On 17 December, the Taoiseach’s tenure as Taoiseach will come to an end, at least for now. By that time, he will have been in this House as a Deputy for 33 and a half years. That is some achievement, as is reaching the highest political office in this land and it would be churlish not to congratulate him on that. My question to the Taoiseach is in his experience and in his tenure in this House, can he tell me how the people can effect change? We elect representatives to make decisions on our behalf or we have referendums.

I have repeatedly raised the issue of University Hospital Limerick, UHL, with the Taoiseach, with the Minister for Health, Deputy Donnelly, and with the former Minister for Health, Deputy Harris, during this Dáil, as have the other representatives from Clare, Limerick city, Limerick county and the broader mid-west. This week, we learned that 72 non-consultant hospital doctors, NCHDs, made a protected disclosure highlighting a series of near misses at the hospital. They said that patients have to wait more than ten hours for a bed in the unit without any medical attention, while other lost patients are sometimes missed and are left unseen by a doctor for a number of days. They say that many NCHDs do not want to work in UHL and that they actively avoid it because of the working conditions. Many people in my constituency and in neighbouring constituencies do not want to go to hospital there. They are afraid to go to hospital there. Most worryingly, they say that there is a great concern among staff about escalating clinical incidents or important issues to the management. There is a fear of retribution or informal punishments, should a person be identified as suggesting change or discussing pertinent issues in UHL. A similar letter, not a protected disclosure but a letter, was written last year and it is my understanding that there was a witch hunt by senior management to find out who wrote it, where they worked and where they intend to work in the future. That is worrying.

I have raised these issues in UHL with the Taoiseach repeatedly and he has said that it is not for this Government to manage a hospital, but it is a matter for the HSE and for the management. I have repeatedly asked the Taoiseach about cases where they are not managing it adequately. It would appear from this protected disclosure, from the letter that was written last year and from a letter that was written by senior consultants which I also brought to the Taoiseach’s attention, that the system is not working. How then do we effect change? I accept that it is for management in the HSE to run hospitals, but when they are not doing this, what happens?

I could highlight other incidents. I highlighted the National Driver Licence Service, NDLS. A resolution was passed unopposed by this House, but nothing has changed. We got a document from the Ceann Comhairle’s office. It is nice, yellow and it kind of represents parchment, but that is the extent of it. There was a Covid-19 committee on which Deputy Devlin, who is sitting behind the Taoiseach, sat, as did Deputy Donnelly before he became Minister. That produced a report, yet nothing has happened. There has been no accountability for the billions of euro that was spent, a lot of which was squandered, although not all of it. There has been no accountability for the deaths in nursing homes. How, then, can the people effect change? If democracy does not work, then the centre does not hold. An issue the Taoiseach has highlighted often himself is the importance of democracy and the importance of the centre holding, but the centre has to respond to legitimate concerns in order for that system to work.

I thank the Deputy for raising this very important issue and I appreciate his interest in my longevity in politics. On a serious note, we have to keep working hard to effect change. We all have to keep at it.

It is interesting that in the last 20 to 25 years, health has been transformed. There is no comparison between outcomes and survival rates today when compared with 20 or 25 years ago. I said yesterday in the House that the reason for this was that we took a more strategic approach to the big diseases that were killing people. There are a number of aspects to health. There is access, which the Deputy touched on, and of how people are treated in an emergency. There are also the matters of how we increase life span, how we increase quality of life and how we reduce the burden of disease on people. To me, that is the big story in health that always gets lost in the most immediate headlines and that is frustrating for many people who are working.

As I mentioned yesterday, I spoke to a consultant in stroke care who posted a story on Facebook last year about an almost miraculous intervention with a patient through thrombectomy. The patient got to hospital in time.

He got 1 million views. The point he was making to me was that we were not communicating events like that. It just took off. It was a very good story about how a person was saved through modern methods of dealing with stroke, but also a better strategic approach to dealing with stroke in terms of stroke units. The cancer strategies have been immensely successful, with the centralisation of cancer centres and so on. The cardiovascular strategy has been very successful. However, numbers are growing because the population is growing and I feel that services have not grown over the 20-year period to match population growth. That would be a view I would have, and I think that manifests in health.

In terms of the specific issue, my understanding is that the protected disclosure might have been sent in June. I stand to be corrected on that. The Minister has met with the NCHDs concerned. As the Deputy knows, the HSE performance management and improvement unit led an intensive engagement with the hospital group and the mid-west community healthcare organisation, CHO, throughout the summer in response to how the hospital was functioning. To be fair, it was not just NCHDs. I think HIQA also raised issues about the hospital. The unit worked with UHL to support and oversee the implementation of rapid improvements in services in the region. These measures include a renewed focus on hospital avoidance, patient flow discharge planning, and regular and frequent assessments of patients with long stays. The performance management and improvement unit is still supporting UHL. It remains a work-in-progress.

There is a bespoke site-level plan for Limerick as part of the national winter plan. It needs more consultants and the recruitment of extra staff - two emergency medicine consultants and discharge co-ordinators to target patient flow. That is now happening and they have been hired. The plan also includes improving access to diagnostics in the emergency department, the enhancement of GP out-of-hours services, and committing to the presence of senior decision-makers on a 16-hour, seven-day-per-week basis. The workforce in Limerick has grown by 833 whole-time equivalents. That is an increase of about 29%.

This issue was raised repeatedly in the Dáil, so why did it take a protected disclosure for the Minister to meet the staff? What is actually changing? We can list out reams of statistics. The Taoiseach spoke about changes over 20 years, but the single greatest change over those 20 years has been that people in Clare no longer want to be brought to that hospital. That is a major change. People on the street and in the countryside do not have confidence in the hospital and NCHDs do not want to work in it.

At this stage, it should be evident that the hospital is not working. We can pour as much water as we want into a leaking bucket or throw as much money as we want at a system that does not work, but none of that will improve matters. I do not want to speak about individuals, but will the hospital's management structures be examined? Until we do that, the profound change required will not happen.

I think I understand fully where the Deputy is coming from. There has been huge pressure on that hospital over recent years. The workforce has increased - I went through that with the Deputy - and the budget went up 20% in one year alone. In 2022, it is €315 million, an increase of 19%. Actually, that is since 2019, so it was not in one year. The new 60-bed module was put in in 2021 and has opened. There were rapid-build projects. There will be further developments. Work has just commenced on a new four-storey, 96-single bed acute inpatient ward block. That has to happen. I know the Deputy is saying that we are pouring water, but Limerick is the key hospital in that region, so we have to work to improve-----

And the only one-----

Yes, and we have to work to-----

-----in the wider region.

No. In the south west, it is essentially Cork University Hospital, CUH. There is Mercy University Hospital and so on, but CUH is a tertiary-----

A smaller area, though.

A bigger population. It does not matter. We need to resource and advance Limerick more. We have to. It does need more capacity in terms of personnel, facilities, beds and so forth. The enhanced community care side of it is very important also so that we can reduce the number of people presenting who do not need to go to accident and emergency departments. It is very important they have proper, good-quality care at different sites and different centres.