard to bringing forward policy, enacting it and ensuring services are provided.

With regard to the HSE service plans, last January we had more smoke and mirrors from the Minister when he sent back the service plan because he was not happy with it.  Surely, he should have been involved in drafting the service plan as he has claimed that he is the one ultimately responsible.  The HSE and the board signed off on a plan, but the Minister took a look at it and sent it back to the board saying he wanted substantial changes.  What substantial changes did he want?  As far as I am aware, no changes were made.  That was just another spin by the Minister to show he was flexing his muscle in terms of being in charge.  Unfortunately, he has not stood up to the responsibility of ensuring the HSE brings in its budget on time and within limit.

The fundamental issue is the delivery of services to the people.  We have already begun to see hospital managers under huge stress and pressure.  We have heard claims that trolleys are being moved to wards in order to reduce the trolley count.  We have eminent consultants saying that lives are now being put at risk.  Front line health service providers and nurses are stating that they are working in areas that are not fit for purpose in terms of delivery of emergency care.  These issues are being raised continually, but that is nothing new.  They were raised last December also.  We have highlighted these issues regularly, but the Minister seems to be incapable of understanding or acting on these warnings.  It is time for him to act because the CEO of the HSE has said that it cannot come in on budget unless there is massive dislocation to health services throughout the country.   This is just the seventh month of 2012, but huge adjustments are required if the HSE is to come in on target.

The adjustments required will, unfortunately, affect vulnerable people most.  We had a situation not long ago when incontinence pads being provided for patients in a nursing home in Kilkenny were being counted out to them.  At the same time as this is happening, the Minister has failed to make the savings in the areas he proposed, agency staff, generic substitution and price referencing.  He identified massive savings in these areas, but the CEO has stated that these savings have not been realised at all.  I understand the challenges are difficult and we are all aware of the reality of the situation we face.  However, the least the Minister should do is to try to bring forward the legislation that will allow him to make savings, that will allow him to substitute brand drugs with generic drugs and allow him to price reference and address the agency issue.  More importantly, he must bring about proper corporate governance and ensure accountability at the highest levels to ensure Government policy is enacted.  That is not happening now.

On the issue of community nursing homes, the Minister has stated that the most important issue with regard to acute hospital services is to ensure a throughput of patients and to ensure that people do not remain in intensive care or high maintenance units in hospitals when they could be in community nursing homes.  At the same time, the service plan he rejected initially and then sought to implement has proposed closures of over 800 community nursing home beds in one year.  Without any stretch of the imagination, that is contradictory to what the Minister is trying to achieve, namely, to move people who should not be in hospitals into the community setting.

I never come into this House and question anybody’s integrity but other Deputies have raised the issue of conflicts of interest in terms of private nursing homes and support for them and a slash and burn of our community nursing homes without any logical explanation as to why they should be closed.  The Health Information and Quality Authority was used as a reason for closing them in some cases while in others, other reasons were used.  However, there is a fundamental question we must all ask.  What is the logical reason for closing community nursing homes which we all accept provide the highest standard of care to our elderly people in the community setting and which benefit, in every way, the transfer of people from the hospital setting to the community one which, as the Minister says, is stated policy and yet he reverts to type and closes them without any consideration for the residents or the community?

I refer to other areas causing huge dislocation.  The Minister placed great store on his special delivery unit.  This was the answer to all his difficulties and would resolve all the problems he faced.  The special delivery unit is spending an awful lot of time dealing with people who are waiting more than one year for procedures.  However, it is benefiting from the fact that people cannot get to see a consultant to be assessed and to find out whether they need to become inpatients.  Hundreds of thousands of people are waiting to see consultants to be assessed but they are not being allowed into the system.  I know of a woman in her 90s who is waiting more than four years for an audiology assessment.  People are waiting ages for orthodontic services.  What is happening to orthodontic services is shameful, in particular in regard to our young people who simply cannot get to see an orthodontist.

We must be honest with ourselves.  The Government has failed to bring forward the legislation which would allow it to deliver the services our people need.  I do not know the reason but the Minister promised three pieces of legislation.  He also promised with great fanfare some time ago that he would renegotiate consultants’ contracts but he has just thrown that aside.  He said he might get more productivity out of them.  At the same time, some consultants are continually in breach of their 80:20 public-private mix.  There are contracts with a 70:30 mix but some consultants are even in breach of that.  Nobody is taking them on.  When he was on this side of the House, the Minister promised he would do the devil and all when he moved to the other side.  He has moved to that side of the House but everything has almost stopped.

The Minister of State, Deputy Shortall, is as accountable as the Minister because she is representing the Government in this Chamber and in this debate on the budgetary process.  The Government has quite clearly failed.  When it is closing hospital wards, hospital theatres and nursing homes in the future, it might reflect on the fact that if it had been active in the legislative area to bring about the savings identified in the budget, we would not have to take the drastic action we may yet have to take.  What exactly will the Government do at this late stage with one week remaining in this session to bring forward legislation to allow it to at least affect some savings between now and the end of December so that we will not have the dislocation of services which will inevitably happen if we continue on this path?

I refer to the issue of accountability and the HSE.  We must find out once and for all to whom we speak.  Is it the Minister, the Secretary General of the Department or the CEO or all three – the three wise men?  At committees, I see the Secretary-General of the Department, the Minister and the CEO of the HSE all defer to each other.  The Minister must take a hands-on approach at some stage.

I refer to the other commitments in the programme for Government.  I only have 20 minutes to speak so it would be wrong of me to take up more time than that but we will have to revisit the issue of primary care.  The Minister promised at the Irish Medical Organisation conference that he would transfer money from the hospital budget to the primary care setting.  Has that happened?  This is a key question to which we must know the answer.  The Government cannot continue to spin its way out of this.  The fact is that services are continually being downgraded by stealth and people will be waiting for longer periods, not necessarily on hospital trolleys, to see a consultant.  People cannot get to see consultants for assessment. 

This motion is an opportunity for us to highlight the Government’s abject failure to address the budgetary problems which have been evident since early January.  This was highlighted in the context of private health insurance and the fact that charges for public beds has not happened.  The CEO of the HSE said last week that this did not transpire.  In one fell swoop, the Government has lost millions of euro through inactivity on the legislative front and, as I said, people will suffer because of that.

I refer to the issue of agency staff.  We highlighted the fact the Government did not have a plan for retirements on 29 February.  The more I look at this the more I see that it is by pure accident rather than design that we have not had worse dislocation of health services.  We have an issue in regard to agency staff and the Temporary Agency Workers Directive.  A key component of the budget was to address the reliance on agency staff which would save more than 50%.  The Government has made no effort to do that.  The recent figures from the HSE, the Minister or the Department – I am not quite sure from where they came, although I presume they are accurate – state that the agency bill has increased.  We are becoming more reliant on agency staff even though it is the Department of Health’s stated policy, and it was stated in last year’s budget, that this issue would be tackled and that the Government would address the issue of agency staff once and for all.

I hate to say it but after a short period time, the Government has driven the health services to the brink because of inactivity.  It is not always about a lack of funding but rather inactivity and a deficit of ideas and action.  That is the situation we face.  When people must wait long periods of time to be assessed, to get medical cards and to get orthodontic treatment and when someone of 90 years of age must wait four years for audiology services, the Government can consider its abject failure to bring forward the legislation it promised the people and the Dáil when it passed the budget last year.  I am convinced – it was said at the time – that it was aspirational at best or dishonest at worst.  The jury is still out that particular issue.   It gives me no joy to say – let it be conveyed to the Minister – that it is a very serious breach of trust when a Government passes a budget and fails abjectly to bring forward the legislative measures which would bring about savings so that people who require services will not have to carry the burden due to inactivity and its failure on the legislative front.