Mary Henry (Independent)

I welcome the Minister to the House. Despite being one of the university Senators I hope she will forgive me if I do not concentrate on the funding for third level education. I appreciate it greatly and welcome everything the Minister said in her speech. As I have been involved for many years in medical education I will concentrate on the Fottrell report.

Although it has been said that the report is timely, it is long overdue. For years we have known we were in a dire situation regarding the production of our own graduates. For almost 30 years there has been a cap of 305 and we have known it was far too small, even for replacement numbers. We had a policy of taking people from the third world to perform much of the service commitment in our hospitals. That was wrong and I am delighted to see that this report has come forward now.

I am cheered by the Minister's response to the report. I am sure her decision before the report was published to provide an extra 70 places for EU students this year was due to the motion I placed before the Seanad last year encouraging this to happen and which was supported by the Independent Senators. It is nice to see one's advice taken occasionally.

I will quote from the report:

In this new model of medical education there will be more students, more diverse delivery settings, more small-group work and interaction, including mentoring procedures and more inter-disciplinary contact. This therefore involves considerable logistical support on a scale not seen to date. The gain will be graduates more fitted to the complex, increasingly multi-cultural society Ireland has become.

Judging by the Minister's speech today and by what she has said outside this House her approach to the report has been wise. The recommendations cannot be brought in on what may be termed a "big bang" basis with everything implemented at once. I have examined the various scenarios as to how undergraduates and graduates would be phased in to the system over a certain number of years from years one to 11 and how the non-EU graduates, who, it has been said by everyone, have been supporting the system financially, will be phased out. It is extraordinarily optimistic and the Minister's approach is wise.

As the situation regarding admission requirements has concentrated most people and will concentrate the public, I will deal with it first. The Minister is wise to focus on undergraduate students. Everybody agrees that doing interviews in such a small country is not a good idea. The Minister should be careful with aptitude tests. Other university subjects have high demand and high points. Why are veterinary medicine, pharmacy and physiotherapy not also singled out? A wide range of people are needed in medicine. A pathologist is not the same kind of person as a general practitioner. No survey has yet concluded that very intelligent people are less compassionate or less able to communicate than people with lesser intellectual abilities. I was delighted to see the chairman of the Irish College of General Practitioners, a discipline in which communication and compassion are most needed, saying that.

The Minister should be careful with aptitude tests, particularly given that the US Commission on Civil Rights has complained about them in 2002 saying they are biased against socially disadvantaged people, ethnic groups and even women. Some 300 universities have abandoned them or said they must be taken in conjunction with a school-based assessment. This is from the 2003 report on the website of the National Centre for Education Statistics. Professor Kathleen Lynch, professor of equality studies in UCD and senior lecturer in education, has frequently pointed this out. In the United Kingdom the biomedical admissions test, BMAT, is said to considerably favour those who are taking higher mathematics and physics as subjects. There was a House of Commons debate on this recently and we must be careful we do not get involved in a pseudo-science that favours the best-off who can afford grinds in aptitude tests, as happened in America. This is the reason they have made such a mountain of them.

We urgently need to address curriculum changes. The pre-clinical changes have taken place, to a certain extent, because people are entering with higher qualifications in sciences in general than was true when I entered medicine 40 years ago, which means the problems are not great. Some of the medical schools have reduced their courses from six years to five. Five years is recommended for those who enter as undergraduates in this situation. However, before we can introduce all the Fottrell recommendations, we need to bring all colleges around to this idea, as it cannot be implemented on a piecemeal basis. A great deal of consultation will be required even at the pre-clinical stage to ascertain how colleges can shorten some of their courses, in which people have greater expertise than they had in the past.

I qualified 40 years ago last year and the clinical training and how it is delivered have not changed much over the years. What is suggested in the report will be incredibly expensive. The expense will arise in numerous areas. It is not widely recognised that most clinical training is done by people who are not paid to do it. Only 40 academic whole-time equivalents are being paid to give clinical medical training. When students complain about frequent no-shows of those who are to give clinical training — the report states this can be as high as 30% — it is important to remember that those people are not being paid to do it. It has an enormous impact on service work. That will take considerable retraining and re-skilling of those who are involved in the clinical training.

One group has not been mentioned. There will be considerable change for patients. Patients could be described as the raw material for teaching these students in clinical training. I was rather disappointed that the report laid no emphasis on them. It has been suggested that patients be seen in different settings. Most students see patients either in acute hospitals or within primary care practices. It would be good if they could see patients in their own homes or in community care settings. However, the logistics would be significant. A very significant level of support staff would be required in this regard.

Students are frequently taught in clinical sites that were never designed for teaching. I never allowed more than three students into a cubicle with me. However, the students must wait outside in order that the patient's consent can be sought to allow them be present for the consultation and examination. It is necessary to seek consent for students to be present even if the patient is to be anaesthetised. All this takes some time. I have had cases where, for example, a patient has agreed to give consent provided their daughter can be present. The daughter had a child in a buggy. The cubicle contained me, the nurse, the patient, the daughter, the child and the buggy. When the three students came in the cubicle became very congested, which would be made worse if we were forced to increase the number of students to four, five or six.

A doctor must try to treat a patient and teach at the same time. I always enjoyed teaching, so that was not a problem. Most places have few or no tutorial rooms and small lecture theatres, which are the types of issues mentioned in the report. It will cost a considerable amount to put these facilities in place before we can, with any dignity for patients, introduce much of what is suggested in the report. I regret that such reference to patients was left out of the report.

I like the phased approach of the Minister for Education and Science and while her partner is the Minister for Health and Children, both of them will have trouble with their superior, the Minister for Finance, who will need to give far more than the €4 million he has given this year. That will be very little given that a sum of €100 million is mentioned in the report. Enormous sums of money will be needed for all the small units in the hospitals in this city where doctors will be trying to teach increased numbers of students while still giving the patients the dignity and privacy all of us would want them to have. This area needs to be addressed with the greatest of care.

Non-EU students provide approximately 60% of the funds to run the medical schools, which is enormous. Owing to the approach the Minister for Education and Science is taking, she will need to ensure that the Minister for Finance understands that he cannot turn off the tap in four years' time and suggest increasing the numbers of non-EU students to increase the money coming in. We cannot have a turn-on and turn off- approach. It has taken 20 years to get many of those students to take up places here, given the tremendous competition from universities in the United Kingdom. This type of scheme is so popular that Italy now has medical courses in English. We need to commit to a long-term approach.

It is a very good idea to bring in more graduates, as is done by most medical schools by giving places to approximately 20 such students each year. While they do well, it is much more difficult for those who graduated from arts disciplines than for those with science backgrounds. They have frequently told me they never realised they would need to work so hard. In general they are extremely committed, work very hard and do very well. However, now many of them will also have a significant financial commitment and they will start their medical careers either with huge loans, which they will need to repay or with obligations relating to grants given to them. This is what happens in America resulting in increased medical charges, as the doctors must repay their huge loans. Most medical graduates in America now finish with a loan of approximately $120,000, or €100,000, which is very big.

While we are enthusiastic about getting more graduates — one of my colleagues said they are much less trouble as it is not necessary to spend half as much time minding them, etc. — we must remember that they will also have their own problems, for example, having families to deal with. As pointed out in Dr. Buttimer's report, flexi-training becomes far more important.

Hospitals will need more facilities to allow for clinical training with clinicians and will also need more facilities for students, which will cost more money. I would suggest that sufficient account has not been taken of this matter either. It is disappointing that we have been considered to be falling behind in development both nationally and internationally, which is one of the most important matters for the Minister to tackle. She should try to encourage those involved in teaching to raise whatever standards are needed.

I come to the issue of the intern year. Much medical care is still provided by non-consultant hospital doctors. The Tánaiste and Minister for Health and Children is working towards consultant-provided health care but we still have many non-consultant doctors whose numbers we are trying to cut down. In view of the increase in the number of medical students we will have to increase the number of intern posts by approximately 300, but what are interns looking for? They seek junior house officer posts and, subsequently, they will seek senior house officer posts. We know from the Buttimer report the number of them who go abroad for training but, unfortunately — I can speak from family experience — unless consultants' posts in those disciplines in which the person is training abroad are available here when they finish training, they will take up places in the United Kingdom, America, Australia and elsewhere and are then lost to us.

In addition to the situation regarding the intern posts, which will cost the Minister for Finance a fortune, we also must address the question of improved training programmes in this country. We should get rid of the non-consultant hospital doctor posts for which there is little training and concentrate on those with good training because we have to improve the position as outlined in the Buttimer report whereby many people go abroad. After all the Minister's fine efforts in helping them get through medical school, they end up running the large hospitals in New York, Washington, London, Newcastle and elsewhere and do not come back here to treat the Irish public as many Senators want.

I congratulate the Minister on her approach and implore her not to be pushed into taking measures too rapidly. We had to wait a very long time for this report, and I compliment the former Minister for Education and Science, Deputy Martin, on commissioning it. Now is the time to consider it carefully; there is no need for a big bang approach. What the Minister is doing to date is extremely good.