Dáil debates

Tuesday, 12 October 2004

Private Members' Business.

Health Services: Motion.

7:00 pm

Tony Gregory (Dublin Central, Independent)
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I move:

That Dáil Éireann, noting the first statement of the Tánaiste and Minister for Health and Children in Dáil Éireann on Wednesday, 29 September 2004 that 'the one thing I want for the country I love is to have a health service that is accessible to every citizen, regardless of their wealth', notes with grave concern the failure of the Government to deliver a health service accessible to all citizens regardless of their financial circumstances;

and in particular notes:

—the two-tier health service with access based on ability to pay rather than on need;

—the failure of the Government to deliver on the promise of providing an extra 200,000 medical cards and the fiasco where well over 100,000 medical cards have been taken out of the system since 1997;

—the failure of the Government to deliver on the promises of 1,000 extra hospital beds, which will become more acute as we enter the winter season once again;

—the failure of the Government to address the underlying problems which contribute to the gross overcrowding of accident and emergency departments leading to the unacceptable loading of ill people on trolleys;

—the failure to develop a coherent strategy for outpatient waiting lists with special regard to those suffering on rheumatology, neurology, urology, orthopaedic and dermatology waiting lists;

—the failure of the Government to deliver on the primary care strategy regarding which €130 million was promised per year over ten years, but only €15 million has been delivered in total after three years;

—the failure of the Government to end cancer care apartheid by providing multidisciplinary care including radiotherapy services to those who live outside Dublin and Cork such that some cancer patients will endure more radical surgery, or a painful death, due to an inability to properly access radiotherapy services;

—the failure of the Government to act on the feasibility study into an all-Ireland helicopter emergency medical service, HEMS, completed since April 2004, which is costing lives unnecessarily due to dangerous transport practices between hospitals and is causing permanent disability, we being the only country in Europe without this service;

—the disgraceful underdevelopment of our hospital oncology services;

—that the number of consultant rheumatologists per 100,000 population at 0.3 is the lowest by far in the European Community, and also considerably lower than non-EU countries such as Croatia and the USSR;

—the failure of the Government to extend the mid-west pilot on cervical screening to the entire country, we being the only developed country in the EU which does not have a national cervical screening programme;

—the failure to extend the BreastCheck programme nationally in 2000, leading to needless death and suffering for our female population in the south west of Ireland;

—the failure of the Government to ensure an acceptable ambulance response time of 20 minutes resulting in a lesser chance of successful treatment and survival in acute medical emergencies such as road traffic accidents and heart attacks;

—the failure of the Government to address the promised upgrade of Ennis Hospital; the failure to provide adequate nurses for the Mayo dialysis unit; capital funding for Ballinrobe community nursing unit; development of Tuam Hospital; and the health care facility at Our Lady's Hospital, Cashel;

—the failure of the Government to invest in the development of new parallel services before contemplating the withdrawal of existing medical services; and

—the failure of the Government to extend to the rest of the health services the model already existing in general practice, i.e. delivery of a same day and same place GP service, with equal access for public and private patients;

calls on the Tánaiste and Minister for Health and Children to state her position on:

—equality of access to the health service based on need and not on ability to pay;

—whether she intends to implement the Hanly report in view of the absence of public support, and no alternative services being available;

—the financial threshold for qualification for a medical card to be increased so that the 200,000 extra medical cards promised can be delivered;

—the urgent provision of 1,000 extra hospital beds — with full supporting staff;

—the Government to urgently address the overcrowding situation in our accident and emergency departments;

—strategy to address the disgraceful outpatient waiting list situation;

—the proper funding of the primary care strategy as promised;

—adequate access to radiotherapy services for those outside of the Cork and Dublin areas;

—the immediate establishment of an inter-hospital helicopter emergency medical service, HEMS, for Ireland;

—the full development of oncology services in our hospitals;

—the immediate appointment of consultants to include consultant rheumatologists and other necessary consultants to address the gross shortage existing presently;

—the extension of cervical screening nationally;

—the extension of the BreastCheck programme to the south and west of Ireland;

—a guarantee that all citizens be within a 20 mile radius of the nearest ambulance station and that adequate ambulances are available; and

—the full development of Ennis Hospital as promised; adequate nurse staffing for the Mayo dialysis unit; capital funding for the Ballinrobe community nursing unit; the opening of the completed health care facilities at Our Lady's Hospital, Cashel; and approve the planning brief for Tuam Hospital;

and calls on the Minister to provide funding immediately to allow these projects to proceed.

Deputies:

Hear, hear.

Tony Gregory (Dublin Central, Independent)
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I wish to share time with Deputies Cowley, Healy, James Breen, Sargent, Boyle and Ó Caoláin.

Photo of Rory O'HanlonRory O'Hanlon (Cavan-Monaghan, Ceann Comhairle)
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Is that agreed? Agreed.

Jerry Cowley (Mayo, Independent)
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I wish the Tánaiste well in her new position as Minister for Health and Children. She uttered fine words but, as we all know, addressing the problems in the health service requires more than words. It requires action. The performance of this Government and its predecessors highlights the problem that the failures identified in this motion have not been addressed.

The Minister spoke well but then stated she would implement the Hanly report recommendations. I have said from day one that the report is a dead duck. It should carry a health warning because it will really only satisfy the centralising bureaucrats. People will not be able to get to accident and emergency units because of the greater distances they will have to travel to central services.

There is apartheid in the cancer care system and the Cancer Care Alliance was set up to address it. BreastCheck was organised by the alliance. A march was held and within 48 hours it was announced that BreastCheck would be extended, yet we are still awaiting this extension. Sixty-five people die in the south and west every year because BreastCheck was introduced for only half the population. Therefore, the health apartheid continues and some 260 people have died needlessly, including sisters, mothers and nieces.

The Tánaiste referred to the treatment purchase fund. What good is this to the 100,000 people on the unofficial waiting list who are waiting to get on to the official one? Such people include men with prostate cancer who have been waiting for months for an appointment and who still have not got one and those who must wait six years for an appointment with a urology specialist. We have fewer rheumatologists per 100,000 of the population than Croatia and Russia and we have the lowest number of consultant rheumatologists in Europe.

It is not acceptable that a man with cancer must be made wait. Children are whistling when they talk because they do not qualify for orthodontic treatment. Some have to purchase such treatment using money they do not have. It is either this or whistle for life.

The problems in Ballinrobe date from 1971. The number one priority, a community nursing unit for the elderly, has still not been provided. A sum of €400,000, a small amount, is required to enable the project to proceed to tender stage.

Despite the fact that there is a dialysis unit in Mayo General Hospital, seven people, including older people and wheelchair users, have to travel to Galway three times per week to use dialysis services. This involves a round trip of 1,000 miles per week to survive. Their whole lives rotate around travelling to Galway.

A report on a helicopter emergency medical service was commissioned in 2002 and was not published until 2004, giving one an idea of what the Government feels about this issue. Some days ago an ambulance had to travel from Dublin to Galway at 30 mph to avoid potholes as the person it was carrying had a very serious back injury. It is disgraceful that this person should have had his life risked by travelling in this onerous way. Helicopter emergency medical services are available in every other country. Some €16 million was spent entertaining EU Ministers during the six months of Ireland's EU Presidency and €52 million was spent on electronic voting, yet €16 million was not made available for helicopter emergency medical services.

The Western Health Board area is unique in that it has ambulance bases that are not within the recommended 20 miles of the population, thereby putting lives in jeopardy. It is disgraceful that people on the minimum wage still do not qualify for a medical card. Some 200,000 medical cards were promised yet 100,000 have been removed from the system. What about the sad, silent migration of old people into institutions? A defined Revenue funding scheme would certainly sort this out, as well as being good value for money.

There will be no end to the accident and emergency crisis until such time as the Government provides an adequate number of beds. The system is inadequate and as a result the crisis is continuing. It is not acceptable for the Government to sit on its hands and allow this situation to continue. Every one of us is anxious to do what we can to support any Minister, but no matter what a Minister may say or do, it is a question of delivering, and the Government has not delivered on this matter.

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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There are two fundamental issues involving the health service, first, the two-tier nature of the system where access is based on ability to pay and not on medical needs and, second, inadequate funding. There is much evidence to prove that ability to pay is the determinant for access to facilities. I recently heard of a case involving a person awaiting an orthopaedic procedure, who was told that he would have to wait from eight to 12 months for an outpatient appointment. That person asked his general practitioner to refer him to a private consultant. As a result, he received an outpatient appointment within a week and the procedure was completed within ten days. That is the type of service available under the two-tier system, whereby if one has the money one will be looked after but if one does not, one will be on a long waiting list.

The second difficulty involves inadequate funding. Today's report by the ESRI states that Ireland is second last when it comes to health funding. Of the 22 countries surveyed, Ireland spends 7.3% of gross domestic product on health compared to an average of 9% for the other countries. That is a serious difficulty which has arisen.

Another matter identified in the ESRI report is that low-income families are not able to access GP services because they simply do not have the money to do so. Because it costs too much to pay for general practitioner services and medication there has been a huge fall-off in people attending their GPs, particularly those at the cut-off limit for medical cards. The Government promised an extra 200,000 medical cards yet not only do we not have them, but there are also 100,000 fewer medical cards now than in 1997.

I want to provide a flavour of what the eligibility limits are for medical cards. A single person on social welfare of €134.80 per week will not qualify for a medical card. A married couple aged between 65 and 69, whose sole income is from unemployment assistance or benefit, will not qualify for a medial card. A married couple aged between 65 and 69 whose sole income is from a contributory or non-contributory old age pension will not qualify either.

The Minister should immediately grant an extra 200,000 medical cards by making the eligibility limit at least the same as the minimum wage. I would prefer to see free access to GP services for all, although I know the new Minister will not do that. She should at least increase the eligibility limits so as to include everybody on the minimum wage.

For some time, facilities have been completed at Our Lady's Hospital in Cashel, including an Alzheimer's unit, a physical disability unit and two psychiatric units, which are all vacant. Funds should be made available to open these units immediately. I hope we will not have to take to the streets, as we did in Clonmel, to make these units available to the public of south Tipperary.

James Breen (Clare, Independent)
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How can the Government stand over the millions of euro that have been squandered in the name of health over the past seven years? When will the Government stand up and take notice of what is happening to ordinary people when they enter the health service? Hospitals are going backwards instead of forwards. The shortage of doctors and nurses, particularly at weekends, is adding serious stress and trauma to patients and medical staff alike. When will the Government listen to the doctors and nurses who are trying to carry out their duties under atrocious and depressing conditions? This situation cannot continue. It needs to be addressed immediately. It is unfair to expect one or two doctors to cover an entire hospital at weekends.

There is a two-tier health service in this country. If one can afford to pay for treatment one will get it instantly, but the outcome for those on medical cards is not so good. Waiting lists for services are on the increase and people wait well over 12 months for treatment that they have a right to receive. We should examine other countries that have successful health services and must not be afraid to adopt their best practices.

The new Minister for Health and Children needs to adopt a common sense approach. She must be prepared to tackle the bureaucracy, examine critical staffing levels in each hospital and ensure that money is spent on patient care, thus fulfilling the Government's promises. What measures does the Minister intend to put in place to counteract the crisis caused by the MRSA super-bug, which is now rampant in Irish hospitals?

Will the Minister inform us when the 1,000 extra beds promised by the Government will be delivered? When will the extra medical cards be provided? Will the Minister admit that the Hanley report will never be implemented in full because it is impossible to implement something that would further degrade the health service? The list of such questions continues and every time health issues are raised the list becomes longer.

There have been enough empty promises. I challenge the Government, particularly the Minister for Health and Children, Deputy Harney, to sort out the overcrowding of our accident and emergency units, to tackle vigorously outpatient waiting lists so they will be eliminated, provide an air ambulance service for citizens living in rural areas, develop oncology services in hospitals throughout the country and fulfil the promises made.

The people of Clare want to know when Ennis General Hospital will be upgraded. I will keep asking these questions each time health issues are raised in the House in an effort to put forward the views of the people of Clare and, indeed, other counties. It is time for the Government to provide answers. There should be no more empty promises.

Photo of Trevor SargentTrevor Sargent (Dublin North, Green Party)
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I thank my Independent colleagues for this timely debate, particularly in light of the ESRI study which has so trenchantly criticised the health service. We wish the new Minister for Health and Children well in tackling the challenges she faces. However, notwithstanding her fine words about the heath service being accessible to every citizen regardless of wealth, she has a number of fears to allay. One of the issues behind this motion is whether the Minister meant to say that the health service should be accessible to every citizen regardless of geography. That is an issue about which every Member of the House regularly receives representations, particularly with regard to the lack of progress in providing radiotherapy services and funding for designated oncology units for regional cancer centres. This issue is in my mind because last week I lost an uncle to cancer. He happened to be living within walking distance, if he could have walked, of the Mater Hospital. As such, the issue of radiotherapy was not one about which he had to worry, although because he was so ill he chose not to avail of the treatment.

Having visited Waterford and other areas around the country, however, I understand the trauma and pain involved for many people who must travel to Dublin hospitals for radiotherapy. It is something that no Government can ignore. I hope this debate will provoke action to provide extra radiotherapy services. Currently, enormous suffering is caused due to the inequitable nature of the service throughout the country.

There is an additional fear based on the Minister's appointment, given that while she is the Leader of the Progressive Democrats Party, many of the areas affected by the Hanly report are not represented by Progressive Democrats Deputies or Senators.

I spoke tonight to people in Ennis who fear that, whatever about the former Minister, Deputy Martin, having local representatives in the area, the Minister, Deputy Harney, may need to act swiftly to reassure local communities who have invested a considerable amount of time and money getting a professional critique for the Hanly proposals. They want assurance from the Minister that she will give due consideration to these proposals and meet with the people who are seeking to have the professional critique presented to Government. It is exasperating that €20 million was earmarked for hospitals such as Ennis Hospital over a ten year period and each time questions are asked about where the money is, there is talk about a design phase or another phase and that the money is on the way. This indicates a lack of commitment to providing the service.

Areas like Balbriggan in north County Dublin, where the population has grown from 10,000 to more than 30,000, has no out-of-hours service. Ultimately, we are dealing with a country in which health has become a by-word for absolute exasperation, frustration and suffering. While the Government gives assurances in words, we need action, which we are not getting at present. There is not even an approach being taken which will ensure there is a healthier society.

The former Minister, Deputy Martin, let the cat out of the bag when he was on the rack over waiting lists. He said he can do little about it if people are getting sicker and there is more demand on the health services such as they are. This indicates the need to examine the Green Party's health proposals, which are about preventative as well as curative solutions. Money is not being spent on preventatives measures. Billions of euro are being spent annually on new drugs and medical technologies while very little is being spent on basic medicines, even hospital infection control, which would save a much greater number of lives than the drug applications. There is need for a holistic health service. When I look at the track record of the Minister, Deputy Harney, I see someone who has espoused market forces as the solution to almost everything. The health service is certainly an example of where market forces have not made us healthier. They have, in fact, made us sicker and we are becoming a very obese nation. Obesity gives rise to diabetes, heart disease, cancer and so many other health problems, and an examination of what is becoming an obeseogenic environment should be at the heart of our health strategy. All I see currently is panic to try to come to terms with promises made at election time but which have been broken. We need a health strategy which will ensure healthy people rather than just treating sickness.

Photo of Dan BoyleDan Boyle (Cork South Central, Green Party)
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I commend the Members of the Technical Group for tabling this timely motion. It is timely not just in terms of the changing Cabinet, which sees the Tánaiste take over the Department of Health and Children, but because an ESRI seminar was today presented with a paper which compares the Irish health service to other economically developed countries. To be told by a think-tank, which is well respected in this country, that we are rated 21 out of 22 health services in such countries is a shame and should be an embarrassment to the Government. The Tánaiste has the comfort of knowing that she is beginning her term of office as Minister for Health and Children in the knowledge that, as far as the Irish health service is concerned, it is closer to Boston than Berlin. The only country which has a lower rating is the United States, where almost half the population has no health insurance and where the name of the game in terms of receiving any health care is the size of one's wallet. This is the direction in which the Government has been going for the past seven years and I fear the Tánaiste will lead us further in that direction.

If we are looking for a metaphor for the state of the Irish health service in 2004, we should look at a "Six-one" news report last week about the ambulance service on Aranmore Island. Aranmore Island was my father's native home where he had a fatal attack and died four years ago — I referred to it in the House in the past. At the time the ambulance was out of order and my father's last few hours were spent in the back of a trailer before being taken to a lifeboat and then to Letterkenny. As I explained to the Minister's predecessor and the CEO of the North Western Health Board, I do not think it was a factor, but it certainly did not lead to the dignity which should be afforded on such an occasion. When I saw last week's news, I discovered that four years on the same ambulance is now out of commission for one year. I saw the dilapidation of the vehicle, with a 1992 registration, which is nothing more than a rusted hulk, with nothing in its interior to justify calling it an ambulance. I saw the Irish health service represented as it truly is, and this is the morass the Tánaiste must seek to tackle.

Another note that struck me in this Breast Cancer Awareness Month and the series of advertisements being run on radio and television to encourage women to be more aware of the scourge of breast cancer is the rider "breast check is not available in the south and west of the country". What kind of Government can promote such a partial service which ignores the needs of so many of its citizens?

What really worries me is that in taking up her new office and saying all the right things in terms of what she thinks people want from the health service, the Tánaiste is coming into office with several pieces of baggage vis-À-vis the way in which her party has affected how the health service is run. We recently saw the opening of a private hospital in Galway. It was the first hospital to benefit from the tax incentive in the 2003 budget. Those who invested in such a hospital are getting from taxpayers tax relief of 42%. I read that most of the custom of that hospital — it is custom because it is being run on a profit basis — will come directly from State sources by the State transferring patients who should otherwise be treated in a public hospital system through the national treatment fund. This is privatisation on the double because it includes tax relief, plus the State paying for the privilege of treating its citizens without having a properly funded public health system. What sort of madness has brought about these types of policies?

I am sorry the Tánaiste is not here to respond to the debate. I hope she will do so over the course of tomorrow evening. This is no white horse affair, it is rescuing a health service which has been downtrodden for several decades. We do not have a health service. We have bits and pieces where people have to make do. Their health and the quality of the health care they receive subsequently depends on who they are, where they live and the resources they have. Until the Government and the Minister are prepared to address these central questions, I fear we will not reach the ranking of the countries listed one, two and three on the list supplied today by the ESRI. I also fear that a subsequent report will rank us below the United States, in 22nd place.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Tá Teachtaí Dála Shinn Féin ag tacaíocht leis an rún. Molaimid na Teachtaí Neamhspleácha as an rún a chuir os comhair na Dála, atá oiriúnach mar tá Aire nua sa phost. Is mór an trua nach bhfuil an tAire sa Teach, ach an tAire Stáit. The Sinn Féin Deputies will support this motion, even though I am disappointed the Independent Deputies highlighted the case for some hospitals but failed to mention Monaghan General Hospital, which is a glaring omission.

The Government's amendment is insulting. It makes no effort to address even the main issues raised in the motion and repeats the two-part mantra that we have heard ad nauseam of increased spending and the Government's health strategy. It has been amazing to listen to the commentary since the appointment of the new Minister for Health and Children, the leader of the Progressive Democrats, Deputy Harney. One would think the Government's health strategy had only been published last week instead of three years ago. Will the former Minister, Deputy Martin, be air-brushed out of history?

A prime example is the speculation that the new Minister might be the one to take on the consultants. The consultants' contract was supposed to have been renegotiated two years ago under the Government's health strategy. In the section entitled Acute Hospital Services, the strategy promises that "greater equity for public patients will be sought in a revised contract for hospital consultants". The target date for agreement on that revised contract was the end of 2002. Last year the then Minister for Health and Children, Deputy Martin, told me that only preliminary talks had begun. The new Minister, Deputy Harney, is aware that even those preliminary talks are, to all intents and purposes, postponed indefinitely. The consultants have doggedly refused to proceed until the insurance cover dispute is resolved. The consultants' position is unquestionably an obstructionist tactic.

The Minister, Deputy Martin, described the consultants as kings in their own domain. This was a very strong statement but the words have not been matched by actions. We have not heard the Government's position in the negotiations. It should at least demand that all new consultant posts be entirely in the public system, as recommended in the Brennan report. There must be real accountability from consultants for work in the public system. If the Taoiseach and the Tánaiste are not prepared to do this and to weather the storm, there can be no real health reform — I believe the Minister of State, Deputy Brian Lenihan, who is present, accepts that.

As the motion states, the Tánaiste and Minister for Health and Children has stated that she wants "a health service that is accessible to every citizen, regardless of their wealth". If that is the case, we need to hear the Government's plan for ending the two-tier apartheid system whereby wealth buys access to what can only be regarded as excellent private care while the public system and the public patient are lagging way behind. The Progressive Democrats Party was nearly as extravagant as Fianna Fáil in its pre-election promises although it did not promise 200,000 extra medical cards. It pledged, however, to "ensure income eligibility criteria would at least keep pace with movements in incomes". That has not happened. Some 100,000 fewer people have medical cards than was the case in 1997 when this relationship was first launched.

The Progressive Democrats also made a commitment to "ensure regional cancer care centres are established so that patients do not have to travel 100 miles for ongoing radiotherapy". It declared: "This will be an immediate priority for us." The Tánaiste must fulfil that promise and she will have the support of all opinion if she earnestly pursues and delivers on that. She should ensure that promise will mean not only that the additional centres that have been signalled will be established but also all the others that have been argued for, in Waterford, Limerick, Letterkenny and so on. She should not neglect, as many others have failed to mention, the needs of the north east, north of Dublin and to the Border, which is repeatedly forgotten by many commentators.

I tabled a series of questions on this issue before notice of this week's Private Members' business was given. I am sorry the Ceann Comhairle has vacated the chair, but he disallowed most of my questions although, inconsistently, he allowed others, including one in another Deputy's name, which also addressed cancer services. My questions were specific and did not anticipate the Private Members' business of the Independent Deputies, of which I had no knowledge. I regret that most of my questions were disallowed this week.

Before he left office, the former Minister for Health and Children, Deputy Martin, met personnel in the North Eastern Health Board and issued a public statement about hospital services in Counties Monaghan and Cavan. I tabled a question asking the Minister to confirm that statement and the promised measures, and to put a timescale on their delivery. On the basis of the answer I received, I can only conclude that much of what the former Minister announced is already unravelling. The Minister, Deputy Martin, promised a CT scan for Monaghan General Hospital but the new Minister makes no mention of it in her reply. Is it still on the agenda? The Minister, Deputy Martin, spoke of the immediate recruitment of five junior doctors for the same hospital but the new Minister simply states that the board proposes to recruit these five doctors to facilitate the early restoration of around-the-clock medical cover. The Minister, Deputy Martin, spoke of an emergency room to be provided at a cost of €1 million. A week later, the new Minister speaks of a treatment room — there is a difference — with Government funding of €750,000.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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It is the same room.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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When one is talking about accident and emergency services, it is obvious why the word "emergency" is used. It is not just today or yesterday that we have been addressing these issues in Cavan and Monaghan.

The Minister, Deputy Martin, said ten additional beds would come on stream immediately, but the new Minister tells us the board intends to commission ten additional day beds. There is more information being pulled in and pulled back, it is an incredible vista. In her reply, the Minister conspicuously avoids the part of my question which asks for a timescale for the delivery of these facilities. That is at the kernel of the whole matter. We simply do not know when services will be delivered. There has been a change of Ministers — we are delighted to see the Minister of State, Deputy Brian Lenihan, is still here, taking the flak for those who should be in this Chamber addressing these issues directly — and the new Minister is getting off to a bad start by following the example of the Minister, Deputy Martin, in failing to come before the House for Private Members' business and answer the solid charges made by the Independent Deputies and those who support their motion. Whatever about the change of Ministers, there has been little change in terms of the need for vigilance by communities.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"commends the Government for the unprecedented increase in the level of investment in the health service since 1997 and for its comprehensive reform programme, supports the early implementation of reform measures, notes the progress that is being made already in implementing the health strategy, Quality and Fairness — a Health System for You, and supports the Tánaiste and Minister for Health and Children in her commitment to provide better health services for all members of the community."

I will share time with the Minister of State, Deputy Tim O'Malley.

In examining the motion tabled by the Independent Deputies, I was amazed to note the reference that the number of consultant rheumatologists per population is the lowest in the EU and considerably lower than in non-EU countries such as Croatia and the USSR. Are the Independent Deputies aware that the USSR as a political entity vanished approximately a decade ago?

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
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It vanished in the same manner as the rheumatologists.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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Some of the thinking from the Independent Deputies is resonant of the type of thinking that informed public administration in the USSR. As the Deputies are aware, the USSR was administered under a system whereby block grants were endlessly thrown at State services in the hope that they would work.

Jerry Cowley (Mayo, Independent)
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The USSR had a better health service than Ireland.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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After decades of corruption, inefficiency, official manipulation and control by vested interests, the system entirely collapsed. The warm public response to the appointment of the Tánaiste as Minister for Health and Children is a reflection of the public's recognition that the entirety of the problem in the health service is not exclusively to do with the allocation of money, as some Deputies protest.

Jerry Cowley (Mayo, Independent)
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Why are there not more rheumatologists?

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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It was also bound up with a considerable number of vested interests that have clung barnacle-like to this rock down the years.

I welcome Deputy Ó Caoláin's intervention in the respect that he offered support to the Government in the difficult negotiations we must embark on with the senior branch of the medical profession. On the issue of Monaghan Hospital, I assure the Deputy that the Government's announcement on it has received a broad welcome within the medical community involved. We will work to address the issue.

The Government is committed to implementing fundamental reform in the health service. The essential elements of that programme are improved patient care, better organisation and improved delivery. I accept that some of the points made by Independent Deputies are well made and constructive.

The reform programme will progress in tandem with further investment in our health services. Evidence of this is the recent announcement of the additional €85 million allocated for the opening of new facilities in hospitals. These facilities include: new accident and emergency departments at Cork University Hospital, Naas General Hospital and Roscommon County Hospital; a new surgical block, an intensive care unit, operating theatres and an accident and emergency department at James Connolly Memorial Hospital, Blanchardstown; two new operating theatres at Our Lady's Hospital for Sick Children, two at Limerick Regional Hospital and at South Tipperary Hospital, Clonmel, for which Deputy Healy has called many times——

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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I hope they open the units now and they will not be left vacant for two years.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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We must fund these facilities also. The Deputy made his political claim to fame urging the citizens of his native town to not pay for the rubbish that must be collected.

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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I made it by demanding that the Government produce the goods and not leave a €7 million unit which was vacant for two years.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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One must pay for the goods in order to have them produced. The facilities also include: increased capacity in intensive care, coronary care and high dependency units at Portiuncula Hospital, Ballinasloe, University College Hospital Galway and Naas General Hospital; a new day ward and day surgical centre at St. James's Hospital Dublin; new orthopaedic services, trauma and elective, in Galway and Mayo——

Jerry Cowley (Mayo, Independent)
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We are still waiting for the services in Galway and Mayo.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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——a new maternity suite at Letterkenny General Hospital and a new medical assessment unit at Midland Regional Hospital, Mullingar.

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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When will the Government build the Cashel unit?

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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These new units include provision for more than 200 additional beds between inpatient and day places——

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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I get no answer to that question.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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——and when fully operational it is estimated that the new units will increase inpatient and day case activity by up to 40,000 patients in a full year.

Jerry Cowley (Mayo, Independent)
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What about the provision of services?

Séamus Pattison (Carlow-Kilkenny, Labour)
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Order, please.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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Some 1,200 staff has also been approved to deliver these improved services throughout the country. I propose to concentrate on the substantial progress in recent years on the development of a comprehensive cancer policy. The Government has invested extensively in a national cancer strategy. Nationally, there has been unprecedented investment in radiation oncology services and a significant development of hospital oncology services. There is a planned extension of the national breast screening programme and increased investment in the cervical screening programme.

Improving cancer care is a major priority of this Government.

Jerry Cowley (Mayo, Independent)
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What about Waterford and Letterkenny?

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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I will come to them in a moment. There is broad recognition among health service providers of the significant changes that have taken place in recent years in improving cancer care.

James Breen (Clare, Independent)
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How many recognise it now?

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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Between 1995-97 and 1998-2000 overall relative survival from cancer excluding non-melanoma skin cancer increased from 48% to 50% in women and from 38% to 44% for men. For women, there were survival improvements for the four commonest cancers, breast, lung, colorectal and lymphoma. For men, survival improved for almost all cancers, notably for cancer of the prostate and stomach as well as for lymphoma and leukaemia.

Jerry Cowley (Mayo, Independent)
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If they can get to hospital.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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This has changed the experience of cancer. There is real hope for patients and families. The Government's focus is to ensure that there is access to services that deliver this experience for each and every person who is diagnosed with cancer. There is no doubt that this is a major challenge to our health services and a major disease, with 20,000 people diagnosed with cancer each year between 1994 and 2000. It is also a major cause of mortality and premature mortality, accounting for one quarter of all deaths. The burden that cancer places on the health services is reflected in the fact that there were almost 81,000 hospital discharges and more than 48,000 day cases with a diagnosis of cancer in 2002.

The report on the development of radiation oncology services was published in October 2003. Government has accepted its recommendations and has agreed that we now require a major programme to rapidly develop clinical radiation oncology treatment services to modern standards. The first phase of the programme will be the development of a clinical network of large centres in Dublin, Cork and Galway. The development of these centres is of critical importance and will, in the shortest possible time frame, begin to address the profound deficit in radiation oncology services identified in the report.

There has been significant progress in implementing the report's recommendations. There has been approval for the appointment of more than 130 additional staff and full-year current funding of approximately €15 million provided to open the new radiation oncology department in University College Hospital, Galway and to expand capacity at Cork University Hospital. This will enable the appointment of an additional five consultant radiation oncologists, for whom recruitment is under way.

In developing this model, radiation oncology centres will be required to provide services on an equitable basis that will ensure that patients of equal need will have equal access. Geography will not be a barrier to equal access. Radiation oncology centres at major teaching hospitals will be required to provide outreach services to hospitals in adjoining regions as is currently the case. As more consultant radiation oncologists are appointed, it will be necessary to ensure that there is an equitable spread of outreach services.

The Government has decided that in the future development of services, consideration should be given to developing satellite centres at Waterford, Limerick and the north west.

Jerry Cowley (Mayo, Independent)
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It needs more than consideration.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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However, the number one priority is the development of the "backbone" of the service.

Jerry Cowley (Mayo, Independent)
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We need more. People are being transported like cattle all over the place. They are too sick to get to the centres.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Order. The Minister of State to speak, without interruption.

Jerry Cowley (Mayo, Independent)
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The only consideration we hear being given here is being given to Waterford.

James Breen (Clare, Independent)
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Only to Waterford.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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The position as I understand it was that we had Dublin and Cork. Now we will have Dublin, Cork and Galway. Deputy Cowley should know that the report on the radiation services was prepared with the co-operation of his profession. It is the profession's recommendation. The Deputy must defer to the expertise of those with whom he has worked for the greater part of his life and respect their judgment in these matters.

James Breen (Clare, Independent)
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What about Ennis?

Jerry Cowley (Mayo, Independent)
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How about the alternative——

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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I am not surprised at some of the other Deputies interrupting, but I am surprised at Deputy Cowley in this context.

James Breen (Clare, Independent)
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What does the Deputy mean by that remark?

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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An independent evaluation——

Séamus Pattison (Carlow-Kilkenny, Labour)
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Order, please.

James Breen (Clare, Independent)
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How dare Deputy Lenihan speak like that? What about the promises made by Government? The health service is a disgrace and scandal to the country.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Deputy Breen is being disorderly. He should resume his seat.

James Breen (Clare, Independent)
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Millions of euro have been poured down the drain. Where are the improvements? How dare the Minister of State speak like that? He is lucky that he was not moved out of his position last week. How dare he castigate any Deputy on this side of the House?

Séamus Pattison (Carlow-Kilkenny, Labour)
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The Deputy should resume his seat.

James Breen (Clare, Independent)
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He should be ashamed of himself.

Séamus Pattison (Carlow-Kilkenny, Labour)
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The Deputy is out of order. The Minister of State is in possession.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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Deputy Breen did not refer to radiation services in his contribution.

An independent evaluation of the 1996 national cancer strategy was launched last December. This report concluded that the key achievement of the 1996 national cancer strategy, a 15% decrease in mortality in the under-65s, was achieved in 2001, three years ahead of target. This reflects the cumulative additional investment of approximately €550 million in cancer care since 1997.

Jerry Cowley (Mayo, Independent)
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How about all the hospitals down——

Séamus Pattison (Carlow-Kilkenny, Labour)
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Order, the Minister of State should be allowed make his statement without interruption.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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Investment to date under the national cancer strategy has enabled the funding of an additional 104 consultant posts, together with support staff in key areas such as medical oncology, radiology, palliative care, histopathology and haematology throughout the country. An additional 245 clinical nurse specialists have also been appointed in the cancer services area. The benefit of this investment is reflected in the significant increase in activity that has occurred.

Since 2000, the Department has provided a total cumulative investment of €49 million to support the BreastCheck programme.

Jerry Cowley (Mayo, Independent)
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Only in the east.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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During the period February 2000 to December 2003, BreastCheck carried out approximately 133,000 screenings and detected around 1,040 cancers.

Jerry Cowley (Mayo, Independent)
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Not in the west.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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The attendance rate for BreastCheck screening is in excess of international standards of 70%, with approximately 77% of those invited attending.

Jerry Cowley (Mayo, Independent)
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That is great for those who get it, or those with the money for it.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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The next phase, for which I assume Deputy Cowley is calling, is the roll out of the programme to the rest of the country, to which the Government is fully committed. Approval has been given for the establishment of a design team to work up detailed plans for the construction of the clinical units in Cork and Galway.

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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When? What is the timescale?

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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Capital funding in the region of €20 million has been earmarked as part of the capital investment programme 2004-08.

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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Progress is definitely being made on that list now.

Jerry Cowley (Mayo, Independent)
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We are still waiting.

Séamus Pattison (Carlow-Kilkenny, Labour)
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The Deputy will have an opportunity to reply tomorrow evening.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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BreastCheck, the relevant hospitals and the Department are fully committed to the expeditious roll-out to the rest of the country. Representatives have met to progress the design process, the next stage in the process.

The cervical screening programme was introduced on a phased basis, with phase one commencing in the Mid-Western Health Board area in October 2000. Under this phase, approximately 74,000 women in the 25 to 60 year age group are being screened free of charge at minimum intervals of five years. To date, almost 45,000 women have availed of the screening programme. The motion refers to the failure of the Government to extend the mid-west pilot project on cervical screening on a national basis. It is prudent to evaluate an initial pilot phase in any programme before considering its extension.

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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When? This is four years later.

Jerry Cowley (Mayo, Independent)
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We are still waiting. It took a long time to introduce BreastCheck. It was promised nationwide years ago.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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This is taking place to test the organisation and delivery of a cervical screening programme in a given area.

Jerry Cowley (Mayo, Independent)
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There is a 20% mortality rate.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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The number of smear tests nationally has increased by almost 20% in recent years and additional cumulative funding of €11 million was provided by the Department since 2002 to assist the laboratories in meeting this demand and improving colposcopy services. The Department is also investing in new technology through extending the use of liquid-based cytology.

International evidence is that better clinical outcomes are achieved in hospitals with specialist staff, high volumes of activity and access to appropriate diagnostic and therapeutic facilities. Best results in treatment are achieved where patients are treated by staff working as part of an integrated multidisciplinary specialist team.

Jerry Cowley (Mayo, Independent)
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Not in Waterford, Kilkenny and Limerick.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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This core principle must inform the current organisation of services and how we plan future services across the various modalities of cancer care. The National Cancer Forum is developing a new national cancer strategy. The strategy will be published by the end of the year.

We are fortunate that those involved in cancer care provide a professional, high standard of care that is very much appreciated by those with cancer and their families. I recognise and acknowledge their dedication and commitment. The Government's objective is to ensure the substantial investment is reflected in improvement in health outcomes for cancer patients.

Jerry Cowley (Mayo, Independent)
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More investment is needed.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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I am glad of the opportunity to place on the record the substantial developments that have taken place in cancer services.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
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It should have been much better.

Photo of Brian Lenihan JnrBrian Lenihan Jnr (Dublin West, Fianna Fail)
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More needs to be done and nobody takes issue with that. However, a substantial amount has been invested and it is a record any Government can stand over. It is appropriate that this House should commend the Government on its positive and demonstrable commitment to improve health services, especially cancer services.

Tim O'Malley (Limerick East, Progressive Democrats)
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It is important to put in context the provision of acute hospital services. There have been many important advances in surgical technology, including less invasive surgical methods and advances in anaesthetics. These advances have allowed the range, safety and effectiveness of surgical procedures to be enhanced to a greater extent. However, innovations and technological advances have led to increases in the demand for surgical procedures, especially elective procedures.

Activity in our acute hospitals continues to increase. The number of patients discharged from hospital having been treated as either inpatient or day cases in 2003 was more than 1 million. This is the first time the number has exceeded 1 million. This represents a 5% increase over 2002 and an almost 30% increase in the number of patients treated compared to 1997. The increase in acute hospital activity is a direct result of the Government's investment in capacity and staffing.

The Government's aim is to clearly focus on reducing waiting times for public patients who require admission to hospital for elective treatment. The national treatment purchase fund was established to help to achieve this aim. The fund's task is to achieve reductions in waiting times and, particularly, to offer treatment to those who have been waiting longest. The NTPF was set up on a statutory basis on 18 May 2004 and has made significant progress in the meantime. The fund has undertaken validation of those waiting longest for treatment and has taken account of factors such as patients not available for treatment, patients not medically suitable to undergo treatment, patients no longer requiring treatment and patients postponing treatment at their own request.

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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How many have died?

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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Patients must wait for between 12 and 18 months for outpatient appointments.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
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This is a sham.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Order, please, the Minister of State, without interruption.

Tim O'Malley (Limerick East, Progressive Democrats)
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The NTPF reported in May 2004 that waiting times have reduced significantly, with 37% of patients waiting between three and six months and 43% waiting between six and 12 months for surgery. Therefore, 80% of patients wait less than one year for surgical treatment. This represents a major reduction in the time patients must wait.

The fund has substantial capacity to treat patients and will continue to focus on reducing waiting times even further. The fund's target is to treat more than 12,000 this year — it has the capacity to treat a minimum of 1,000 patients per month. This will allow the fund to make further significant progress in reducing the average waiting times for surgical procedures. Since it commenced operations, the fund has been successful in locating additional capacity and arranging treatments for more than 19,000 public patients up to the end of September 2004.

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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At what cost?

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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Nothing has been done.

Tim O'Malley (Limerick East, Progressive Democrats)
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We were told at the time there was no capacity in the system.

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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Hospitals have been closed.

Tim O'Malley (Limerick East, Progressive Democrats)
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In most instances, anyone waiting more than three months will be facilitated by the fund.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
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That is rubbish.

Tim O'Malley (Limerick East, Progressive Democrats)
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A total of 19,000 patients is rubbish. How dare the Deputy say that?

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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How dare the Minister of State close hospitals?

Photo of Séamus HealySéamus Healy (Tipperary South, Independent)
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How many years are people on outpatient waiting lists? We are being honest.

Tim O'Malley (Limerick East, Progressive Democrats)
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An important element of acute hospital services is the delivery of emergency services. Comhairle na nOspidéal published a report on accident and emergency services in February 2002, which noted that a hospital-wide response was needed to meet the requirements of the emergency service. Delivery of the emergency service at hospital level is interdependent on the inpatient elective service and day and outpatient care. The effective delivery of emergency services, therefore, cannot be dealt with in isolation from the delivery of all hospital-based services.

Many of the difficulties and delays experienced in emergency medicine or accident and emergency departments reflect system-wide issues such as the demand experienced by each hospital, the resources available to it, as well as the structure, organisation and staffing profile of the hospital. It is necessary, therefore, to take a whole-system approach involving primary care, acute care and sub-acute and community care to tackle the problems in emergency medicine departments.

A number of initiatives are under way to address pressures in emergency medicine departments. Improved and expanded emergency medicine departments are being provided through national development plan funding in many acute hospitals. For example, new departments have been provided at Cork University Hospital, James Connolly Memorial Hospital, Naas General Hospital, South Tipperary General Hospital, and Clonmel and Roscommon General Hospitals. New departments are also under construction at St. James's Hospital and Tullamore General Hospital. The establishment of minor injuries units, chest pain clinics and medical assessment units will also improve the operation of emergency medicine departments.

The Department has approved Eastern Regional Health Authority proposals for a range of short and medium-term solutions to the problems associated with emergency departments in the Dublin academic teaching hospitals. The cost of these new initiatives is €2.4 million in a full year. Areas covered include the appointment of specialist nurses, the establishment of rapid assessment clinics and the provision of multidisciplinary teams to assess patients.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
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Are they working?

8:00 pm

Tim O'Malley (Limerick East, Progressive Democrats)
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An additional 29 emergency medicine consultant posts were approved in 2001. There are 51 emergency medicine consultant posts in acute hospitals, which is a 260% increase in numbers since 1997. The availability of senior medical staff in emergency medicine departments should facilitate rapid clinical decision making and enhanced management, diagnosis and treatment of patients.

Pressures on the hospital system, particularly in the eastern region, arise from demands on emergency departments and difficulties associated with patients who no longer require acute treatment but are still dependent. Full year funding of €8.8 million was provided to the ERHA in 2003-04 to facilitate the discharge of 280 patients, mainly elderly, to more appropriate settings. An additional €5 million was provided in June 2004 to facilitate the transfer of a further 200 patients, including young chronic disabled people. The Department provided €3 million to the ERHA to transfer a further 120 patients in August 2004.

My Department and the Department of Health, Social Services and Public Safety in Belfast commissioned a feasibility study and report on the costs and benefits associated with the introduction of a dedicated helicopter emergency medical service for the island of Ireland. The decision to commission the study was made on foot of a recommendation by a cross-Border working group on pre-hospital emergency care. The group is one of a number established under the North-South Ministerial Council to examine cross-Border co-operation in the health area. The report of the consultants appointed to undertake the study was published on 30 April 2004 and is available on my Department's website.

Possible roles for a helicopter emergency medical service identified in the report include primary and inter-hospital response. Primary response involves travelling directly to the scene of an incident to take a patient directly to hospital whereas inter-hospital response is the planned, rapid transfer between hospitals of patients who require specialist care under the escort of skilled professionals. The report concluded that an inter-hospital transfer service would be more appropriate in an all-island context. According to the consultants, the provision of such a service with a single helicopter would involve significant capital investment costs of €12 million and annual operating costs of €4 million. Additional helicopters could be added with an additional annual cost per aircraft of over €3 million.

Jerry Cowley (Mayo, Independent)
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It is very good value for money.

Tim O'Malley (Limerick East, Progressive Democrats)
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The development of a dedicated helicopter service would involve a considerable lead-in time. Key elements of the process would include the recruitment and training of appropriately skilled staff, development and implementation of education awareness programmes, the procurement of aircraft and the identification, development and certification of landing sites. According to the report, the timescale for completion of this wide range of activities would be approximately three years from the date of a decision to proceed. My Department is exploring options on the development of a helicopter service in light of the recent study, as part of which exercise it has initiated discussions with the Departments of Defence and Communications, Marine and Natural Resources. A meeting is scheduled to finalise an air ambulance service level agreement between my Department and the Department of Defence.

A more immediate priority in the area of pre-hospital emergency care is the development of the ground ambulance service. Funding provided by my Department in recent years has facilitated significant advances in the development of the ambulance service. Among the developments have been a major upgrading in training and standards, the equipping of emergency ambulances with defibrillators and the training of ambulance personnel in their use, the introduction of two-person crews and improvements in communications equipment and control operations. Principal among the developments currently being addressed are the elimination of on-call as a means of providing emergency cover, improved fleet reliability and the roll-out of the advanced paramedic training programme.

The elimination of on-call is designed to facilitate further improvements in response times. My Department is providing funding in excess of €4.3 million in the current year to facilitate the continued phasing out of on-call in a number of regions. This is a programme which I hope to be in a position to extend. My Department provided additional capital funding of €2.5 million in December 2003 and a further €4.9 million in the current year to enable health authorities to continue with the fleet and equipment replacement programmes which are essential pre-requisites for enhanced, speedy and appropriate care. In addition, the previous Minister, Deputy Martin, announced policy approval for the development of the advanced paramedic training programme and considerable work has been done to prepare the legislative base necessary to give it effect.

I am pleased to advise that the new statutory instrument amending the pre-hospital emergency care council's establishment order was recently amended to facilitate the introduction of the training programme. The programme's introduction also requires the amendment of the Misuse of Drugs Regulations 1988 and the Medicinal Products (Prescription and Control) Regulations 1996 and the necessary legislative changes are being progressed as a priority by my Department. The combined amendments will provide a statutory basis for the administration of additional medications, such as cardiac medications, and it is intended that the expanded service will commence roll-out in 2005 following the completion of training of ambulance personnel.

Emergency care and related services have been the subject of significant departmental and management attention and investment. The Government will continue to focus on the delivery of emergency services to provide high-quality care and ensure that patient access and treatment remains at the centre of health policy.

James Breen (Clare, Independent)
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There was not one word about medical cards.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I wish to share time with Deputies Crawford, Connolly and Twomey.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Is that agreed? Agreed.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I welcome this debate and compliment the Independent Deputies on their initiative in proposing it. I am pleased to have an opportunity to contribute on behalf of Fine Gael.

The Ministers of State, Deputies Tim O'Malley and Brian Lenihan, must be extremely concerned at the confirmation today of the Opposition contention over a number of years that the health services fare badly when considered in a global context. Our service compares poorly to 22 national health systems according to a survey published by the Economic and Social Research Institute today. In fact, the Irish health system came last and second last in two of the three categories examined. The Republic rated joint last with Japan in terms of non-medical factors, including tobacco and alcohol consumption, road traffic injuries and immunisation rates, of which the Government has made great play since entering office. Ireland ranked just above the United States of America in second last position in terms of outcome in rates of heart attack, cancer and suicide. The Republic's performance on life expectancy at birth for men and women was in the bottom third of countries. These are key criteria by which the success or otherwise of a health system is examined.

Ireland is the lowest spender alongside Finland in terms of financial resources devoted to health across the 22 countries examined. We devote just 7.3% of our GDP to health spending compared with an average of 9% across the 22 states. We hear constantly that we are spending more and more and both Ministers of State present this evening said as much again. We have been shown internationally to be the lowest spender of 22 states examined by the ESRI.

The drop in medical card numbers is one of the key issues which has been raised recently. Members of the Opposition have been recalling that while 200,000 medical cards were promised almost two and a half years ago, 101,000 fewer people are covered by the medical card scheme than when the Fianna Fáil-Progressive Democrats coalition was elected. Approximately 37% of the population had medical cards in 1997, a proportion which has been reduced to 28%.

The people most affected are those on incomes marginally above the level at which they would be entitled to a medical card. They cannot afford doctors fees and access to basic medical care. General practitioner care is becoming unaffordable for a significant minority of people on the margins of eligibility and they are suffering great hardship. People on the margins are now presenting late in illness and neglect chronic problems because they cannot afford the cost of accessing early a medical doctor. The absence of a medical card is particularly problematic for people with chronic illnesses such as heart disease and diabetes. Failure to treat such problems could result in serious difficulties later, such as heart disease, kidney failure and stroke. The Government is penny-pinching and will pay later when these diseases, which could have been prevented with early intervention, arise.

The medical card scheme was introduced to provide care for those on low incomes. The vast majority of medical card holders today are those on social welfare, those aged 70 years and over, those suffering chronic illnesses and those who qualify under exceptional circumstances. It is my experience that fewer people are now eligible under the chronic illness criteria. It is as though a message has gone out to the health boards to clamp down in this area.

The Minister of State referred to the issue of over-crowding in accident and emergency departments. There is an urgent need to deal with this issue as we enter a period of climate change with many elderly people and others likely to present with symptoms of influenza. We should not have to seek to deal, under Standing Order 38 or by way of Adjournment debate, with matters such as people being treated in the back of ambulances or hospital yards, or awaiting treatment for days in emergency departments. Something by which the new Minister for Health and Children will be judged this winter will be the number of issues, such as people awaiting treatment in emergencies, raised by way of Adjournment debates or under Standing Order 38.

The Minister of State spoke at length about the reduction in waiting lists. However, he did not refer to those awaiting placement on waiting lists. Many people are awaiting consultations which will enable them to get on to waiting lists. I was approached by a person two weeks ago who has been waiting for four years for an ENT consultation following which he will be placed on a waiting list. The Minister of State may boast that he will receive surgery within 12 months. That may be true, but he will have had to wait four and a half or five years for that intervention. The Minister should, in an effort to be open and transparent on this issue, speak of those awaiting placement on waiting lists.

While I welcome the motion, it does not refer to mental health, an issue which I raised with the Independent Deputies. I am disappointed the Minister of State did not speak of mental health as an issue in terms of the general health service. I am also disappointed the Minister did not address that issue. However, I am hopeful that, as a member of the Progressive Democrats holds the senior Ministry in this area, the Government will respond favourably in terms of the availability of resources for the mental health system.

Some 11% of the total health budget was devoted to mental health when the Fianna Fáil-Progressive Democrats Government took office. That figure now stands at 6.7%. It is not unfair to ask the Government, on behalf of the 25% of the population who at some stage will suffer a mental illness, those who suffer in hospitals or from trying to access them and those who suffer because members of their families have taken their lives as a result of the lack of proper treatment in the mental health area, to restore the mental health budget to that which obtained when the Fianna Fáil-Progressive Democrats Government took office in 1997. It is only then that the Minister will have a base from which to work in improving the situation. I could be emotive and critical on this issue but I implore the Minister to seriously examine the mental health area.

I hope the new Minister for Health and Children will respond positively to the Minister of State, Deputy O'Malley, as a member of her party, in addressing that issue. I again welcome the debate and congratulate the Independent Deputies on tabling this motion.

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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I welcome the opportunity to contribute to this important debate. I also welcome the Minister's initial comments in terms of what she proposes to do in the future. I would like to address the North Eastern Health Board area. It is interesting that of the €85 million recently allocated not one penny was allocated to the North Eastern Health Board region, an area along the Border which is supposed to benefit from Government, international and peace initiatives. I question the Government's commitment to the Border region when it makes no effort to assist it when it has money to spend.

The population of the North Eastern Health Board region has increased by 12.7% since 1996, the highest population increase in the country. From 1971 to 2002 the population increased by 40.7%, beaten only by the Dublin health board area. There has also been an increase of more than 1,000 in those aged 85 years and over. Care of the elderly is therefore significant in that region. Last but by no means least, the region has the largest number of asylum seekers per capita than any other part of the country. Providing for such a population costs money, yet the North Eastern Health Board area was left €42.5 million short in the last budget. While that shortfall was based on historical reasons, if one bases it on actual statistics the region was left short €130 million. While I often criticise the activities of the North Eastern Health Board, one has to remember that without money it cannot provide services.

The average per capita allocated to the North Eastern Health Board region for 2004 is €1,591 — the national average is €2,018 and in the Dublin health board area it is €2,362, leaving the North Eastern Health Board region short on average €427 per capita. We also have the lowest ratio of staff per patient. While I criticise the administrative staff level in the area, one has to take into account those figures produced independently. At least 300 extra beds are needed in the region, yet we have been promised only ten day beds at Monaghan General Hospital with money allocated and 19 extra beds in Cavan General Hospital with no money allocated.

I apologise if I was emotional when the Minister of State, Deputy O'Malley, was making his contribution. However, I have very good reasons for acting that way. The Minister of State spoke of the reduction in the number of people on waiting lists. As my colleague, Deputy Neville, said, the Minister of State did not refer to those awaiting placement on waiting lists. I asked the previous Minister, Deputy Martin, what it costs to send a person and his or her spouse to Birmingham or elsewhere in the UK for treatment under the national treatment purchase fund when the particular treatment could be undertaken in Monaghan General Hospital were it not taken off call. The theatre and staff at that hospital remain idle. I do not suggest the national treatment purchase fund is not a good scheme, but surely we should utilise what we have before spending such money.

We need somebody to oversee how money is spent, an issue which brings me to speak of the Cavan-Monaghan region that I represent. I am somewhat amazed by the motion tabled by the Independent group. I support it in principle but I cannot believe the hospitals of Cavan and Monaghan have been left out of it and that it has been signed by my Independent constituency colleague, Deputy Connolly. Cavan and Monaghan have had the most serious problems in the country, highlighted in the news and by the Independent Members of this House, but facilities in Ballinrobe, Tuam and across the country are mentioned here with no mention of the need for an upgrade for Monaghan Hospital.

In case anyone thinks everything is all right there, I refer to the fact that the previous Minister for Health and Children, Deputy Martin, issued a statement at the eleventh hour in which he thanked Deputy Connolly for being constructive. The bottom line is that the previous Minister can make a statement but the new Minister for Health and Children, Deputy Harney, tells us the facts. She told us in no uncertain terms that there will be no CAT scanner and that only limited money is available. Above all she tells us that Cavan General Hospital, as part of the configuration of services, will have the possibility of 19 beds examined. This is a serious situation. There is a crisis in the north east that could be solved in the morning if the initiatives were put in place to allow Monaghan General Hospital to reopen. I welcome the discussions between the health board and the consultants to bring about a level of agreement but this package must be delivered.

The Government promised to provide 200,000 additional medical cards but took away 100,000 in seven years. Of the 100,000 medical cards that have been taken away, 6,035 were in County Monaghan, which has a population of 50,000, while in the former Minister for Health and Children's constituency in Cork, 8,000 were taken from a population of 500,000. Why have I had to raise the issue of medical cards so often in this House? It is ludicrous, mean and unacceptable.

Paudge Connolly (Cavan-Monaghan, Independent)
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I welcome the opportunity to speak to this motion and support it wholeheartedly. Health, or, more importantly, the lack of health facilities around the country, has been a topical issue during my term in the House. I was elected on the health issue as a hospital action candidate, I am expected to deliver and I hope I will do that before my term is over.

Paddy McHugh (Galway East, Independent)
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Can Deputy Crawford hear that?

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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I am listening.

Paudge Connolly (Cavan-Monaghan, Independent)
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I have regularly raised the issue of Monaghan General Hospital in this Chamber and I have used every opportunity to engage with Ministers on it by calling for the Adjournment of the House under Standing Order 31 and using Adjournment debates. I hope the people who tabled this motion this evening get the same response that I got on Monaghan General Hospital in recent times.

Paddy McHugh (Galway East, Independent)
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Hear, hear. What about that Deputy Crawford?

Photo of Seymour CrawfordSeymour Crawford (Cavan-Monaghan, Fine Gael)
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We will wait for delivery.

Paudge Connolly (Cavan-Monaghan, Independent)
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That package will be delivered. I acknowledge this is a promise but there is not much point in me asking for a second promise. I have been involved in negotiations since May 2003 at senior political, administrative and professional level and I am convinced that the contents of this package will be delivered. That is why I was elected. The announcement of a 24 hour a day, seven days a week unit at Monaghan General Hospital is what the people of Monaghan want. They want a CAT scanner, services and junior doctors. That package will be delivered and I thank Deputy Martin for delivering it. Be it at the eleventh or any other hour, I am glad the commitment was made.

I will be here to see the package is delivered and I have nailed my colours to the mast in saying it will come. On my first day in Dáil Éireann my call was for the retention of an on-call accident and emergency service at Monaghan General Hospital and for the provision of a CAT scanner. I have a commitment on that and I expect it will stand. There are difficulties with timeframes but it is a challenge for me to ensure the package is delivered. If the CAT scanner is left out of a speech or an answer, it is my job to ask the questions and to remind the new Minister, whom I wish well, to deliver it. This will remove the vagueness.

The major concern of the people in Monaghan, Ennis or Nenagh is the accident and emergency service. The new Minister and the Government must find a way to deliver that service to the people. People have no problem with centres of excellence, they will travel for a hip operation or heart surgery, but they want a facility nearby in an emergency where they can be stabilised after a head injury or receive anti-thrombolic medication within the critical 20 minute period following a heart attack. If one then needs to go further so be it. The accident and emergency service is vital. In the national spatial strategy we talked about hub towns and gateways and a hospital is a key facility in each town. It makes it easier to attract industry and ensure it stays.

I agree with Deputy Neville's comments on mental health services. We must pump extra funding into that area. We talk about mental health services and suicide, wring our hands and leave it at that. Money is needed. We have a new way to deliver mental health services, they are more home-based and cost effective and I ask the Minister to take on board the appeals for extra funding.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
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The Minister of States' speeches were too slow and too little. The grand plan for radiotherapy services and cancer treatment services across the country will need at least another three years before anything happens. We have already been waiting for them for two years. The Minister of State, Deputy Brian Lenihan, focused on oncology, saying that investment in the national cancer strategy has amounted to €559 million since 1997. That works out at €70 million per year, less than 1% of the health budget, but the Government boasts about such a small amount of money. It might look like a lot when it is added up but we know from dealing with cancer patients there is a pathetic service that needs much greater investment before we see any improvements. The radiotherapy report is sitting in the Department of Health and Children gathering dust. The Government comes in here and talks about what will happen and what will be done but we will see another Government implement it at this rate.

Pressure on the hospital system, particularly in the eastern region, arises from demands on emergency departments and difficulties associated with patients who no longer require acute treatment but who are still dependent. My consultant used to say that to me when I was working in the Meath and Adelaide Hospitals in 1993. Why did the Government not deal with this issue? It has been in Government for seven years, with major health budgets. It knows the problem in accident and emergency departments is a result of the running down of primary care. As a result more people use the accident and emergency service because they cannot get a GP leading to long stay patients taking up beds. Nothing has been done to correct that.