Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)

This Bill should not be necessary, as the Minister and I both agree. It arises from the inappropriate way in which medical staffing, training and practice are configured in the State. It has been known and widely recognised for years that the hospital system is totally over-reliant on junior doctors. Successive Governments have failed to address this over-reliance and inappropriate staffing, with the result that a crisis has arisen this year. Emergency departments in hospitals across the State have come under renewed threat. I say "renewed threat" advisedly. These departments have been under threat in recent years because of the long-standing and ill-conceived hospital centralisation strategy pursued by former Governments led by Fianna Fáil, Progressive Democrats and the Green Party, successive Fianna Fáil and Progressive Democrats Ministers for Health and Children, including the former Minister, Mary Harney, and their creation, the HSE. Sadly, that policy is now being continued by the Fine Gael-Labour Party coalition and the current Minister for Health.

I stated during the Sinn Féin Private Members' debate on accident and emergency services that the junior doctors crisis is being used as a smokescreen for the advancement of the centralisation strategy. The first victim in this episode was the emergency department in Roscommon. Last night we saw people from Roscommon and surrounding counties, as well as other communities where hospital services are coming under threat, protesting in their hundreds outside the gates of Leinster House. It was a huge turnout on an evening of pouring rain. That is the bigger picture and we will continue to fight to defend the right to safe and accessible hospital services for all our citizens. A cornerstone of my approach as health spokesperson is that citizens throughout the length and breadth of the State are entitled to access quality acute hospital services on the basis of need rather than their ability to pay or geographic location. That is an absolute demand not only for Sinn Féin, but also for the increasing numbers of people who realise that the critical services which they depend on in times of need have come under the threat.

The Bill before us concerns the immediate crisis of the non-consultant hospital doctors shortage. It is a stop-gap measure and Sinn Féin will not oppose it given that it is designed to avert the widespread shutdown of services. Let us be clear, however, that our position is in no way an endorsement of the manner in which hospital staffing is configured. Still less is it an endorsement of the HSE's plans to implement a so-called reconfiguration of hospital services. The junior doctors crisis has led to the hasty drafting of this Bill. It was published only yesterday, a matter which I raised in the House in the presence of the Minister for Health, and it is being rushed through all Stages in both Houses of the Oireachtas over today and tomorrow in order to meet the 11 July deadline for the non-consultant hospital doctor turnaround. This is no way to deal with important legislation and it is certainly no way to plan health services. I listened carefully to the Minister's remarks and I hope we will not have to face a repeat of this situation in the future.

It is ludicrous that we should have to send teams of people to India and Pakistan to find doctors to staff hospitals across this State. Recruiting sufficient additional junior doctors is required in the immediate term and the substance of the Bill provides the means to do that by changing the system of registration. The Minister has assured us these incoming non-consultant hospital doctors will be properly qualified, assessed and supervised. It is vital for patients that his commitments are met because skilled professionals are required in these posts. By no means the least important of the skills required are good language and communications skills to deal with patients and other staff. This is an issue which is repeatedly raised by the patients who go through our hospital system.

This Bill facilitates the continuation for the time being of the current system or, I should say, prevents its collapse and the consequent loss of services. How long will this ramshackle structure stand before it is replaced by a proper system of medical training and hospital staffing? What is the Minister's plan, if any, to end the reliance on junior doctors and get better value for patients from consultants?

Sinn Féin has put forward a range of proposals to address this issue. Irish hospital consultants earn €250,000 per annum for a nominal 33 hour week. The implementation of the consultants' contract cost the Government more than €140 million in 2009. Consultants who practice privately in public hospitals are being paid twice to treat the same patient, once by the taxpayer and a second time by the patient or the patient's health insurer. Some consultants have been reported to spend 40% of their working time on private practice, part of which is reimbursed by the National Treatment Purchase Fund. This is a serious matter which has been highlighted by the Comptroller and Auditor General. Hospital managers have been obliged to write to a significant minority of consultants who consistently breached their contracted duties of public acute hospital service provision. That must be met head-on. Furthermore, the cap of 25% on time spent by publicly employed consultants in private practice is effectively in dispute, with medical unions taking issue with HSE monitoring mechanisms. Questions arise over the reported provision of public care in addition to the known extent of private practice.

In 2009 the Comptroller and Auditor General stated:

As part of contractual arrangement agreed in 2008, consultants undertook to limit private practice to set levels.

There has been limited progress in implementing this provision in that

- private practice levels in many hospitals continue to exceed permitted levels, in some cases significantly so

- monitoring is very much in arrears being reported up to nine months after the work was done

Although an implicit objective of Consultants Contract 2008 was to remove any financial incentive on the part of consultants to engage in private practice above an agreed level, no financial adjustment has yet been effected.

That is a serious and damning statement on the oversight and management of consultants' time.

Sinn Féin takes the view that no monitoring mechanism can adequately deal with a perverse and absurd system which we can no longer afford. The perverse incentives that currently apply to the selection and treatment of patients should be removed. This is necessary so that we can afford to train and employ the medical consultants and general practitioners we so badly need to meet the needs of patients and bring the country up to the OECD average.

We also advocate the introduction of a new public-only consultant contract, capping the salaries of medical consultants. Let us be clear about it; €150,000 is not a petty return. Although we have to go to the people in a referendum to deal with the judges' issue, we do not have to do that with consultants, yet this is not being addressed as it should. It is still unclear how the Government's proposed model of insurance-based health care funding would work in this respect. We need clarity and detail about its health care reform plans, which is something the Fine Gael Party promised but has yet to deliver.

Little attention has been paid in this debate to the constructive contribution of nurses. I want to commend the INMO, whose considered intervention on junior doctors is very worthy of the Minister's consideration. The INMO has stated that it is an exaggeration to say that a unit should close because of a shortage in one profession. I disagree with the earlier contributor who put such strong emphasis on the NCHDs as the back bone of the system. We agree with the INMO view that up to 70% of the care given in emergency departments is provided by nurses. Under medical supervision and protocol, they may be in a position to carry the bulk of the services in many of the departments facing a shortage of NCHDs. The INMO stated the following:

We should have nurse led units, for example, minor injury units, walk in chest pain clinics, stroke units etc. There should be direct referral to nurses and other health professionals e.g. physiotherapists, occupational therapists and others.

Nurses are on duty 24/7 and they are best placed to deliver high quality care around the clock. We need to use the expanded role of the nurse to do procedures previously done by NCHDs. There are nurses already trained to do so.

I will not continue with the rest of the quotation because time is going to beat me.

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