Following this week's budget, we now have spending of €14.6 billion on our health services. That is a huge increase. It is almost 20% of total spending by this Government of taxpayers' money. We have one of the highest health spending ratios in the OECD but we continue to have some of the worst health outcomes. I acknowledge that there are many excellent outcomes and very good practices going on in our hospitals daily, but huge issues remain. The Minister's experience and that of the Minister for Public Expenditure and Reform, Deputy Donohoe, who tried to divvy up the funding with the Minister for Finance, Deputy Noonan, means they understand the process. It is a headache. A sum of €500 million was already added in October by the Minister for Health, Deputy Harris, whom I wish well in his post. Now €490 million is to be added to that.

That is almost €1 billion extra this year, on top of an extra €1 billion last year. There is no accountability. Unfortunately, our outcomes are not improving especially at our accident and emergency departments.

St. Joseph's Hospital, now called South Tipperary General Hospital, in Clonmel is a small hospital when compared nationally. It consistently has 30 or more patients on trolleys every day. The front-line staff are under enormous pressure. A long time ago, when the Minister, Deputy Noonan, was the relevant Minister, when there was agreement to amalgamate and move to Clonmel, we spent €20 million to upgrade Our Lady's Hospital in Cashel to a magnificent state-of-the-art facility and it lies idle. There are no lights on and the doors are closed except for some small activities during the day. It makes no sense.

Why do our citizens have to beg for home help? People with intellectual and other disabilities have to beg and have to deal with HSE bureaucracy. There is something really bad with the bureaucratic system of the HSE. It is past time for this to be tackled. We need to get accountability and proper standards, and we need care for our citizens. That is a very basic right: we are not in a Third World country.

Why are 24 year old mental health patients forced to lie in a psychiatric ward when they should be treated in the community? Mental health services were taken away from Clonmel without putting community services of any value in first. We are making these decisions.

As we speak, in Clare and north Tipperary there is a review of our first responders and ambulance services following the closure of accident and emergency departments in Nenagh and Ennis. Now these will be taken away from us. We have Civil Defence and Red Cross ambulances trying to bring people to hospitals, augmenting the service of the HSE.

I am asking the Minister, who is an experienced Minister, and his colleagues in the minority Government to deal with the layers of management in the HSE. We have 35% more managers in the HSE now than we had in 2007, right at the beginning of our crisis and all the suffering that went on. We have terrible outcomes and scandals such as the recent one with drug payment overcharging by a company, which just paid it back and nobody was held accountable. We need accountability in the HSE. I am demanding that the Government do it. The people want accountability but are not getting it. There are too many issues with people waiting for orthodontic treatment and everything else. There is no proper accountability or transparency.

I compliment the effort of people working on the front line in the health service. It has been a very difficult number of years for them. We have had almost a lost decade in terms of investment in the health service when we would have been building capacity in key areas and that has not been possible. However, despite that and despite a near 10% reduction in the number of people working in the health service, the statistics reveal a 20% increase in the number of patients treated in accident and emergency departments. There was a similar increase in the number of procedures carried out, indicating that our hospitals and care services are delivering.

However, we need to continue to invest and there are gaps, as the Minister, Deputy Harris, has made clear. This year for the first time ever, he will bring the HSE's budget in on target. He will do that next year. As the Minister, Deputy Donohoe, said in his budget speech, there will be very close scrutiny of the way in which health spending is being rolled out, with a precise eye to the sorts of issues the Deputy asked about: waiting times and the experiences of patients at the front line.

Two specific options are being explored in respect of the Clonmel hospital - a modular-build extension, fitting out space in an area currently under construction; and in parallel the HSE will examine the potential for the development of a step-down facility in Clonmel. It is recognised that there has been an 8.6% increase in the number of people who have come to the accident and emergency department in this hospital in the past 12 months, which means there is increasing pressure on those services from growing patient need. The winter initiative specifically targets that hospital as part of the initiatives being taken to try to relieve that pressure.

We will not solve a lost decade of investment in one or two years. This will take a systematic programme of reform and delivery. From the Minister for Health, Deputy Harris, and his predecessor, Deputy Varadkar, we have had a clear strategy to implement change within the health service and deliver better at the front line as well as a better working experience for those in it.

I would like the Minister to correct the record. At the Government formation - he was there - we were told there was an overrun of €200 million to €300 million at that time. As he knows, the Minister, Deputy Harris, recently added €500 million. The Minister, Deputy Bruton, needs to correct what he said about it coming in on budget this time.

We are looking in the wrong places.

Fundamentally, the HSE has cannibalised itself and it is not fit for purpose. It is outdated and unfit. We cannot continue to throw money at problems; €1 billion extra last year and €1 billion this year is phenomenal money. I acknowledge there are good outcomes but there could be more although it does not help when the Government closes services in Nenagh and other locations, such as the backup services in Waterford, where patients were coming. We need to correct the record and not throw money at a dysfunctional outfit which is outdated and wasteful. The Minister said we wasted a decade but where was the decade of reform? I want a reply also on the issue of so many less staff in the HSE. There are front-line nurses and doctors, our best, brightest and educated, who will not work here. We cannot keep them in Ireland and they are being sought after worldwide. Why are there 30% more managers? There is a problem in the mushrooming of management while there are no front-line services. The lunatics are in charge of the asylum in the HSE and it is time they were reined in. I want the record corrected by the Minister that health is coming in on budget this year because €500 million has already been added, and with the additional allocation of €490 million it will be €1 billion extra this year.

I understand the budget will come in on target. We will wait and see at the end of the year. I also understand that the provision being made this year for a €900 million increase will allow the HSE to develop a service plan, soon to be available to Members, that will show significant improvement in service across the board. The plan will be monitored very closely to make sure that it too comes in on budget and delivers the improvements. It will include the employment of 1,200 extra people at the front line. There are already 92 primary care centres and the plan includes a continued roll-out, with 30 more under construction and moving into place. That is the sort of long-term reform that would take pressure off the hospitals, see more patients treated within their own communities and have more access to home care support, which is the kind of environment in which people want to be treated. There is a real direction of reform but it will take time. I agree with Deputy McGrath that we have to monitor carefully that the money we put in delivers the results. One could see from the Ministers for Health and for Public Expenditure and Reform a very clear commitment that the monitoring will occur in the next 12 months and we will expect to see value for the money that we ask the taxpayer to put in.

We will not.