Dáil debates

Wednesday, 14 October 2009

Medical Practitioners (Professional Indemnity)(Amendment) Bill 2009: Second Stage

 

The following motion was moved by Deputy James Reilly on Tuesday, 13 October 2009:

That the Bill be now read a Second Time.

Debate resumed on amendment No. 1:

To delete all words after "That" and substitute the following:

"Dáil Éireann:

1. Supporting the important role of the State Claims Agency in its administration of the clinical indemnity scheme, whereby the State has assumed responsibility for the indemnification and management of clinical negligence claims arising from the diagnosis, treatment and care of patients;

2. Welcoming the recommendations contained in the report of the Commission on Patient Safety and Quality Assurance to ensure that safety and quality of care for patients is paramount within the health care system;

3. Acknowledging the establishment of an implementation steering group this year to drive implementation of the commission's recommendations;

4. Noting with satisfaction the passing by the Oireachtas of the Medical Practitioners Act 2007, the main objective of which is to provide for a modern, efficient, transparent and accountable system for the regulation of the medical profession and to satisfy the public and the profession that all medical practitioners are appropriately qualified and competent to practise in a safe manner on an ongoing basis;

5. Welcoming the ongoing commencement of provisions of the Medical Practitioners Act regarding registration, fitness to practise procedures and for supervising medical education and training at basic and specialist level;

6. Endorsing the work of the Medical Council in preparing for the commencement of provisions in relation to the maintenance of professional competence of all medical practitioners;

resolves that the Medical Practitioners (Professional Indemnity) (Amendment) Bill 2009 be deemed to be Read a Second Time, on 31 January 2010.".

-(Deputy Mary Harney).

7:00 am

Photo of Liz McManusLiz McManus (Wicklow, Labour)
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I congratulate the Ceann Comhairle on his appointment. I am sure he will do a great job.

I welcome this Bill and compliment Deputy James Reilly on his initiative. The Minister's response is also welcome. Her acceptance in principle of the Bill makes sense. Many people would be surprised to learn that there is no legal requirement for a practising medical practitioner to have insurance.

This statutory measure will protect patients and doctors. I hope it will also open up the route towards the regulation of private clinics, which currently are not regulated. The growth in cosmetic surgery was a feature of the Celtic tiger years and private clinics have provided services with doctors flying in from Britain, carrying out procedures and then flying out again. Whether the private clinic delivers cosmetic surgery or IVF there is an obvious need to set standards and ensure their robust enforcement.

It is not, however, the private clinic that is causing controversy at the moment. It is the public health service and how it is managed. The public is outraged at the latest news of the lavish €70,000 bonus sanctioned for the CEO of the Health Service Executive. The Minister for Health and Children has simply washed her hands of the issue but it will not go away. Let us look at the facts. Since he took up the post of CEO, Professors Drumm has received €180,000 in bonuses. This year alone his total salary package is worth more than €500,000, a staggering figure. While the HSE sanctions this reward to its CEO, it is setting about making cutbacks of €1.2 billion in the coming year.

The argument being put is that this bonus relates to 2007 and therefore is a contractual obligation, but the question still has to be asked: for what exactly is the bonus being given? We are told by the chairman of the HSE board that there is a process of evaluation in determining the level of bonus. It would be helpful to know the criteria used in that process. Are they related to patient outcomes, improved patient care, higher standards, quality assurance or speed of access? If they are, and they should be, let us look at the record. Susie Long died in 2007. She was a young woman with cancer and she died because the HSE did not provide her with the care she needed in time. Women were misdiagnosed at Portlaoise hospital in 2007. Again, the HSE failed to protect and care for very sick women. In the year in question, 2007, the HSE was not even capable of keeping within its budget. A supplementary estimate of €244 million was drawn up because of a failure of management that drew criticism from the then Minister for Finance, Deputy Brian Cowen. He said he was not satisfied that the HSE was giving sufficient priority to tackling the causes of its budgetary difficulties. For the failure to manage the accounts in 2007 a reward of €70,000 is now being given to the CEO responsible. Is it any wonder the public is offended? It appears to be all about responsibility. The proposals in this Bill will ensure doctors cannot walk away from responsibility when something goes wrong. All of us understand that doctors are not infallible. Allowance must be made for the unforeseen, the unplanned or the human error, quite apart from the negligent.

Patients deserve protection from medical negligence but also from political incompetence. When the Minister for Health and Children, Deputy Harney, proceeded in her bull-headed fashion, to establish the HSE without giving it the time needed to ensure proper management structures, I warned her in this House that she would create a monster bureaucracy. The rush to get the HSE up and running by a politically-driven deadline of 1 January 2005 gave us a cobbled together structure with weak foundations constructed by the Minister, from which she then walked away. It has been tottering ever since. Never in my wildest dreams did I imagine just how bad the situation could get.

Currently, three years after the Minister declared a state of national emergency, the accident and emergency crisis continues. According to INO figures there are almost 300 patients on trolleys around the country. Perhaps those patients should have recourse to making an insurance claim for the distress caused. There were 9,000 cancelled operations in the first half of this year, a 27% increase on last year. Perhaps those patients should be able to claim. This year there has been a 70% increase in delayed discharges. What about them? It is the powerlessness of patients that is so worrying and to provide patient power would require a fundamental transformation of the health service. However, that is a debate for another day.

This Bill is a simple measure to amend and extend the Medical Practitioners Act 2007. It should not be necessary for an Opposition Deputy to introduce this legislation yet it was the Fine Gael party that published the legislation. That is to Fine Gael's credit but it also raises questions about the role of the Department of Health and Children. The Minister, Deputy Harney, specifically transferred responsibility for financial management by making the HSE the Accounting Officer. Since then, the role of the Department has been always uncertain. It was to deal with policy while the HSE was to deal with implementation. It has not worked out quite like that. Surely a Department with such a reduced area of responsibility should be capable of delivering legislation to meet current needs. Insurance cover for medical practitioners is one such area that seems very obvious.

The Bill provides that the Medical Council will have the power to set the appropriate type and level of insurance to be held by different classes of practitioners. Today, the Medical Council has no such authority and, while it does require that doctors must have adequate cover, there is no system to check that doctors have cover and that it is adequate.

The Medical Practitioners (Professional Indemnity) (Amendment) Bill 2009 has the support of the Labour Party, as made clear by the spokesperson, Deputy Jan O'Sullivan. I have no doubt it will bring reassurance to both patients and doctors. We must ensure that, with mobility developing across the EU, standards for medical care applied in this country are on a par with standards in other countries. We do not have that, whether in respect of indemnity, the provision of hospital beds or the provision of services at primary care level. We could debate many issues relating to health care tonight. This is a modest Bill that deals with a specific area of medical indemnity to ensure doctors have the insurance cover to protect their patients. I welcome this measure and look forward to the Minister pursuing this Bill to bring it into law.

Photo of John CreganJohn Cregan (Limerick West, Fianna Fail)
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I propose to share time with Deputies Barry Andrews, Dooley, Conlon and Byrne.

I am pleased to speak on this legislation, which is important from the point of view of general practitioners and the public. I commend Deputy Reilly on introducing this Bill. On occasion we criticise the Opposition during Private Members' time but it is only fair to give credit where it is due.

Photo of Denis NaughtenDenis Naughten (Roscommon-South Leitrim, Fine Gael)
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Deputy Cregan never does that.

Photo of John CreganJohn Cregan (Limerick West, Fianna Fail)
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I do not, as Deputy Naughten knows. Due to his profession, Deputy Reilly is au fait with what is required.

The main provisions of the Bill are that medical indemnity cover is to be compulsory for all medical practitioners specified by the Medical Council as requiring such cover; the Medical Council will make the rules specifying the categories of practitioners required to hold medical indemnity cover, the form and level of such indemnity cover including the minimum sum of medical indemnity cover for each class of practitioner, and the bodies recognised by the council for the purpose of providing such cover; written evidence of appropriate indemnity cover is to be a requirement for the Medical Council to issue a registration certificate, which is the main thrust of the Bill; and it is to be an offence to practice without medical indemnity cover or to falsely represent having medical indemnity cover with penalties for summary convictions or convictions on indictment. We have had cases where members of the profession from other countries have practised here and they were not always insured to do so. This is highly dangerous.

In recent years we have moved to a far more efficient system for providing for indemnity of professionals in our public health services. Under the clinical indemnity scheme, the State has assumed responsibility for the indemnification and management of clinical negligence claims arising from the diagnosis, treatment and care of patients. The clinical indemnity scheme was established because commercial insurers either withdrew from offering insurance cover to obstetricians, gynaecologists and those in obstetric units who were not in a position to provide cover at affordable rates. This was due to the escalation in the size of court awards and associated costs in case of birth related cerebral injuries.

The scheme was established in July 2002 and is managed by the State Claims Agency. One of the main advantages of the scheme is that it has rationalised the myriad of medical indemnity arrangements which had applied up to that point. Under the clinical indemnity scheme each hospital or HSE area assumes legal liability for its employees' alleged clinical negligence.

The Commission on Patient Safety and Quality Assurance was established in January 2007 to develop clear and practical recommendations to ensure the safety and quality of care for patients is paramount throughout the entire health care system. Its report, Building a Culture of Patient Safety, was published in 2008 and approved by the Government in January. The report contains 134 recommendations including proposals for legislation; licensing of all public and private health care providers; developing standards on patient safety and quality that will apply across the entire service; and the introduction of systems of credentialing and privileging for health care professionals.

Measures taken by the Minister and the Department to restore public confidence in the health service include the establishment and continued strengthening of HIQA and the Office of the Chief Inspector of Social Services, the assignment of executive responsibility for all matters relating to patient safety to the Office of the Chief Medical Officer and the commencement on 1 March of the provisions of the Health Act 2007 on protected disclosures.

I welcome the Government's position on the Bill. It recognises that some of the issues in the draft Bill may be worthy of further consideration and I believe they are. However, a number of matters require further research and reflection and these include, but are not limited to, the competence of the Medical Council to determine what is an appropriate minimum sum of indemnity coverage for each class of practitioner and EU issues regarding freedom of mobility. These will need to be considered and will require further investigation and legal advice. The Minister has given a commitment to put in place a review group and to report back by January. I welcome that commitment. The Minister is taking the right approach and I commend Deputy Reilly on bringing the Bill to the House.

Photo of Barry AndrewsBarry Andrews (Dún Laoghaire, Fianna Fail)
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I welcome the opportunity to participate in the discussion on the Bill tabled by Deputy Reilly which deals with the need to ensure that all doctors are properly indemnified and have appropriate medical negligence cover so that patients can be compensated in the event of unsatisfactory treatment.

This is an area in which I have some interest having been a barrister, a profession which has professional indemnity insurance and where compensation is provided for negligence. In my case, amazingly, it did not have to be called upon at any time but it provides a certain assurance to clients who use these professional services and develops the profession in many ways. The type of cases that are thrown up tends to inform professional standards and professional development. It serves the purposes of compensating those who have been wronged and brings along the profession, and is something that would be appropriate to other professions.

My area of responsibility as Minister of State with responsibility for children involves me with the work of social workers. The work they do is extremely complex. They deal with some of the most at risk and vulnerable children and children who have been failed by many other professional services, whether it be schools, family support or agencies of the Department of Social and Family Affairs. Some of them come to social workers damaged and very difficult to reach. For that reason the work that social workers do is extremely complex, yet it attracts a deal of criticism from people who should know better but who are probably not very well informed in these areas.

Nevertheless, like every profession there is bad practice but unlike other professions there is not sufficient examination of that bad practice. In medical negligence that practice is examined in forensic detail in court hearings and allows for learning within the profession. Might it not be appropriate to have more examination of those types of cases in social work? It strikes me that the reason this has never happened is that the clients and their families who avail of social work services are generally not well off and probably not aware of their rights or the type of compensation to which they normally might be entitled in the event of professional negligence. Negligence is not widespread in social work, or no more so than in any other profession, but it would benefit from the same type of forensic analysis that takes place in the medical negligence cases with which we are all familiar.

It is very clear from the debate to date that all Deputies share the view that we must do everything possible to avoid negligent care in the first instance. Patients have a right to a high standard of care and to patient safety, which is a priority for the Government. I will concentrate on measures which the Government has initiated on patient safety and quality assurance. There have been several developments in patient safety in recent years which reflect the Government's determination to deliver in this area. Two of the most significant are the establishment of HIQA in 2007 and the work of the Commission on Patient Safety and Quality Assurance which was also established in 2007.

HIQA has statutory responsibility for setting standards on safety and quality of services throughout the entire public health service with the exception of mental health services, which are the responsibility of the Mental Health Commission. HIQA also has responsibility for undertaking investigations as to the safety, quality and standards of services where it believes there is a serious risk to the health or welfare of a person receiving services. I want to take this opportunity to thank HIQA for the enormous contribution it has made to the development of child protection services in the State, particularly in the children's detention schools and in the area of youth justice. The standards it has set and the work it has done with the HSE is phenomenal and it has made a huge contribution to the implementation plan that followed the Ryan report.

HIQA has developed standards on care in symptomatic breast disease, hygiene, infection prevention and control and residential care for older people. It completed the hygiene service quality review of acute hospitals in 2007 and 2008 and it has also undertaken three major investigations, the result of which has been clear significant recommendations to improve the safety and quality of our health service. These are at an advanced stage of implementation.

There is no doubt the patient safety and quality environment which our public service delivers has seen a marked improvement in the past two years in particular. It is interesting to note that two weeks ago the European Health Consumer Index saw the Irish health service rising a further two places from last year and a total of almost 15 places over the past four years to 13th position among European health services. This gives us ample room for improvement but also cause to remark that the HSE has made a contribution to improvement in those standards. It is important that we challenge the often undisputed received wisdom that the HSE has made no difference since its establishment. I fundamentally reject that argument. The Health Service Executive, HSE, is the one development acknowledged by the European Consumer Health Index, as having contributed to the improvement in Ireland's position in the past four years. Due acknowledgement should be afforded to the HSE because it is an issue of morale for the thousands work in it who are routinely and systematically vilified in the media and this House.

The work of the Commission on Patient Safety and Quality Assurance is also significant. It was established in 2007 to develop clear and practical recommendations to ensure that the safety and quality of care for patients is paramount across the health care system. The commission's report, Building a Culture of Patient Safety, was approved by the Government last January and is being implemented. The report contained 134 wide-ranging recommendations, including proposals for legislation and licensing of all public and private health care providers, the development of standards on patient safety and quality that will apply across the service, a comprehensive national programme of clinical audit, mandatory reporting of adverse events and the introduction of a system of credentialing and privileging of health care professionals.

On the licensing of all public and private health care providers, the commission recommended that it should begin with acute hospitals and other health facilities based on an analysis of potential risk to patient safety. It specifically stated the first phase of licensing should include facilities where medical treatment is given under anaesthesia or sedation and obstetric services, a welcome recommendation. Following the introduction of this framework in these areas, the commission's view was that the licensing system should be subsequently rolled out to other facilities, such as primary, community and continuing care, following comprehensive consultation with all the relevant stakeholders.

We cannot underestimate the complexities involved in this major task. Preparatory work has already commenced in the Department and it is intended to bring detailed proposals to the Government next year. In the meantime, in advance of the introduction of legislation for licensing and in line with the commission's recommendations, the Health Information and Quality Authority, HIQA, is working towards the development of national standards on safety and quality to be applied to hospitals and all future licensed health care facilities with priority in areas where a high and immediate risk to the health and welfare of patients is identified.

HIQA has developed a model for quality and safety based on research and analysis of international and national literature on safety, quality and standard development. The process of wide consultation with stakeholders, including patient, service-users and patient advocates, clinicians, and service providers both in public and private health care, has commenced.

Credentialing is a process whereby health care organisations will be enabled to review the qualifications and track record of doctors and other professionals. Privileging is used by health care providers to define the scope of practice of health care practitioners. It is an important area with the development of private medicine. The intention behind the commission's proposals on these is to develop systems which will enable employers and regulatory bodies to share and verify information regarding the qualifications, competencies and disciplinary records of regulated health professionals operating in the public and private sector. These systems will enable employers to make informed decisions as to the appropriate range of treatments and services to be provided by each regulated professional, thereby enhancing patient safety and promoting the quality of care.

While the full implementation of these proposals will take some time, it is intended to prioritise work and information already in the public arena which could be more efficiently organised and shared without the need for significant changes. It is fully intended these systems will work across borders both within the EU and internationally.

I welcome the agreement by the Minister for Health and Children, Deputy Mary Harney, particularly in light of the complexities and sensitivities of medical indemnity insurance, to give the issues raised in the Bill detailed reflection from a legal, administrative and practical perspective. In particular, the issue of the further consideration of how best to provide for mandatory professional indemnity cover for medical practitioners will receive careful attention. Many issues arise which must be carefully thought out to ensure solutions are practical, proportionate and workable. Most important, the solution to this complex issue must have at its heart the protection of the public and the promotion of public safety.

Photo of Margaret ConlonMargaret Conlon (Cavan-Monaghan, Fianna Fail)
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I thank Deputy Reilly for introducing this necessary Bill. I respect the Minister for Health and Children's leadership in not taking a partisan stance on this issue. I also welcome the establishment of a group to examine the issues raised, with a view to returning to the matter by the end of January 2010.

The Minister for Health and Children proposes the Bill be re-examined fully. Its stated purpose is "to regulate doctors so that they must have appropriate insurance in order to practice medicine in Ireland". This needs to be done to update legislation so it moves and adapts with the changing nature of medical law. The public needs to have confidence in the medical services. The relationship between a patient and their general practitioner is personal and intimate. It is important patients treated in an improper manner are fully compensated.

The State, under the clinical indemnity scheme, takes responsibility for the indemnification and management of clinical negligence claims arising from the diagnosis, treatment and care of patients. The scheme was established because commercial insurers were not interested in continuing with many medical practitioners or were not in a position to provide cover at affordable rates due to ever growing court costs and high awards.

The State Claims Agency, established in July 2002, manages the clinical indemnity scheme. It was imperative that it would rationalise the many and varied indemnity arrangements which applied up until then. The scheme allows legal liability for various health centre's employees' alleged clinical negligence.

While this Bill is needed, we need to analyse further its implications from legal, administrative and other angles. As the indemnity scheme is not an insurance-based scheme, it would, therefore, fall outside the current drafting of this initial Bill. I agree with the Minister's desire to re-examine this Bill in its entirety so as to ensure further add-on amendments are not needed to cover provisions that may have been missed.

In January 2007, the Commission on Patient Safety and Quality Assurance was established to develop clear and practical recommendations to ensure that safety and quality of care for patients existed across the health care system. The commission's report, Building a Culture of Patient Safety, was published in August 2008 and approved by the Government in January 2009. It contained 134 wide-ranging recommendations. The implementation steering group, chaired by the Department's chief medical officer, was established in June this year. The group's initial report is due presently and I look forward to its publication.

HIQA is already well advanced on the development of national standards of patient care. We need the highest levels of quality and safety across all health care sectors. Patients and their families demand and deserve nothing less. HIQA has developed a model for quality and safety based on research and analysis of international and national literature on safety, quality and standard development. There has been wide consultation with stakeholders which is to be welcomed.

I commend the Minister for Health and Children and her Department as she aims to restore the confidence of the public in the health services. This is being achieved through the establishment and continued strengthening of HIQA and the Office of the Chief Inspector of Social Services. The significant developments in patient safety including quality and risk, complaints management, incident reporting and learning in the HSE, particularly in the past two years, are also acknowledged as is similar work in the regulatory bodies.

It is important we continue to create a culture of openness in the health system. A patient's dignity must always be respected. Many are often vulnerable who must believe they are protected from malpractice. Members on this side of the House recognise several issues raised in the draft Bill need further analysis. This will allow the space, time and expertise to deliver more fully fledged legislation. I acknowledge Deputy Reilly's efforts in introducing this Bill.

Photo of Timmy DooleyTimmy Dooley (Clare, Fianna Fail)
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I welcome the opportunity to contribute to this significant Bill and to recognise the considerable work that Deputy Reilly has done in putting it together. It will no doubt lead to legislation. Like my colleagues I am happy to recognise his input, professionalism and experience. He is well positioned to do this type of work. It shows that while we often cross swords in this House we have the capacity to share the wisdom of all in an effort to provide a better outcome for our citizens. I hope that this will be respected on another day.

It is vitally important that the appropriate mechanism is put in place to give security to those who work on behalf of the citizens and allow them to do their job without fearing the threat of negligence or of a risk that might evolve later. We need to change the method of communication between patient and doctor, something on which I am not qualified to speak except as a rare patient. The patient's belief that the doctor is infallible and there is no risk creates a barrier. The patient sees a visit to the doctor as a mechanical situation like bringing one's car to the garage where a part is taken out and a new one slotted in and everything is solved.

With advances in medical science the expectation of the medical practitioner becomes greater. We must accept that there are limitations to medical practice and that there is a risk inherent in almost all visits to hospitals or when one undergoes an operation or any other clinical procedure. That needs to be communicated and the patient needs to be more cognisant of it. We must recognise, as a consultant once said to me, that medicine is more an art than a science, and that we cannot always expect a 100% successful outcome. There is work to be done from the layman's perspective which hopefully would help to bring about a culture of more openness and transparency. Clinical professionals have not been good at that.

Several celebrated cases from my constituency have been discussed in this House particularly two cases of misdiagnosis in Ennis General Hospital, of young Edel Kelly and Ann Moriarty. I do not mention them to cause any distress to the families concerned but to highlight the point that there should have been more openness and transparency and communication with the patient rather than a desire by some of the professionals at all levels to conceal, perhaps because of the potential for medical negligence claims, fear that not having done what they should have done would result in a negative peer review, or not wanting to admit blame. One doctor pursued a woman who was at an advanced stage of her illness to plant in her mind and the minds of her family the belief that everything that could have been done was done. That kind of culture has to change because we must all accept that mistakes can be made and ensure that when they happen they are dealt with and addressed in a professional and upfront way.

The Health Information Quality Authority, HIQA, has a role in developing standards. The greatest work remains to change a culture of secrecy based on the notion that the professionals are in some way infallible which they cannot be and perhaps never wanted to be. We need to move that thinking along. If this Bill and the final legislation achieve anything to change the communication strategy and to develop a culture of openness and transparency and the acceptance of reality it will have gone a long way to resolving the issue from the points of view of the patient and his or her family.

I look forward to the passage of this Bill in some shape or form.

Photo of Thomas ByrneThomas Byrne (Meath East, Fianna Fail)
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Tá áthas orm teacht isteach anseo anocht chun labhairt ar son Bille an Fhreasúra seo; caithifimid a admháil gurb iad a thóg é chun an Tí.

I am somewhat surprised that professional indemnity insurance is not mandatory. One assumes when one goes to a doctor that he or she has professional indemnity cover. When the Bill goes to Committee Stage I would like the committee to consider the ups and downs and pros and cons of the solicitors' professional indemnity system because it seems to be causing some difficulties. I believe that some solicitors are calling for the removal of the compulsion to carry insurance. I suppose this is for reasons of cost and because of the way insurance has gone and voluntary schemes have operated. That is not a runner and will not happen. It is essential that every professional is appropriately insured.

While scandals and crises arise in hospitals caused by one doctor or because the system has caused wrongdoing, such as the examples Deputy Dooley cited and some in my constituency, it is important to remember that mistakes will happen to the best doctors and professionals. That is why insurance exists. I have noticed an unjustifiable level of outrage in certain isolated cases of negligence. We and the public must accept that professionals will never get absolutely everything right and mistakes will be made. That is why they have insurance and I am glad that this Bill is being put forward to force doctors to carry insurance.

It is an important aspect of practice to give people confidence that if anything goes wrong one is insured. In my experience as a solicitor it was very important that one posted one's insurance certificate on the wall in the practice, outlining the level of insurance available, to give clients confidence. If one's insurance was not high enough one could tell one's clients that one could not do a transaction. Maybe some of the problems being discussed in other professions would not have arisen if the terms and conditions of insurance had been adhered to and clients been made aware of it.

I am slightly concerned that the Bill leaves a lot to the Medical Council although we do that anyway. It is crucial that the council always has the interest of the patients and the doctors at heart. This is in a doctor's interest too. There has been controversy about doctors who fly in to carry out certain procedures, particularly plastic surgery. More comprehensive regulation may be required.

This is a welcome Bill. It is very short and sensible and I am sure the Select Committee on Health and Children will debate it quickly and it will be made law. For most doctors it will presumably make no difference whatsoever but it is necessary to ensure that 100% of the public can have confidence in doctors.

It is a good that the Government is accepting the Bill because there has been some legitimate criticism of the Government's failure to accept certain Bills on which it had agreed. There is at the same time a duty on the Opposition not to misrepresent Government legislation as happened recently, particularly with the NAMA Bill and there was another example of that today. It works both ways and I am glad to see the Government accepting this Bill.

Photo of Denis NaughtenDenis Naughten (Roscommon-South Leitrim, Fine Gael)
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I wish to share time with Deputies Connaughton and Durkan.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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Is that agreed? Agreed.

Photo of Denis NaughtenDenis Naughten (Roscommon-South Leitrim, Fine Gael)
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I congratulate my colleague, Deputy Reilly, for bringing forward this Bill and having the Government accept it. It is a great honour to have one's Private Member's Bill accepted in the House. I hope that Deputy Reilly is more successful than I have been when a Bill was accepted on Second Stage but the Government blocked it on Committee Stage. I hope this Bill will go through Committee Stage and be enacted into law. A period of reflection is being considered, as proposed by the Minister for Health and Children, but I hope this will not delay the passage of very valuable legislation.

I wanted to speak on the Bill because of a comment I heard on the radio last Sunday week. In a news report, the Government indicated it would give unlimited indemnity to the manufacturers of the swine flu vaccine to ensure the companies involved would not be held liable for any possible adverse effects arising from the administration of the vaccine. What stuck in my craw about that media report was the comment attributed to the State Claims Agency, which stated the move for indemnity was essential to ensure it can pay out compensation to anyone who deserves it and to protect the taxpayer from fraudulent compensation claims. The reason I was so annoyed by that comment is that the State Claims Agency, along with various agents of Government, including the HSE, the Medicines Board and others, has been sitting on a committee since 2007, looking into the provision of a no-fault compensation scheme in respect of the administration of State-run vaccines over the past 30 to 40 years. This committee sat at the end of a very long process initiated five years previously by the then Minister for Health and Children, Deputy Micheál Martin, because Ireland was the only country in Europe that did not have a compensation scheme in place for people damaged by vaccines administered on behalf of the State. We are seven years further down the road since that Minister promised to look into this issue. I became involved because I know a number of the families around the country who have profoundly brain-damaged children. They firmly believe their children were damaged as a result of the State-administered vaccination programme in the 1960s and early 1970s.

I have debated this matter at length in this House. The State has admitted that in at least some of those cases, particularly with reference to 16, it offered a £10,000 ex gratia payment to the children involved in 1982 and 1984. That sum was supposed to deal with the long-term needs of those children. It is vitally important that the State should admit, for the first time, that children have been damaged as a result of the administration of a vaccine. The reason the State Claims Agency is involved in the provision of liability indemnity in respect of the current vaccination programme is that there is a risk. It may be a very small risk but it exists nonetheless and that fact has never been acknowledged in this State. It is the only state in Europe that has never acknowledged it.

One speaker after another has said, rightly, that we need honest and frank admission by medical professionals with regard to mistakes they make. In many cases such issues would not have ended up in the courts costing the State astronomical sums of money if there had been a basic admission in this regard at the start. That has never happened on the part of the State concerning the issue of children who were damaged by the State-run vaccination programmes.

The committee in question took oral submissions on 19 November 2007 and I gave oral evidence at that stage. The one thing I asked for was a quick decision on the matter. The parents wanted that because this has been going on for 30 years. I was given an indication by the group that it would make a quick decision and would make recommendations to the Minister on the matter. However, in December 2008 the Minister for Health and Children was still waiting for that report. She said she would have it very shortly and received it earlier this year. She indicated it was her intention to publish the report when she had deliberated on it. She informed the House of that on 19 May, yet by 16 September she was still considering the report and had made no decision. She said she would make a decision on it shortly.

It is frustrating. A week beforehand, in the Oireachtas Joint Committee on Health and Children, of which Deputy Reilly is a member, officials within the HSE and the Department said they were to introduce a compensation scheme for children who had received a toxic batch of whooping cough vaccine 40 years ago. That was the first acknowledgement from anybody on the State side with regard to that issue. It is greatly frustrating that there has been a cloak and dagger approach to the admission of a wrong that happened to these children over a long period. The frustrating thing for many people on the receiving end of problems with the medical profession is that there is no admission and nobody is honest and up-front in stating that a mistake was made and they are very sorry about it. The families whose children were damaged by the State vaccination programmes were told consistently and repeatedly by medical professionals up and down the country that the matter was all in their imagination, the child had been born with a profound disability and the vaccine had absolutely nothing to do with it. The administering general practitioners had kept grossly inadequate records and, as a result, those parents were not able to go down the road of taking a case against the manufacturers of the vaccine. The only exception was the case of Kenneth Best whose mother succeeded in gaining compensation.

Even at this late stage I urge the Minister for Health and Children to publish the report and publicly acknowledge that it is possible and, in all probability, likely that some of these children were damaged by the administration of the vaccine, that the State was grossly negligent in not ensuring full records were maintained either by the State or the GPs and that we must establish for once and for all a no-fault compensation scheme regarding vaccination programmes in this country. We are the only country in Europe that has not put a scheme in place. The State Claims Agency made its comments last Sunday week, using the argument that similar indemnity is provided in every other member state in the EU, including the United Kingdom. However, every other member state, including the UK, has a compensation scheme in place because people are damaged by vaccines administered by the State.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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The Deputy has one minute remaining.

Photo of Denis NaughtenDenis Naughten (Roscommon-South Leitrim, Fine Gael)
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That is factual and has yet to be acknowledged by this State which is still living in the dark ages regarding this point.

I welcome the provision in the Bill concerning private clinics and private hospitals. I remember the case of the Barringtons Hospital misdiagnosis. Many women from the west were involved in that incident. I was amazed that HIQA and the State agencies could not get involved or carry out an investigation into it because the hospital was private. Complaints cannot be made through the organs of the State to have such issues investigated in private clinics. I hope this will form part of the Bill and that we will have legislation that will put protections in place for patients and bring about a complete culture change in this country regarding the admission of liability. I hope people will at least stand up and be honest with patients once and for all.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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I call Deputy Bernard Durkan.

Photo of Paul Connaughton  SnrPaul Connaughton Snr (Galway East, Fine Gael)
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I am to speak.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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The names are listed in the reverse order, but as the Deputies will.

Photo of Paul Connaughton  SnrPaul Connaughton Snr (Galway East, Fine Gael)
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We switched sides at the last minute.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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I do not believe that would ever happen.

Photo of Paul Connaughton  SnrPaul Connaughton Snr (Galway East, Fine Gael)
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I highly commend my colleague, Deputy James Reilly, on introducing this Bill. I hope that due consideration will be given to what is a complex area.

Since it does not often occur, it is no harm to mention that an Opposition spokesperson like Deputy Reilly can bring his great expertise in the medical profession to the floor of the House. This procedure is good for Parliament and I hope that, when the Bill has been put together, we will have fine legislation.

This is an important Bill because many people would be surprised that insurance cover for medical practitioners was not mandatory. I must admit that I did not know it. From my research today, I understand that most doctors are covered. However, it is not an inexpensive business, with an ordinary practising doctor's premium amounting to €4,000 or €5,000 per year or a part thereof. I am surprised that the Department of Health and Children does not know how many doctors are not insured, but there is no register. This is difficult to understand, but I am told that as many as 40 or 50 people are not insured or have inadequate insurance. Some may be based outside the country yet working in Ireland, although I am not just referring to that cohort as such.

When people digest this debate, there will be an element of worry. I can only speak as a lay man, but doctors are rightly held in high esteem in society. In polls taken over the years, this esteem does not seem to have diminished and I know why. When one is a sick patient, one is in the doctor's hands. Given that the majority of people with whom I have had contact down the years, although thankfully not on a personal basis, have reason to be grateful to doctors, it is a fine profession.

Like every other profession, however, there are always problems. Everyone finds it difficult to say "Sorry" and that they have made a mistake. It is a personal failure among many of us, but it is certainly a failure in medicine. Through the years, I have found this to be the case where obvious mistakes had been made. Mistakes will always be made, but I will discuss that later during the few minutes at my disposal.

Many families have told me that they knew whether their loved ones had been wronged by hospital procedures. The problem is proving it in a court of law. The Minister of State will know as well as any other Deputy that once an issue enters the realm of law, one can certainly take it that the issue will not be patient-centred. Everyone else seems to make more out of it than the patient. This is a significant problem and I hope that something like this Bill will eventually overcome the culture of secrecy. I do not know why that culture has remained, but I suppose it is because ordinary people can be bamboozled by medical jargon. This is understandable. It is against this background that this Bill and related Bills - the Bill before us cannot solve all problems - will overcome that situation. Many people would be less afraid to take on the medical profession, hospital authorities and so on to get their rights.

Now that I know not all doctors might be insured, I have noticed something else. In a car accident involving a driver who, like many people, is not insured, it is bad news for the injured party, but at least there is another stage, in that a case can be brought before the motor bureau for compensation. While this takes many years, it provides some safety. There is no safety in respect of the medical profession. For this reason, a practical provision needs to be introduced and, as such, Deputy Reilly's thoughts will find favour across the country.

I cannot claim to be a professional, but another matter must be considered in this Bill or the eventual legislation. A practising doctor may be duly covered by insurance now, but we all know that, if certain procedures go wrong, problems might not manifest until several years later. There would be no trouble in legally and medically pinpointing which procedure caused a long-term illness. Would it not be the patient's hard luck if the doctor, who had been covered at the time, was no longer covered because he or she had retired or had not bought cover for subsequent years? The jargon in this respect is run-off insurance. This matter is important and I can well imagine the difficulties with an insurance company indemnifying people after a long period. As the Minister of State knows well, the case of a car accident is different. Whatever the injuries, they are caused on that day and any subsequent illness will come about as a direct result. Not so with inappropriate medical procedures, the effects of which might not arise until years afterwards. Have I much time remaining?

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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The Deputy has one minute.

Photo of Paul Connaughton  SnrPaul Connaughton Snr (Galway East, Fine Gael)
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The EU is drafting a Bill to bring member states together where insurance cover is concerned. Given this fact, it is most appropriate that Ireland should have what we believe to be sensible and useful cover.

Just to discuss things going wrong, my research today showed that, in the past three years, 821 objects were left inside patients during operations.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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That is not reassuring.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I would say not.

Photo of Paul Connaughton  SnrPaul Connaughton Snr (Galway East, Fine Gael)
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I am referring to balls of cotton wool and so forth. I hope that larger objects on the table were not buried in poor patients. To be serious, this shows that, even in the world's best run outfit, such mistakes can occur. For this reason, this legislation will be important.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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On that note, prior to undergoing a surgical procedure many years ago, I passed a flippant remark to a receptionist to the effect that I hoped that the surgeon in question collected all of the tools afterwards. The reply was, "You have heard about that". This was not very reassuring. For better or worse I came through the procedure safely.

I thank my colleague, Deputy James Reilly, for bringing this Bill before the House. It is progressive legislation which should have been here earlier for a series of reasons. We must ensure the general public can rely on the full scale of medical procedures available and that they can rely entirely on the fact they are covered in the event of something going wrong. If something goes wrong compensation is little consolation to the unfortunate patient, particularly if he or she is left with a disability for life. We must strive for the best possible practices and the highest possible standards. A situation whereby anyone would be allowed to provide a medical procedure without the necessary insurance cover should be incredible.

I refer to two types of insurance cover, one for the individual carrying out the procedure and the other for the institution concerned, which in this case are the private institutions. Other speakers have referred to situations where patients have found to their cost that there was no cover and therefore no compensation and no recognition of their plight in the aftermath of a procedure. It is incredible that this situation should occur in the current climate under both national and EU law. The highest standards must prevail at all times and those standards are applicable across the European Union, whether in the public or private sector, to ensure the maximum protection for the patient and the general public.

Deputy Denis Naughten made an interesting intervention regarding various procedures and vaccinations. He made a distinction between pharmaceutical companies, practitioners and the State. Where the State advises a particular procedure and if as a result of the procedure being followed the outcome is not in accordance with the plan, in my view the State is liable and we should not walk away from that responsibility. I held this view with regard to hepatitis C many years ago in this House. I believe I was correct at that time and subsequent events have proved me correct.

There are new and ongoing procedures about which a patient may know very little and may be swayed by the views expressed by the person carrying out the procedure. This may well be for the benefit of the person carrying out the procedure. The State has a duty in those circumstances to make it quite clear to any patient the risks involved in any procedure.

With regard to those providing the indemnity, many of us know of instances where the insurers will maintain that the small print of a policy will stipulate that a person was not covered under a certain set of circumstances. I have a cynical view of such practices. Like many Members I am familiar with many cases where individuals believed they were covered for a particular procedure and that they had indemnity in the event of something going wrong but the insurers countered by saying the small print contained the information. This is unacceptable. We must endeavour that the customer, the patient and the public are protected in those circumstances. We should not tolerate the old-fashioned attitude with regard to reading the small print.

I do not wish to deviate too far from the main argument-----

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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I am sure the Deputy will not.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I will try not to, with the guidance of the Leas-Cheann Comhairle.

We have all met mothers whose children have been given the three-in-one vaccination, now called the five-in-one vaccination. They have at times expressed concern about the effects of the procedure. I do not know if there were negative effects because I am not an expert in that area. However, there are worrying factors which have not been clearly and conclusively proven one way or the other. A parent of a child being inoculated will be questioned about family medical history. The parent may not know the history of the extended family members, for instance, whether a relative has had emphysema. It could be that it is unadvisable for that child to be inoculated but this can happen. Parents will say their child was well until he or she was inoculated but this is not always as a result of the parent's desire for compensation because compensation does not address the outcome or the tragedy. I am not completely convinced that we have confronted that situation and that adequate information is made available to parents as to which vaccination should be taken, the three-in-one, two-in-one or five-in-one. Two children from the same family can have varying reactions to the same procedure and this is a cause for worry. Deputy Reilly and I soldiered together on a health board a long time ago and the argument arose on many occasions that in general, in the interests of wider public health, it was preferable to take the procedure because it prevented the spread of disease or a pandemic. I was dubious than and I am still dubious about that argument. This is an issue that needs to be examined over time and which Deputy Reilly will consider in the compilation of this Bill.

Photo of Brendan HowlinBrendan Howlin (Wexford, Labour)
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The Deputy has one minute remaining.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Unfortunately as one gets older time passes very quickly.

We need to explain the risks to the patient. The area of dentistry needs to be considered in this regard, particularly as dental patients are being treated in other European countries. This is not a reflection on the type and quality of the procedures but it is necessary that the highest possible standards apply at all times and that a clear indication is given to the potential patient about the situation in the event of a procedure going wrong and that financial help will be available in some form.

Photo of John MoloneyJohn Moloney (Laois-Offaly, Fianna Fail)
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I wish to recognise the contribution of Deputy James Reilly and to acknowledge the importance of the proposed legislation.

It is unusual that such important proposed legislation attracts so little attention from the public as demonstrated by the empty Public Gallery. Deputy Paul Connaughton made the point that the public would believe that all medical practitioners are covered by insurance. This brings the matter into sharp focus and the proposed legislation before the House is timely. It strikes me as strange that it has not come before the House before now. I was pleased to hear the Minister, Deputy Mary Harney, reflect last night on the proposal made by Deputy Reilly. She agreed to remain in close contact and introduce legislation sometime in the new year, which I welcome.

Deputy Reilly's Bill makes several proposals which the Minister for Health and Children and the Government consider merit serious consideration and analysis. I am pleased that the proposal has not been long-fingered. There is a specific timeframe involved, leading to early in the new year. I am pleased that the debate has focussed on the protection of patients in their dealings with the medical profession, something upon which all Members agree.

In her contribution last night the Minister emphasised the importance of a health system characterised by trust, patient involvement, responsiveness, fair processes and continual learning. I acknowledge these are the hallmarks of and the background to Deputy Reilly's proposal. We have made great strides towards achieving a system characterised by such principles and the developments which have been implemented to date support that assertion.

Much has been said of the role of the Medical Council, the significant changes to its functions and the procedures arising from the implementation of the Medical Practitioners Act 2007. The new role is characterised by open procedures, accountability, patient involvement and, most important, producing a system which will require doctors to maintain their skills and competencies on an ongoing basis. This point shows the importance of the proposed legislation.

Deputy Connaughton asked if the Department had a full database of those who were insured and those who were not. I acknowledge that I did not know and I had to check with officials. The presumption was correct and there is no such register. This underlines the importance of what is before us. We can presume that legislation will come before us and will succeed in going through the House. Medical practitioners will ensure that they will continue to upgrade their skills. Hopefully, the day will come when insurance will become mandatory. The new role is characterised by open procedures as I pointed out previously.

Many interesting points have been made by Deputy Reilly and his colleagues on both sides of the House regarding the issues arising from the debate. The Government is supportive of the principles of Deputy Reilly's Bill. However, it is keen to ensure that the method we use to introduce more defined requirements for medical practitioners will be practical and workable.

There is a requirement on doctors to have adequate professional indemnity for the work they perform and the need for this has been mentioned by many Deputies. There are circumstances in which doctors have reneged on this ethical requirement and it is the patient who is left with no definitive avenue or means of redress.

I refer to the main points of the debate. Several Deputies expressed concern with the lack of regulation of private clinics. I look forward to the legislation that will come before the House eventually to address this area. There is no point repeating everything that has been said. I recognise the contribution of Deputy Reilly in bringing forward this debate. I am amazed someone did not think of this long before now.

Photo of Dan NevilleDan Neville (Limerick West, Fine Gael)
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I with to share time with Deputy Reilly.

I welcome the Medical Practitioners Bill. It is very important and timely legislation that will ensure the protection of patients. It is important to ensure doctors have appropriate insurance to cover all aspects of their very important work. There is no implication that doctors do not have insurance. I could not put a percentage on it - I am certain Deputy Reilly would agree - but I suspect more than 90% of doctors have insurance. As the Minister stated, the Department does not know how many doctors have insurance or not. The Bill makes insurance compulsory for all doctors.

I refer to the registration of medical people, including the areas of counselling and psychotherapy. There is no registration of counsellors and psychotherapists. There is growing interest in the issues related to counselling and psychotherapy and their regulation in Ireland. The roles of counsellor and psychotherapist are now recognised as being part of best practice in dealing with the health and social care needs of our population. We have regularly discussed multidisciplinary, community-based psychiatric services, which should include the availability of counsellors and psychotherapists as part of the team dealing with psychiatric illness in the community and in hospitals.

It is imperative that the public is protected by promoting high standards of conduct. Education, training and competence in the professions of counselling and psychotherapy are crucial. Protection is currently offered through self-regulation. The relevant bodies drew up the public protection report and made a submission related to the statutory regulation of counsellors and psychotherapists in Ireland. It was commissioned by the Government and reported in 2008. Some 12 of these bodies provide codes of ethics and practice by which their members must abide. Each organisation also provides standards which a person must attain before he or she is accredited as a counsellor or psychotherapist. While this form of self-regulation provides protection to clients of those organisations, it falls far short of optimal protection because under our common law system it is possible for any person to take the title of "counsellor" or "psychotherapist" and practice accordingly without the required teaching and competence. The current anomaly does not lend itself to good clinical governance and maintenance or the improvement of standards of patient care.

The Health and Social Care Professionals Act 2005 creates a mechanism to drive forward the clinical governance agenda. It creates a framework through which practitioners are accountable for continually improving the quality of their service. It safeguards high standards of care by creating an environment in which excellence will flourish and optimal protection is offered. Regularly, I raise with the Minister the matter of having counsellors and psychotherapists included under the Health and Social Care Professionals Act. In other medical professions there is a requirement for a basic qualification in medicine and professionals then continue to specialise. The absence of clear roles and dedicated procedures for those roles creates confusion in the absence of regulation. It also creates a situation in which many calling themselves counsellors in the community and in private practice do not warrant professional recognition. One does not need a recognised qualification or skill base to call oneself a psychotherapist or a counsellor. All that is required is a premises, a gold plaque outside the door and a neck to charge the fee.

At present, there are no means to regulate the situation. The opportunity for untrained people to act as psychotherapists and counsellors and the opportunity for such people to do damage is frightening. I welcome the report in response to this, although it is now more than 12 months old. The report contains the submissions of the psychological therapist forum and outlines a programme of qualification, training and evaluation of skills before practitioners would be admitted under the Health and Social Care Professionals Act.

Vulnerable people in crisis who need professional help can be severely damaged. This situation has been exploited by some practising alternative medicine and some people have been duped out of life savings. There is an urgency by which a regulatory process is introduced in the area of administration of all areas of therapeutic intervention. There is ignorance and not a little confusion among the public as to what is entailed by psychotherapy and counselling and the difference between them. This is compounded by the fact that, according to United States estimates, there are over 400 different named therapies which are used to tackle many medical and social problems, including marriage and family difficulties, anxiety, depression, addiction, sexual abuse, rape, psychosexual difficulties, eating disorders, bereavement, adolescent difficulties, Aids, HIV and many more. There is a range of people operating in these areas, but they must be supervised and regulated to ensure best practice so that people entering them have the necessary training. I have come across people who had bad experiences with so-called counsellors who were not professional and only had a few weeks' training. This was totally inadequate but they set themselves up as counsellors. People have had bad experiences following treatment from such individuals.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Many issues have been raised and I wish to comment on them because they are important. Deputy Neville's statement on psychotherapy and counselling in particular is something I have been concerned about since my time on the health board with Deputy Durkan. As a GP, one refers people to a physiotherapist or another fellow professional who has a base qualification. In the area of counselling, unfortunately, without the required regulation, patients end up going to people who may have done six weekend courses and consider themselves qualified. This is highly dangerous and detrimental to patients. The matter needs to be addressed, but not tonight.

Similarly, Deputy Dooley's concerns were well expressed. As I have said before, we need a patient safety authority that can act as an advocate for patients. HIQA admits that it cannot do this. The idea of a patient safety authority would allow for a discussion of problems without recourse to law. It would be a safe place for patients to go who feel aggrieved where their issues could be addressed. Their advocate could address the medical profession or the hospital concerns, allowing for an honest conversation to take place. According to insurance companies, at the end of the day most patients want an acknowledgement that wrong was done, an apology for the harm caused to them and an assurance that things will change so it will not happen to another patient. In most cases they do not want to go to law, but when they have no other option, frustration will lead them to the courts.

Deputy Naughten raised a point on which I have commented previously. Childhood vaccination is safe, but nothing is 100% safe. When parents vaccinate they are making a decision to protect their children. However, if they decide not to vaccinate that is not sitting on the fence - it is a decision not to protect one's child. Parents should bear that in mind. Some children are at risk and need to be identified. In addition, vaccination can cause adverse effects; it is well known and the statistics are there. It is not due to any fault of the doctor who administers the vaccination, the patient who receives it or the manufacturer who made it. It is simply a fact of life that different people have immune systems and some may get bad reactions. We need a no fault compensation fund to catch those people, compensate them and look after those who have suffered as a consequence. They should not have to go to law and mortgage their homes in order to get justice for their child or other loved ones. In this respect, I am interested in New Zealand's no fault compensation fund, which is working quite well.

I wish to thank everyone who took part in the debate on this Bill today and yesterday. Their contributions have been informative and useful, and will be considered on Committee Stage when any necessary amendments will be made. It is important to reassure all interested groups, such as the Medical Council, the IMO, the IHCA, insurers, indemnifiers and other groups with concerns in this area, that there will be time for them to have an input during this three-month moratorium. Their concerns can be considered on Committee Stage and any necessary amendments made. In getting this Bill to the floor of the House, I fully acknowledge that it is by no means perfect. However, the thrust and principle of the Bill is to protect patients from uninsured rogue doctors, or doctors who through negligence or otherwise inadvertently let their insurance lapse. There will be resource issues for the Medical Council in getting the necessary expertise to carry out that function, but it is important and worthwhile doing. We will find our way around this because where there is a will there is a way.

With regard to Deputy Connaughton's comments, I am told by experts in insurance and indemnity that there could be 30 to 40 doctors in this country who do not have the necessary insurance. This is tiny number out of the thousands of doctors who are responsible and have insurance. Our citizens and our health service depends on them. I do not think doctors have anything to fear from this proposal. As Deputy Thomas Byrne said, this is of no consequence for most doctors because they have insurance. This Bill is aimed at the rogues who let their colleagues down, and for people who come from abroad and do not have appropriate insurance.

The Bill seeks to close off the loophole which allows doctors to register here with the Medical Council without having insurance. As the Minister of State mentioned, the ethical behaviour guide expects that doctors will be insured. It advises that they should be insured, but this Bill will make it a legal obligation punishable at law if it is not observed, which is not the case at present.

I wish to thank the Minister for not opposing the Bill. I construe this as an acknowledgment that all sides of the House seek to improve the protection of patients in the area of medical litigation. In this regard, I also want to thank Deputy Jan O'Sullivan and the Labour Party and the Sinn Féin Party for their support.

I commend the Bill to the House.

Amendment No. 1 put and agreed to.