Earlier this year, the Minister wrote in the HSE national service plan that we were to get rigorous oversight and transparent reporting over HSE funding. This was to be the year of no supplementary budgets, the year when agency spend was going to go down, not up. How is it then that ten months later, the Minister and this Government are about to record the second largest deficit in the history of our health service, a deficit with very real and potentially deadly consequences for patient safety on the ground?

We have heard from Cork with regard to CT scanners lying idle because of a lack of sanctioned staff. We know the national neonatal transport service, NNTP, carrying the most fragile and vulnerable babies across our country has been threatened because of a lack of sanctioned maternity cover. We hear from Limerick and Naas that they are terrified of what is in store and what is going to happen this winter. At the heart of this crisis, the Minister, her Department and the Department of public expenditure and reform are failing to plan. Fail to prepare, prepare to fail, as Roy Keane memorably told us 24 years ago. That is exactly what is happening now. The Government's budget is based on a 2% demographic growth, yet we are seeing actual demand in the health service far outpace that. Emergency department, ED, admissions are up 6.75% this year, general admissions are up 3.5% and there was a 10% increase in outpatient waiting lists last year. I have replies to parliamentary questions from the HSE telling me it is forecasting demand for next year only now, after it has got its budget allocation. No wonder the health service is in crisis. No commercially viable business would ever operate like that, so why does the Government make the HSE, with a budget of €29 billion, operate like that? It is a complete nonsense.

If we are to understand the pressure hospitals are under, we should look at the reliance on surge capacity before winter kicks in. I have HSE internal documents which show the south west was relying on 88% more surge beds at the start of October than at the same time last year. In the west and north west, it is 51% higher; in Dublin and south, it is 50%; and winter has yet to come. This is terrifying, and God forbid there is a flu or any other major health event. There are two fundamental issues here: how you plan and, crucially, how you respond when your plan goes wrong. The response by the Government and the Department speaks volumes. We all know agency staff are more expensive than those directly employed, yet when I look at the internal HSE cost and productivity report, we see direct pay is being suppressed. It is €133 million under what is budgeted to the start of October, yet agency is surging ahead by €255 million. All that is taking place alongside an embargo on recruiting graduates. It makes no sense.

Then we look at community services. We are all about ensuring more investment in community services to keep people out of hospitals, yet that is where the cutbacks are happening - cutbacks to one-on-one top-up care in nursing homes - and those patients will end up back in hospital.

Will the Minister commit to employing those nursing and other health professional graduates who were told they would have jobs in the health service and are desperately needed? Will she commit to a supplementary budget beyond what is needed for drugs? What is she going to do to end the fanciful, flawed budget-making that is taking place every single year within the Department, which ensures we are underproviding for our health service year after year?

In the first instance, it is completely predictable that nurses will graduate every year. That is what we want. The State invests in training our nurses and we want them to stay in Ireland. More nurses are staying in Ireland than we have ever seen before, according to the NMBI, not me, and we want them to stay. Some 83% of graduate nurses this year have been offered positions, which is what should happen. It is incumbent on every regional executive officer to plan strategically for their recruitment for the following year. They got a budget uplift of 6% last year and 6% this year, higher than other parts of the Government, and they have an obligation to plan every year for what is known, such as things that are going to open. These include new community nursing beds, a surgical hub and the fact graduate nurses will come on stream and be available to work in the system. These are things that are planned. This year, with the NSP, I am requiring a strategic recruitment plan from each region to show, as HSE Dublin and North East is well able to do, how recruitment is going to be used each year.

The Deputy mentioned a CT scanner in Cork. I go back to the fact Cork University Hospital has hired 233 people. Why has it not prioritised resources for that CT scanner? Beaumont has. I went into Beaumont one Saturday morning and there were 60 people in the emergency department. Six or seven of them needed a CT scan. I went in and saw a CT scanner that was not being used. The lights were turned off. It was a brand new investment not being used. The region recognised the problem and prioritised investment and resources to make that CT operational, which it now is. It is about strategic, intelligent decision-making by everybody. It cannot just be about growth. The health budget has doubled in ten years, and in the last five years, we have had a 52% increase in taxpayers' money going into the health system. There has been a 33% increase in the number of people working in the health system, but only a 16% increase in the actual activity in the health system, including when accounting for complexity. The most expensive part of healthcare are inpatient day cases, not emergency departments. Activity there has increased by only 2%, notwithstanding a budget increase of 6%. We plan based on demographics; that is what we do. We plan to grow based on demographics, because we have already invested in so many people but we are not using them in the correct way. We have not been using the integration that should happen in all the different regions.

I have demonstrated this repeatedly throughout the year when talking about Mallow and CUH, but I see it happening in other regions, particularly HSE Dublin and North East, where that integration has been much more successfully achieved and where recruitment has been strategic and planned. It is important now that the Oireachtas see where the strategic recruitment plan is for next year.

It is important now that everybody has transparency, including the REOs, about how they will use the additional 3,000 people that may go into the health system next year, on top of the 3,000 that went in this year. That 3,000 was contingent on reducing agency spend and overtime by reorganisation, redeployment and making better use of resources. That has to happen, too.

I think we are in parallel universes here. Directors of hospitals tell me they are being blocked from recruiting their graduate nurses, and the Minister is saying something very different. We need to get the truth. The Minister talks about demographic growth but she has not mentioned once the rising complexity of care within our health system, which is driving the increase in admissions and the issues within our hospitals. The reality is we have a serious crisis in our hospitals right now with regard to delayed transfers of care. For about 215 days this year, we have seen over 500 people stuck in hospitals. They no longer need to be there but have nowhere else to go, and the Government has no answer to that.

I do not use names lightly but I am thinking about a man today, Christy Murphy. He is in a nursing home because of the benefit of one-on-one care through the HSE. He was in St. James's Hospital for many months because they could not find a nursing home for him and then they found a nursing home in Finglas. The family, who are from Dún Laoghaire, are so grateful but they have been told that the one-on-one care has been pulled and that patient will end up back in St. James's Hospital. That is wrong. I am hearing nothing from the Minister about prioritising community care and ensuring we get people out of our hospitals when they no longer need to be there, and ensuring that those graduates are actually recruited.

It is so important to prioritise community care, which is why the challenge in here is articulated in terms of acute hospitals and not always in terms of community care. Let us look at that because the acutes have always pulled from community, as the Deputy is aware, but the resources need to go into community. That is why we are trying to focus on making sure there are beds going into model 2 hospitals like Mallow and Bantry. The Minister of State, Deputy Kieran O'Donnell, opened a community nursing unit with 50 beds in Midleton last week, an area the Deputy is very familiar with. We will be opening community nursing units in Donegal and Kerry for the same purpose. All of these are facilities to try to get people out of the hospital, and that investment is just as important. What I find challenging is the conflict between the articulation that hospitals need more money but we also need to get people out. When we put money into other hospitals and facilities, they have to be used. Those beds cannot lie idle. People need to move out of those hospitals, so it has to be both. However, it also has to be articulated as both. It cannot always be more money for CUH but not recognising how much has gone into that region. I am thinking of Mallow, Bantry, the South Infirmary beds, the additional private beds and the new community nursing unit. It has to be everything, and it has to be articulated that way too.