John O'Donoghue (Kerry South, Ceann Comhairle)
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Anois, Ceisteanna na gCinnirí, Ceannaire an Fhreasúra, An Teachta Enda Kenny.

Enda Kenny (Mayo, Fine Gael)
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Tá feabhas ag teacht ar Ghaeilge an Cheann Chomhairle lá i ndiaidh lae. Tá sé ag déanamh go maith agus sílim go bhfuil sé ag cleachtadh a chuid ráiteas.

Mary Hanafin (Dún Laoghaire, Fianna Fail)
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Tá Gaeltacht ina dáilcheantair.

Enda Kenny (Mayo, Fine Gael)
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The third national hygiene audit of hospitals was published today and does not make encouraging reading. The results show that not one of our public hospitals has been found to have a "very good" standard of hygiene. Seven were rated as "good", 35 were "fair" and nine were "very poor" or "poor". The results show that the standard has deteriorated since the Health Service Executive published the second audit in June 2006. That audit rated 32 hospitals as "good", 19 as "fair" and only two as "poor" compared with nine today. This confirms what most people believe, that the standards of hygiene and hygiene management programmes in our public hospitals are not what they should be. People are scared that hospital acquired infections such as MRSA and those derived from other superbugs are a real threat to patient safety in hospitals and other health care settings. We are spending €15 billion on the health care system and every member of the public understands that it is a fundamental requirement that hospitals be clean.

I accept the inspections were unannounced and that in many cases hospitals might be clean on the day of the inspection. However, the issue is that many hospitals do not have a sufficiently robust hospital management hygiene programme. That is resource and skills related. In many cases, with respect, contract cleaners, who do their best, may not have the specialist training and skill to deal with hospitals where there is a risk of spreading MRSA and other superbugs. The difference between the days of matrons running hospitals and the hospital management system that exists now is that standards of hygiene in many hospitals now are lower and this is reflected in the findings of the third report today. Can the Taoiseach honestly say that the management system in our public hospitals is ready to put forward its public hospital hygiene management programme? Can we as citizens and politicians say the programme is ready, the standards are set, the resources are in place and we will see continued improvement in what is so fundamental? Everyone who enters a hospital should be aware of how important it is to be involved in the hygiene management programme. Is there a sufficiently robust programme in every hospital as a result of this third audit?

Bertie Ahern (Dublin Central, Fianna Fail)
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I wish to point out that this is the first national hygiene services quality review report from the Health Information and Quality Authority, HIQA, the new agency the Government promised. This report cannot be compared with the previous ones because it was carried out on a different basis. The report is part of an important new development in the Irish health service that will see standards set, monitored and reported on objectively.

The report gives the results of the review conducted in the 51 acute hospitals between March and September. While hospitals generally performed well in the areas of hygiene and in-service delivery, the results on governance were poor — that aspect was not included in previous reports. This contributed to disappointing overall results. While improvements have been made and are acknowledged in the report, no hospital received a very good rating. Seven were categorised as good, 35 as fair and nine as poor. The clear message of the report is that hospital managers and health boards must take hygiene and infection control seriously.

The method of assessment and the criteria used in the latest report are substantially different and, rightly, more onerous than those pertaining to the previous audits carried out by the Health Service Executive, HSE, and the results, therefore are not comparable. Previous audits concentrated only on service delivery.

The review also includes assessments of corporate management to ensure efforts at governing, identifying, managing and reducing infections are sustained. Hospitals should concentrate more on these matters because while hospitals generally perform well on hygiene, governance is poor. The audit shows that there are weaknesses in some hospitals relating to the priority placed on hospital hygiene — that is the governance issue. Today's report gives us an opportunity to impress upon the management of each hospital the improvements that must be made to make hospitals cleaner.

I agree with Deputy Kenny's comments on the superiority of the old system of matrons and religious orders and I worked under such a regime. They moved heaven and earth on the wards to ensure hygiene prevailed and my generation will remember the smell associated with hospital hygiene that is no longer evident today.

Enda Kenny (Mayo, Fine Gael)
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That was Jeye's fluid.

Bertie Ahern (Dublin Central, Fianna Fail)
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This will serve as notice to corporate management in hospitals to make hygiene a far higher priority in the coming months and years.

I welcome HIQA's emphasis on a whole-system approach to hygiene, which makes this the most comprehensive quality review of any kind in Ireland. The review is intended to provide a detailed assessment of performance across the entire range of areas that impact upon hygiene so individual hospitals can identify areas of strength and areas that need improvement.

The challenge laid down by this new report, the first of its kind, is for management, from senior management down through the system, to do far better. The report also aims to see contractors in hospitals abiding by far higher standards — they are, frankly, being paid enough and should abide by the standards set by HIQA.

The Health Information and Quality Authority is the organisation to drive standards and to fight the difficulties posed by hygiene problems, MRSA and other infections in the health system not only in this country but in other countries. This report has set the benchmark against which people will be judged and improvements are needed, particularly in the area of governance.

Enda Kenny (Mayo, Fine Gael)
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I wish to draw the Taoiseach's attention to what he said in his reply. The first two reports were carried out for the HSE by external contractors from the UK. This report was carried out by HIQA, which evolved from the Health Service Accreditation Board, using peer review group systems here so it is more robust. The Taoiseach suggests the first two reports cannot be compared to the latest one but the Department of Health and Children terms this audit as the third report. The Department of Health and Children and the HSE relied on standards set in the previous two reports, which were conducted for the HSE by external contractors. If the figures in the first two reports were inaccurately positive, the Department of Health and Children deems this as HIQA's report.

The Taoiseach has not said whether he is satisfied that every hospital has a real hygiene management programme. He mentioned that contractors are paid enough to do their jobs but does he not feel that to realise the high standards to which everyone is entitled, pay should be related to reform of the health service? This does not appear to be Government policy in other areas regarding performance and pay.

Problems like this will arise because hospitals here operate at 100% occupancy while international best practice suggests 85% is the correct level. This is a problem in many hospitals; for example, Beaumont Hospital where one in three patients with MRSA cannot be isolated due to a lack of beds. This is a cause of huge concern for people attending hospital for treatment. The infection control team in Beaumont Hospital says that due to overcrowding, staff shortages and poor compliance with hand hygiene, outbreaks of otherwise preventable infections have occurred. However, it is good to note that many hospitals provide the appropriate solution with which visitors can wash their hands.

The Organisation for Economic Co-operation and Development, OECD, notes that Ireland has 2.8 acute hospital beds per 1,000 people compared to the OECD average of 3.9. Does the Taoiseach accept that more hospital beds are needed to allow trained specialist cleaners deal with the high levels of bed occupancy?

Does the Taoiseach accept, despite the many promises of his Government and the absent Minister for Health and Children, this report is another indication of his failure to implement a management system which oversees a public hospital hygiene programme that will stand up to scrutiny? I am glad that the inspections were unannounced but an ongoing hospital hygiene programme is needed. Will inspections of private hospitals be carried out in the same manner?

Bertie Ahern (Dublin Central, Fianna Fail)
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There was no report before the previous two reports and the reason we wanted to tackle the hygiene problem in hospitals was that there were no benchmarks. There was no league table to help us examine the health service and enforce standards.

The point I made on my first intervention was that the method of assessment and criteria used in this report are substantially different from and more demanding than the previous audits carried out by the HSE. I support that, but my point is that they are not comparable and, therefore, neither are the results. Previous audits concentrated totally on service delivery. Issues of governance, management and the need to reduce infection must be considered. That is a better way of doing it. Nevertheless, there is huge room for improvement. The overriding message in this report is that most hospitals can and should do better. The criteria that now pertain under the national hygiene services quality review will be followed up into the future. That sets a new standard.

We have stated that we will provide, in the lifetime of this Government, additional staffing to deal with health care acquired infections, particularly MRSA. We are working to ensure the Health Information Quality Authority sets and enforces a clear standard for health and information and that the new system of licences will put a strong emphasis on infection control. HIQA will work to reduce significantly health care acquired infections in hospitals. We must take into account the need to guard against infection in the refurbishment of existing hospitals and the construction of new hospitals. The authority will establish a specific financial incentive that will reward hospitals that achieve excellence in hygiene standards, thus ensuring management concentrates on hygiene as a major issue. HIQA will continue to carry out regular hygiene audits without notice, at minimum annually, and will publish the results. It will also introduce measures to reduce the prescribing of antibiotics, which is part of the problem in terms of health care acquired infections.

It should be noted that, according to the service delivery section of the report, most hospitals achieved either extensive or exceptional compliance with the standards. The majority of hospitals have a multidisciplinary team in place to oversee hygiene practices, but most of these teams were newly established and roles and responsibilities were not clearly defined. We have some way to go to embed that culture and practice of measuring, monitoring and improving. Where risks were identified, these were notified to the individual hospitals and are receiving attention. A quality improvement plan must now be drawn up by all hospitals individually and collectively by the HSE. This will continue to be monitored by HIQA as part of its ongoing quality assurance efforts. The establishment of HIQA means we are now seeing a regulatory management system being put in place. This will force hospitals into a position where they must take account of these issues.

The issue raised by Beaumont Hospital and other hospitals regarding hygiene, particularly hand hygiene in wards, is important. One of the reasons for limited visiting hours in hospitals in previous times was to control hygiene matters. This is no longer the case and people can visit for extensive hours during the day. Hand hygiene issues are difficult to enforce when that happens, as we have been told by hospital management. It is something that must be enforced, however, because, according to this and other reports, it is one of the most important issues in maintaining hygiene standards in hospital wards.

Eamon Gilmore (Dún Laoghaire, Labour)
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In recent weeks there has been much public debate about the quality and adequacy of cancer care services. It is fair to say that public confidence in these services is low. The solution proposed by almost everybody is the notion of centres of excellence. It is the strategy being put forward by the Government and the HSE, and all political parties as well as most medical professionals have subscribed to the idea.

However, I am not clear as to what the Government means by "centres of excellence". How many such centres will there be? Professor O'Higgins spoke about 12 in his first report but the HSE now seems to have eight in mind. The announcement by the executive in September identified eight "designated cancer care centres". Will these be the eight centres of excellence? Has the Government approved those eight centres? What is the position regarding the north west? The Minister of State, Deputy Jimmy Devins, seemed to indicate that Sligo will be added to the list at some point. Will there be nine centres of excellence rather than eight?

In regard to the timescale, the HSE has stated that all cancer care services will be transferred to these eight centres by the end of 2009. Where does this leave cancer care services that are being provided in private facilities? Is it intended that they will continue separately or will they also be transferred to the centres of excellence? How will we know that a centre of excellence has been deemed to be such? Will there be some statement to the effect that there is now a centre of cancer care excellence in Hospital X? Is there some formal process by which it will be communicated to the public that these centres of excellence are in operation?

What is the budget? The chairman of the working group overseeing the plan, Mr. O'Brien, says that no costings or budget have yet been worked out for its implementation. Professor Keane, the interim director of the cancer care programme, says transitional funding will be needed in the next two years to bring the centres of excellence into being. However, it seems no budget has been identified. How will they be funded?

Bertie Ahern (Dublin Central, Fianna Fail)
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I will try to answer as many of the Deputy's questions as possible. In June, the Minister for Health and Children approved the national quality assurance standards for symptomatic breast disease services under the Health Act. The aim of the standards is to ensure that every woman who develops breast cancer has an equal opportunity to be treated in a centre that is capable of delivering the best possible outcome. In September, arising from the designation of cancer centres and to comply with those standards, the HSE directed 13 hospitals with low case volumes — fewer than 20 procedures — to cease breast cancer services immediately, to be followed by a further staged reduction in the number of hospitals providing cancer services from 22 to eight.

Several of these hospitals have in practice already discontinued or are in the process of discontinuing symptomatic breast services. The National Hospitals Office has already planned the redirection of this symptomatic case load. Additional groups of hospitals will be similarly directed, and this process will go on, as the Deputy observed, for the next year or two. That will be done in line with the further development of quality assured capacity in the eight designated centres. The HSE plans to have completed 60% of that transition from the current 22 to eight designated breast centres by the end of next year, and 90% by the end of the following year.

Discussions between the HSE and the four managed cancer control networks will focus on identifying the capacity issues for the eight designated centres so that a detailed transitional plan can be put in place to facilitate a progressive and carefully managed transfer of services in the next two years. That work has not yet been undertaken but it is the next issue. The HSE announced last week that within weeks, breast care services will be transferred in some of these hospitals and this will happen progressively.

In regard to cost, the development and improvement of diagnostic and treatment services for breast cancer patients is a major priority development for cancer care services. The national breast screening programme, combined with the quality-assured symptomatic breast disease services I have mentioned, is a key element of the cancer control programme. Resources totalling €60 million have been put into this already.

The next stage begins when Professor Keane takes up his role on Monday. When he examines the work over the next six weeks or so, he is expected to designate the national clinical leaders for radiation, surgery and medical oncology. Arrangements are in hand to enable him to take control of all cancer services between now and the Christmas period. From 1 January he will take charge of all existing cancer services and related funding and staffing.

He will start with the work done to date and take over everything as it progresses into 2008. As I understand it, he intends to designate the locations for a range of cancer specialties by early January, so he must make that call at that time when he is fully briefed on the position and the ongoing work. As soon as he arrives, he will engage in detailed planning to facilitate these designations and the orderly phased transfer of services between the locations. He plans to have completed 50% of that transition of services to cancer centres next year and 90% of the transition by the following year.

Eamon Gilmore (Dún Laoghaire, Labour)
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The Taoiseach has described how we will have fewer centres providing cancer services. He has not said how these remaining eight or nine centres will be better. That is what the public wants to know about. For the past week or more we have been speaking about centres of excellence, and the expectation is that these will be better facilities than we have currently. How will they be better?

For example, last week it was announced that the service in Mullingar was to be discontinued and patients would be transferred to the Mater Hospital. What has happened in the Mater that will lead to a better service? Has it received extra equipment as a result of this? Will there be extra staff or is it just a case of the hospital having extra patients? How will the service be better in hospitals that will simply have extra patients?

The Taoiseach noted Professor Keane is due to start on 1 January. What budget will he have to provide the new and better services people are being led to believe will be provided? The difficulty is that there is now a general concern about the quality and availability of cancer care services, and there is a programme to reduce the number of centres where such services are being provided. This is being led on the basis that there will be centres of excellence but how will these centres be better?

Is this just a rationalisation of the number of centres and a reduction in the number of centres without the service in the larger centres necessarily being better?

Bertie Ahern (Dublin Central, Fianna Fail)
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Professor Keane will take over the entire budget. Every year we have allocated more resources, both in capital and on the current side. Much of this relates to staff. Last week I may have said 120 consultants were taken on, but 111 consultants have been taken on. The problem is these consultants are spread about in the system. It is important to emphasise that the decision to reorganise the service is about achieving optimum outcomes. It is not in itself a value judgment on work being done in the existing centres, some of which have a relatively large caseload at present but will not be part of the future centres.

The bottom line is that to achieve the very best outcomes, we must concentrate all cancer work in just the eight centres. That necessarily means that there must be reorganisation and resources must be applied. The discussion on management, designation and operational procedures must take place before these centres move. The relevant individuals will be involved with that.

We have progressively been reducing the number of centres, and we have already moved the number to 13. The object is to quickly designate the clinical national leaders for radiation, surgical and medical oncology. This is to ensure that in each centre there will be people who will be responsible, who will have a primary role along with Professor Keane. They will be responsible for radiation, surgical and medical oncology services.

We have been told there are multidisciplinary teams in some centres at present but this will bring such teams to work together. They will have the resources and the throughput. The argument is that the more patients being dealt with in centres, the more expertise is built up and we get quality staff. Without denigrating staff at any centres, this system attracts people with expertise and competence who can carry caseloads. They clearly need other facilities but that issue is being dealt with by the management of the various hospitals and the HSE.