Tim O'Malley (Limerick East, Progressive Democrats)

It has the highest incidence of people who have voted with their feet and paid for VHI and BUPA. The people of Limerick should have a choice. I note the Senator's remarks. Many people in Nenagh and north Tipperary will note them also.

Senator Tuffy questioned the validity of the treatment purchase fund. She should ask any of the 20,000 public patients who have had treatment paid for by the fund rather than raise it as an issue with which to beat the Government. Those 20,000 people are very happy with the service they have received. As a result of the success of the fund the Government is considering extending the system to take more patients from outpatient waiting lists. I hope that proposal will be acted upon to the benefit of patients.

Senator Browne said the Minister for Health and Children had blamed her predecessors, Deputies Cowen and Martin, for deficiencies in the health service. I ask him to come here and tell the House when the Tánaiste made those remarks. I am not aware of them and I never heard her make those comments.

I wish to put on the record of the House exactly what the Government is doing, the amount of money that is being spent and the success of the Government in this area. This year we will allocate over €10 billion to health care, an increase of almost €1 billion over 2003. This investment has ensured the employment of extra health professionals providing quality services to patients.

In the past eight years, an extra 8,000 extra nurses have been employed in the health services. That is an average of 1,000 nurses per annum. Listening to some commentators one would swear that no new members of the nursing profession had been employed in that period, or that there was a deficit of nurses. An additional 500 consultants have also been employed along with an extra 1,800 other medical and dental personnel. We have also employed an additional 660 occupational therapists, 450 more physiotherapists and some 200 extra speech and language therapists.

Some speakers castigated the Government and said much of the money was being spent on paying people but, obviously, if people are employed they must be paid. I have no problem in paying good wages to the many excellent personnel we have in the health services.

These figures illustrate the extent of the Government's commitment to allocating extra resources where they will have most benefit — to staff providing services to patients and clients. The increased funding in the hospital sector is reflected in measurable increases in services. The number of patients discharged from hospital having been treated as either inpatients or day cases in 2003 was more than 1 million, an increase of over a quarter in the number of patients treated compared to the number in 1997.

Many people do not yet realise that day activity is now a significant component of hospital-based care. There has been a substantial increase of over 80%, from approximately 243,000 cases to 447,000, between 1997 and 2003. That represents a major change in practice, which has provided a successful outcome. That is the way modern surgery is going to go with many more day cases being treated.

In 2003, there were some 1.2 million attendances at emergency departments and some 2.2 million attendances at acute hospital outpatient departments. It is important to view the current debate about hospital services in the context of these figures. We have invested in services, provided thousands of extra health professionals and are seeing the benefit to patients in terms of increased services over the past seven years. There is no doubt that more remains to be done but it is important to acknowledge also what we have achieved.

The Labour Party motion refers in particular to maternity services. It is important to set out a number of facts to set in context the debate on the availability of maternity care. In recent years, staffing levels have risen substantially in the three Dublin maternity hospitals. Medical staffing has increased by 25%, nursing staff has increased by 15% and health and social care professional staff has risen by 36% since 1998.

The Government has acted to address concerns about capacity and infrastructure in a number of maternity hospitals. During the summer, the previous Minister for Health and Children, Deputy Martin, approved proposals at the National Maternity Hospital, Holles Street, designed to increase capacity in delivery rooms, theatres and neonatal intensive care units, as well as providing improved postnatal facilities for mothers and babies. He also approved the appointment of staff to oversee and manage the project, and the process of selection of a design team is under way.

The Department of Health and Children has been working closely with the Coombe Women's Hospital and the ERHA to progress the future development of the hospital infrastructure in response to increasing demand for services. We have approved the appointment of a design team at the hospital to allow planning to commence on a new capital development, which will include an extension to the neonatal intensive care unit, upgrading the existing ICU, a new caesarean section theatre, a day assessment unit, an ultrasound suite, a parent craft-admissions unit, an upgrade of mechanical and electrical services, and ward upgrading. The estimated capital cost of these works is almost €20 million.

At the Rotunda Hospital, a development which included the amalgamation of the paediatric and neonatal intensive care units, as well as the upgrading of postnatal beds on the third floor, was commissioned in 2003, at a capital cost of approximately €10 million.

The Eastern Regional Health Authority has also been working with the three Dublin maternity hospitals to consider ways to address the increase in births — up by 8% between 1998 and 2003 — and to introduce initiatives that would alleviate some of the current pressures. These initiatives include the further development of community-based midwifery lead services, such as the Domino and early transfer home programmes.

The Government has acted to develop maternity services in other parts of the country and to address specific pressure points. For example, the Mid-Western Health Board has recently been given financial clearance for a seventh consultant obstetrician-gynaecologist. A capital development is under way to provide an additional delivery suite, theatre and an extension to the admissions-reception area. These improvements are expected to be ready in early 2005.

Work has also commenced on the development of new midwife-led units at Our Lady of Lourdes Hospital, Drogheda, and at Cavan General Hospital at a combined estimated capital cost of €1.5 million. This service will offer women greater choice and control within the maternity services. It is anticipated that these units will be fully commissioned early next year.

The Government has provided additional revenue funding of €1.2 million to commission the new maternity unit at Letterkenny General Hospital in early 2005, together with equipping costs in the region of €0.8 million. The new unit will provide enhanced facilities and additional midwife staffing, as well as some increase in capacity.

Construction work is continuing on a new amalgamated maternity unit at Cork University Hospital. Construction is expected to be completed by the middle of 2005. This new maternity hospital represents an investment of €75 million and will replace the existing facilities at St. Finbarr's Hospital, Erinville Hospital and the Bons Secours Hospital, Cork. The unit is designed to cater for approximately 7,000 births annually.

The product of these investment initiatives in maternity services will be reflected not just in terms of expenditure, activity and employment numbers but also in the continual drive towards improving the quality of services provided. The Government is committed to the further development of maternity services in line with available resources.

Accident and emergency services have been the subject of considerable concern in recent times. I, too, am concerned about the present situation and the difficulties being experienced by patients in accident and emergency departments. Patients should be treated with dignity and respect. It is important to put the provision of acute hospital services in context. Over the past two or three decades there have been numerous important advances in surgical technology and in anaesthesia. These advances have improved greatly the range, safety and effectiveness of the procedures that can be offered by modern health systems. Modern medicine has allowed us to live longer and have a better quality of life. As a consequence, however, there have been dramatic increases in the demand for treatment.

Delivery of the emergency service at hospital level is interdependent on the inpatient elective service, day and outpatient care. The effective delivery of emergency services cannot be dealt with in isolation from the delivery of all hospital based services. A key conclusion of the Comhairle na nOspidéal report on accident and emergency services, published in 2002, was that a hospital-wide response was needed to meet the requirements of the emergency service. Improved processing of patients through the emergency department, via minor injuries units or medical assessment units, is but one aspect of the hospital-wide response needed.

Earlier today, Comhairle na nOspidéal formally presented its report on acute medical units to the Tánaiste. This report recommends how acute medical units should be developed and operated to improve the experience of acute medical patients through the hospital system.

In tackling the problems in accident and emergency departments it is also necessary to look beyond the acute hospitals and to examine the impact of primary care, non-acute care and community care on the accident and emergency service. We need to take a whole systems approach, which addresses the needs of people on a timely basis in the most appropriate setting. The Government has already introduced a number of initiatives aimed at improving the delivery of acute services and alleviating the pressures on accident and emergency departments.

Improved and expanded accident and emergency departments are being provided. Recently, new accident and emergency departments have been provided at Cork University Hospital, James Connolly Memorial Hospital, Naas General Hospital, South Tipperary General Hospital in Clonmel and Roscommon General Hospital. The accident and emergency department at the Mater Hospital has also been refurbished and a new accident and emergency department is under construction at St. James's Hospital.

Following a submission from the Eastern Regional Health Authority in June 2004, the Department of Health and Children approved proposals for short and medium-term actions to be taken to address the problems associated with emergency departments in the Dublin academic teaching hospitals. The cost of these new initiatives is €2.4 million in a full year and includes the appointment of a consultant in emergency medicine and specialist nurses, the establishment of rapid assessment teams and a clinical decisions unit, and the provision of multi-disciplinary teams to assess patients.

Additional emergency medicine consultant posts have been approved. Some 51 emergency medicine consultants are now employed in acute hospitals, which represents a 260% increase since 1997. The availability of senior medical staff in emergency medicine departments should facilitate rapid clinical decision-making, and the enhanced management, diagnosis and treatment of patients.

Pressures on the hospital system, particularly in the eastern region, arise in part from difficulties associated with patients who no longer require acute treatment but are still dependent. Funding of €16.8 million has been made available to the ERHA, which will result in some 600 patients being discharged to a more appropriate setting. Planning for the discharge of patients by acute hospitals and the liaison with the community services has been prioritised on an ongoing basis by the Eastern Regional Health Authority. Initiatives such as Homefirst, Slán Abhaile and home subvention are all contributing to providing alternative care packages allowing older people to be discharged. A total of €5 million is also being provided to the Southern Health Board under the delayed discharges initiative in 2003-04 to facilitate the discharge of patients from the acute hospital system.

Increasing acute bed capacity will also have an impact on the delivery of emergency services. The Government is committed to increasing acute hospital bed capacity as indicated in the health strategy. Since 2002, funding has been provided to hospitals to open an additional 900 beds. Some 600 of these beds are already open and the rest will come on stream in later this year and in 2005.

Notwithstanding the initiatives that have been introduced to date, the continuing difficulties and delays in accident and emergency departments are not acceptable. The Tánaiste has stated that the delivery of accident and emergency services will be an area for particular attention during her term as Minister for Health and Children. She has spoken of the need to identify the particular pressure points within the health system that affect the efficient delivery of emergency services. As Senators already know, the Government delivers. I am very confident that the Tánaiste will deliver what she has promised by way of a package of measures and initiatives to address problems in accident and emergency departments. She has promised that this will be done in the context of the 2005 Estimates, which are due for publication tomorrow.

Any improvement in accident and emergency services, and in acute hospital services, must be strongly supported by increased emphasis on pre-hospital emergency care. The Government has been working to develop this area. Critical developments include a major upgrading in training and standards, the equipping of emergency ambulances with defibrillators and the training of ambulance personnel in their use, the introduction of two-person crewing and improvements in communication equipment and control operations.

Currently, ambulance personnel are limited in the range of medications they can administer at the scene of an illness or accident. To address this issue, the former Minister for Health and Children, Deputy Martin, announced policy approval for the development of the advanced paramedic training programme. Legislative changes are being progressed as a priority to provide a statutory basis for the administration by newly-trained paramedics of additional medications, such as cardiac medications, to patients. The new measures will mean that patients, wherever they live, will have equitable and rapid access to a wider range of emergency services. It is intended that this expanded service will start to roll out in 2005, following the completion of training of ambulance personnel.

The ambulance service has an important role to play in the delivery of an integrated hospital service throughout the country. To this end, the Government will continue to focus on the development of the service and to ensure that the issue of ready access to treatment remains at the centre or our health policy.

Considerable debate has taken place on how we should organise our hospital services. We face important challenges in developing a service that meets patients' needs quickly and effectively. While inevitably people will hold different views on how we can bring this about, we must acknowledge a number of critical realities if we are to agree on how best to move forward. These realities include the need to reduce the working hours of non-consultant hospital doctors and the importance of ensuring that patients receive the right type of treatment, in the right place, by a senior clinical decision-maker capable of making decisions without delay.

In the debate about the future organisation of acute hospital services, it is important to remember that we are obliged to implement the European working time directive, which involves a considerable — and welcome — reduction in the working hours of non-consultant hospital doctors. We are already involved in a process aimed at reducing average working time to 58 hours per week. This is part of a longer term process to achieve a 48-hour working week for junior hospital doctors by August 2009, less than five years away.

It is not acceptable for doctors to have to work 70 or 80 hours per week, or even more in some instances. Excessive working hours are not good for doctors or patients. We need to find alternative ways of providing services in our acute hospitals so that doctors can work reasonable hours and patients can be sure of a top quality service at all times. While this means considering carefully how we configure our acute services, it does not mean closing hospitals or downgrading them. Many hospitals have substantial scope for increasing the services provided, including those claimed by some as being in danger of losing services or closing. As far as the Government is concerned, we need to harness the potential of every acute hospital to provide the best possible service to the local community.

We must decentralise as many as possible of the elective treatments currently provided in the larger acute hospitals to smaller local hospitals. At present, the larger hospitals tend to provide a very high proportion of all day-surgery and medical procedures. If properly structured and developed, the smaller local hospitals could take on significantly more of these treatments. This would greatly reduce the need for people to travel outside their own region for most procedures. Far from reducing the importance of smaller hospitals, the Government is committed to expanding considerably the services that can safely be provided within local communities. This will be to the benefit of all patients and will ensure that they receive as many services as possible closer to home.

A second reality to be faced in the future organisation of hospital services is the need to provide much greater access to senior clinical decision-makers so that patients can receive speedy and effective treatment. We remain excessively dependent on doctors still in training and we have an insufficient number of consultants. This means that patients who could be diagnosed and treated quickly by experienced clinicians must, in some instance, wait for unacceptably long periods until their condition can be identified and dealt with.

The Government is committed to developing a consultant-provided service, rather than one which is predominantly consultant-led. We need consultants to work closely together in teams, so that senior clinical decision-makers have a substantial and direct involvement in diagnosis, delivering care and overall management of patients. Achieving this will require change. It will involve more consultants and fewer non-consultant hospital doctors, and will require reform of existing work practices.

We can and will make progress in developing our acute hospital services in a way that is in the best interests of patients. Whatever position we take on the future of acute hospitals, it is clear that the present situation is not satisfactory. We cannot continue with more of the same. Change is necessary, and we can achieve it in a positive way that benefits everyone. However structured, acute hospitals need to work closely together in recognised groupings, or networks, so that we can maximise the services that can be provided by each hospital. Every hospital, whether big or small, has a vital role to play. We need to stop talking about hospitals supposedly in danger or under threat and concentrate on how we can harness the contribution of every hospital in delivering quality services for patients.

The initiatives I have outlined for the House represent tangible evidence of the commitment of the Government to the provision of high-quality, cost-effective, timely and responsive hospital services for all. The Government is committed to supporting and developing critical services, including key areas such as maternity and accident and emergency services. Let us move away from scare tactics and unfounded claims of downgrading and loss of services. Instead, let us have a debate about how best to work together to develop a quality health service for the future.