Hospital Services

89. Deputy Marie Sherlock asked the Minister for Health to set out the gap between her Department's forecast demand and actual demand for emergency department attendances, rapid access cancer clinics and endoscopies in each of the tier 3 escalation areas to date in 2026. [73351/26]

The deficit recorded by the HSE this year is likely to be the second highest on record. We have a fundamental problem in how the Department of Health and the Department of public expenditure and reform budget for the health services. We are continually hearing that recruitment is the problem and, in the Minister's view, that the service is overstaffed, but I believe other factors are at play, in particular the failure to forecast demand and the rising complexity of demand in the health services. I have asked the Minister specific questions with regard to the gap between the forecast demand for emergency department, ED, attendances, rapid access cancer clinics and endoscopies in the tier 3 escalation areas and what has actually proved to be the case this year.

I thank the Deputy. I do not think the service is overstaffed, by the way. I have never said that. I am actually advocating more staff, including in this year's budget and last year's budget. In 2025, we came in on the money recruiting. In 2026, we were recruiting and not coming in on the money. Therefore, it is a pattern of behaviour as opposed to any sort of perceptions about the level of the staffing. I am advocating for more staff, just in a strategic way and within budget. There are genuine demand pressures in all of the areas the Deputy has raised. We presumed for demographic growth of 2.1% but activity growth, which is different, has varied considerably across different services. It is important to distinguish between increased demand and increased costs. Approximately 80% of acute hospital costs relate to inpatient and day case activity. That is what costs the most to deliver, not emergency department activity,. Emergency department admissions have increased - there is no question about it - but inpatient activity has grown much more slowly, as only a proportion of patients attending the emergency department require admission or treatment. Inpatient cases, which are what cost 80% of everything, increased by 2.3% to date in 2026 compared with the same period in 2025, broadly in line with the demographic growth assumptions underpinning budget 2026. In the four regions currently subject to enhanced financial control, inpatient activity ranged from a decrease of 1.2% to an increase of 2.6%. By comparison, emergency Department admissions increased by 5.3% nationally, with growth in the four regions ranging from 4.5% to 6.9%. Cancer incidence rates are also increasing annually and are projected to continue to do so, but this does not indicate a uniform increase in demand. Nationally, to the end of August 2026, urgent symptomatic breast referrals increased by 5.4% year on year, lung rapid access clinic activity increased by 1.7% and prostate diagnosis activity decreased by 7%. Therefore, it is not consistent at all. The financial position of the regions reflects a combination of factors, which I will come back to.

I asked the Minister a specific question about forecast demand and actual demand. She provided no answer to that. She has given me the difference in activity between last year and this year. This is the critical and fundamental issue. We have had former and current chairs of the Irish Fiscal Advisory Council, IFAC. saying that the Department is not properly budgeting. I have figures from the HSE stating that the demand for breast cancer clinics is 19.5% off this year. It is 19.5% greater than what the Department of Health and the Department of public expenditure and reform forecast. With regard to lung clinics, there is 23.4% greater demand than what was forecast for this year. We need to get a handle on what the Minister is forecasting and what the demand is. When we put in questions about mental health services demand for 2027, as we did two weeks ago, the HSE, via the Department, told us that it cannot give us those forecasts because they have yet to be worked out. How does it arrive at its budget if it does not even know what the forecast demand is for next year?

What I said is that the forecast is based on demographic growth of 2.1% but everything within that is going to be different. The emergency department presentations and the inpatient case activity are all different. They are at different levels.

The Minister has not given me the figures.

I do not know how else to say it. The assumption is that it is 2.1%. This is very important. There is no correlation between increased demand and the amount of money. Let me give two examples. The mid-west recorded a 9.6% increase in emergency department admissions, higher than the national average and the highest increase nationally, yet it reported a pay deficit of 1.4% growth at the end of August, the lowest deficit nationally. By contrast, Dublin and the midlands recorded lower emergency department growth of 6.9% but it has a pay deficit of 5.6%, the highest of all regions. What I am saying is that the overspend is not coming from the number of people presenting. If it were, there would be a correlation in the mid-west of the same order. It is not that. It is how it is being used. It is much more nuanced.

Let me be crystal clear. It is not what we are spending; it is how it is being spent. I support all efforts to improve productivity. However, the reality is that the Minister set a target of €633 million for savings last year and €181 million for this year. That has gone up in smoke because of the failure to properly plan and forecast demand. The reality is that the Minister is ignoring the specific question that I put to her about what the difference is. For as long as we have this charade, where a figure is being set by the Department of Health and the Department of public expenditure, and the health service is told to fit in with that, then we are going to have a deficit. We have had a deficit every year for how many years? We have this farce where some of the biggest hospitals in the State are only agreeing their service level agreements in September or October of this year. They are asked to take a cut of close to €20 million at the start of the year but are also asked to do more. Surely, any understanding of our health service would suggest that we ask them to do more but not to take a cut of €20 million at the start of the year. We would expect no private sector organisation to set its budget for the year in the third quarter of the year. I do not understand why we do that in health.

I do not know how else to say this. The demand is forecast, essentially. We look at demographic growth but the presentations and how that works are very different. For example, there was a particular presentation of over-75s in the first three months of this year, and that arose more quickly than expected. We base it on demographic growth but the presentations are very different. There is a different presentation for breast cancer than for prostate cancer, for example. The basis of the Deputy’s argument is in relation to demand and spend but they are two very different things. I know the Deputy accepts it is about reorganisation and how the money is spent but that applies across the board. I am happy to go through each piece but it is not about the amount of money versus demand. They are different. How is it that Limerick has the highest increase in demand yet is not over its pay budget? The previous conversation related to the south west. How is it that it is so very much over its resourcing, the number of people to be recruited and its budget, and it has not organised services in a way that reflects that? It is so much about organisation. As the Deputy pointed out, non-pay savings are part of that.

Was my question taken already?

I did not know priority questions were grouped.

Can I just ask the question? I did not know priority questions were grouped like that.

I wish to raise the issue of the serious sexual assault and rape of a woman by an ambulance personnel member. I know the Minister has set up an inquiry into misogyny and the culture within the National Ambulance Service. I have serious questions as to whether what she has established is sufficient, in particular, the scope of the culture initiative and whether a six-month process based on surveys, workshops, interviews and site visits is sufficient on its own. I also want to raise questions about the chair of the commission due to her previous role in the Defence Forces.

Deputy Cullinane and I were paying tribute to the ambulance service and its response in Waterford over the last number of days. We both acknowledged that we would come back to this question on the basis that it was also an issue that had to be addressed. That is what happened earlier. I want to state at the outset my complete support for Major General Maureen O'Brien and the work she has done and will do in addressing cultural concerns within the National Ambulance Service, which do exist. I am informed that the first meeting of the programme board overseeing this process took place on 1 October, at which the objectives for the first six months were agreed. They include, but are not limited to: conducting a formal independent assessment of the current culture and staff experience, which will involve all NAS staff being given the opportunity to share their perspectives; analysing the key findings; developing a set of practical recommendations for culture improvement; and the development and mobilisation of a culture action plan to implement those recommendations. That is the logical approach that any such group would take. The Deputy has more to say, so I do not wish to cut across her.

There are questions. It is nothing personal about this individual. It has to do with questions that have been raised with me by Army personnel when they saw the appointment. Given that somebody occupied very high levels of leadership in one organisation where serious systemic cultural issues emerged in relation to women, it is open to question whether that person was an appropriate choice to independently examine similar complaints in another organisation, considering she played no role, it seems, in challenging that culture. In 2004, after issues were raised by now-Senator Clonan, the major general said that the Defence Forces have an incredible structure for tackling sensitive issues, to use her words. Twenty more years of bullying, harassment and abuse emerged. There is no evidence that this person ever played any role in challenging hierarchy or misogyny in the Army, and I do not see how she can just do it in the ambulance service.

I do not necessarily accept that but I will reflect on what the Deputy has said, of course, as I always would. From my engagement with her, I find her to be extremely strong and capable. She has the experience of a hierarchical uniformed organisation. As I said, I have great confidence in her ability to do it, and do it appropriately. I thank the Deputy for raising that.