I wish to address the topic of governance in the HSE. There are serious governance malfunctions and, in many areas, an absence of good governance in the health service in general. The OECD has found that Ireland has one of the highest spends on health services, yet it has some of the worst outcomes when it comes to accident and emergency treatment times, delayed admissions - with patients left waiting on trolleys - waiting lists for consultations and waiting lists for planned elective admissions. The latter was starkly illustrated two weeks ago by the delay identified in scoliosis surgery for children. Many other patients suffer in silence.

There is lack of clarity in the governance structures between the Minister, the HSE and the Department of Health. The HSE board has been abolished but the HSE continues to operate, seemingly at arm's length from and independent of the Department. There is no certainty in the HSE and its future existence is unclear. The HSE was set up to centralise decision-making and to have consistency in the delivery of services throughout the country. This has failed because our services are as fragmented as ever. Many HSE officials work in an interim or acting capacity and are unclear about their roles and functions. This leads to a lack of trust and undermines any governance consistency. It leads to a lack of trust by patients and by front-line staff.

Hospital groups have been created but most do not have fully functioning boards. It is unclear whether they will become trusts. Community health organisations do not coincide with hospital groups in geographic settings, thus blurring areas of responsibility. The interaction of individual hospitals within groups is poorly defined and model 2 hospitals can be starved of funds and resources while services in larger hospitals are given priority. Hospital services and primary care services seem to work from different budgets and there is no integration. This poor governance leads to substantial inefficiencies in the system and accounts for poor value for money, as identified by the OECD, and leads to much poorer outcomes for patients.

Poor governance decision-making costs money but there is no transparency or accountability in the governance structures of the HSE to account for inefficient spending. Cost-benefit assessment applies to the provision of drugs such as Orkambi and Respreeza, but no such cost-benefit analysis applies to governance decisions. If we demand clinical excellence, we should also demand governance excellence.

Hear, hear.

We cannot expect this to be provided on a voluntary basis and it must be underpinned by legislation to ensure that good governance is rewarded and bad governance is eliminated. When does the Taoiseach intend to put in place legislative structures for the governance of the HSE?

Deputy Harty, as a medical practitioner, speaks from a position of knowledge in respect of many of the issues he raised. We will put €14.5 billion into the health system this year, more than ever before. In some cases, the response is not what we might expect in terms of the excellence in governance and other areas to which the Deputy referred. The work that he spoke of is part of an ongoing process.

This morning the Cabinet approved legislation dealing with a reduction in prescription charges for those over 70, and we approved the inclusion in that Bill of 10,000 medical cards for children in receipt of domiciliary care allowance. There are reports showing a dramatic reduction in cancer rates among children compared to a few years ago. If we were to start with a greenfield situation we might organise the structure of health services around the country in a very different way but many hospital facilities are now state-of-the-art. A major infrastructure programme is to be carried out in the future and we are building a range of primary health care facilities around the country, which are expected to operate on a full-time basis so that people do not have to go to hospital in the first place.

Nobody could disagree with the Deputy's principle of clinical excellence matched by excellence of governance. There has to be an administrative capacity to back up clinical excellence and there is always a demand for this capacity but for many years this country has been behind in its digitisation capacity, whereby we could save time, create efficiencies and make people aware of the scale of what we do. Those at the front line provide a service beyond criticism and those who have moved through centres of excellence will point that out. With an ageing population there are always difficulties and that is what an effective, high-standard health care system is about. The Minister for Health, Deputy Simon Harris, and his Ministers of State are working diligently on this so that we can have a healthy, active and understanding Ireland and can have medical facilities and services as close to people as possible. It is not perfect, by any means, but it is the source of the allocation of €14.5 billion in 2017, an extraordinary amount of money for a small country.

The legislation to which the Taoiseach referred underpins decisions made by the Dáil. I am referring to legislation underpinning decisions made by the HSE and concerning how it administers its funds. There are many examples of where funds are not delivering services, such as in respect of emergency department overcrowding, bed capacity issues, recruitment and retention of staff and the lack of diagnostics. In the mid west the HSE, by closing GP access to medical assessment units in Ennis and Nenagh, is making decisions which compound overcrowding at the regional hospital in Limerick. It makes no sense and ambulances are rushing up and down the road delivering patients to hospitals which are inappropriate to their care.

Hear, hear.

The children’s hospital development is another case in point because a cost-benefit analysis was not done on the question of building on a brownfield rather than a greenfield site, and a huge amount of money is now going to be spent on building a hospital which could have been more cost-effectively built on a greenfield site.

The Grace case is the most recent illustration of a lack of governance in the HSE. The problems were identified but they were ignored and hidden and, ten years on, we have investigations and commissions which are costing huge amounts of money and which could have been avoided if there was proper governance within the HSE. I ask the Taoiseach to introduce legislation to underpin HSE decisions.

Accountability rests with the Minister for Health of the day, because the Vote is now back under his responsibility, not that of the HSE.

Hear, hear.

This means questions can be answered in the House and the trend of spending in the relevant services is determined by the Department, which is also answerable for that spend.

That is not true.

Twenty years ago we were negotiating the provision of a new national maternity hospital which has now been agreed and will go ahead with a state-of-the-art, world-class facility for expectant mothers and their babies for many years to come. There were discussions for many years on the national children's hospital and this will cater for the children of the island for the next 50 years.

That represents an investment in 25% of the population to have world-class standards for them. We have not built a new hospital since 1998. Additions are necessary and fine, but it is important to have governance to back up the clinical excellence about which Deputy Michael Harty spoke.