Mary Harney (Dublin Mid West, Progressive Democrats)

The topic for discussion this afternoon is the health reform agenda. The words "health reform" are meaningless to most people. Essentially health reform concerns improving services to patients in all areas of the health system, including at hospital level, in the disability sector, in the mental health area and in acute hospitals. The journey the Government has begun of reforming the administrative and management system in the health service with the establishment of the HSE, the amalgamation of all the health boards and many other organisations — in all more than 50 organisations were submerged into the new organisation known as the Health Service Executive — is but a means to delivering better health care services for patients.

In the past decade we have increased the funding of health care by fourfold. This year's current expenditure on the provision of health care services will be just under €15 billion and we will spend more than €500 million on capital services. On capital investment in health, along with Norway, we are at the top of the league in the OECD, spending as we do in excess of €500 million this year. In 1997 expenditure on health was 15% below the OECD average. By 2003 we had gone to more than 17% above the OECD average and no country in the world has ever increased its expenditure on public health at the rate at which we have done in the past decade. As we invest that money people are entitled to ask whether we are getting the value for that investment, whether we are getting the outcomes for patients and whether we are getting the services. Clearly investment on its own, without reform and without changing the way we do business will not change the outcomes we all expect for patients.

There have been considerable positive aspects in recent years. Since the cancer strategy was introduced we have employed more than 100 additional cancer consultants and 300 more specialist nurses. Mortality from cancer has been reduced by 15%, considerably ahead of the targets that were set, which is very encouraging. Clearly where we provide a world-class service in terms of the expertise and the manner in which we organise the service, we do well. Children's cancer services used to be provided in two hospitals in Dublin. Even though it may have been delivered in other hospitals around the country, essentially it was planned in two hospitals in Dublin, at Tallaght and Crumlin. That service was centralised into the hospital at Crumlin a number of years ago. Even though it is planned in Crumlin, much of the chemotherapy etc. can be delivered locally in approximately 15 or 16 other places. Ireland is top in the European Union in outcomes in children's cancer. That is not the case with other cancers because of the fragmentation of the service.

Much of what we are doing in health care is trying to bring best international practice to the provision of services. This can be extraordinarily controversial. For example we know from evidence internationally and from experts in Ireland that a woman receiving breast cancer surgery in a unit performing fewer than 100 procedures per year does not have the same outcome as a woman whose surgery is performed in a unit carrying out 100 procedures or more per year. In many places surgeons can perform as few as four or five breast cancer procedures in a year. From all the evidence from both home and abroad we know that does not give good outcomes and does not provide the service women are entitled to expect.

A number of months ago I established a group led by Professor Niall O'Higgins to make recommendations on symptomatic breast cancer to set standards. Those standards are due to be presented to me shortly and will be implemented across the country. The cancer control strategy that the Government endorsed less than a year ago and which is now the policy of the HSE is about ensuring that wherever in the country cancer services are provided, they are all provided to the same national standard which leads to the outcome everybody is entitled to expect.

Much of the debate on the health services centres on hospitals. In reality we spend more than 60% of the day-to-day health budget on primary, community and continuing care. Just over 30% of the budget goes on hospital services. However, much of the focus and public debate is on hospital services. Clearly hospital services are incredibly important. There is a debate on the number of acute beds we need. We have 13,500 acute beds in the public hospital system. At present I believe we have approximately 1,900 to 2,000 beds in the private hospital system. That stock of beds is greater than the number of beds available in Sweden. Some 11% of our population is over 65, compared with 18% in the UK and 27% in Germany. When considering acute hospital beds we must do so in the context of the population. Clearly older people are more inclined to use the acute services because a greater number of people are ill than in countries with a younger population. Therefore the debate should not be just about the number of beds. Clearly we will have the number of beds we require and the HSE is carrying out an audit to establish future needs in this regard. In the past ten years we have invested in approximately 170 new beds each year. In the previous period it was 30 new beds per year.

The issue with beds is how they are used. For the top 20 procedures patients spend 50% more time in hospital in Ireland than they do in Australia. Even within Ireland in some hospitals patients having an appendectomy can spend 3.5 days and in others they spend 6.5 days. For a hip operation it can vary from one week to more than two weeks. Clearly we must ensure we have the appropriate stay in our acute hospitals. One of the most effective ways to ensure people do not spend longer than they need in hospital is to carry out ward rounds every day in order that patients are seen by a consultant every day because if they are not seen by a consultant they will not be discharged to go home.

We have too few consultants in our health care system. We have approximately 2,100 consultants and need double that number. We have more than 4,000 junior hospital doctors and need approximately half that number. While we need 6,000 doctors in our hospital system, we need half the number of junior hospital doctors and double the number of consultants. That is the reason I am keen to employ new consultants on the basis of a new contract of employment that meets the health care needs of the 21st century rather than a contract of employment introduced in different circumstances which most of those who have viewed it would agree does not meet the needs of our health care system. It has been described by Dale Tussing as the most attractive hospital consultants' contract anywhere in the world. I do not necessarily say that is my view. I am sure others would have a different view. The fact is it does not serve our needs.

What do we need from a new contract? We need doctors working as part of a team. We need a clinical director in charge of that team. We all accept the hospital manager is not the appropriate person to be in charge of the independent clinical decisions that are made by physicians or the rota and so on that doctors work. We need doctors available 24 hours per day, seven day per week if that is what is required. Clearly that will not be required in every specialty. We cannot have a position where junior doctors are covering because we do not have enough hospital consultants.

Recently I spoke to a respiratory physician who did a round on a Saturday in his accident and emergency department. He told me he was able to send home seven patients whom his junior doctor had decided to admit to the hospital because he had the confidence to make that decision. He knew they did not require to be hospitalised and was able to make a follow-up appointment with them for his outpatient clinic the following week. That is the kind of decision making one gets when a hospital consultant has the experience and the confidence to make those decisions. That happens in other health care systems as much as it happens in the Irish health care system.

I am optimistic about the talks process which began yesterday. I was happy to read this morning that all sides said the atmosphere was cordial and businesslike. We are now at the stage of discussing what the nature of that new contract of employment should be. It is ironic that it has taken so long to get to this point. One would think the Minister for Health and Children was trying to reduce rather than increase the salary of the doctors. If the reform does not work, there will probably come a day when a Minister for Health and Children will have to negotiate a salary reduction rather than a salary increase. If this is how difficult it is to get a new salary negotiated that will enhance the payments and change the work practices of consultants, I shudder to think what the experience will be of the Minister who will arrive with an opposite agenda.

Obviously the health care system is very dependent on nurses. Some 35% of those who work in health are nurses. There are 12.2 nurses working in the system per 1,000 of population. In France the number is 7.5 nurses by 1,000 of population. In the EU it is 8.5 nurses per 1,000 of population. We have more nurses working in our health care system than in any health care system in the world. As the House is aware the nurses have served notice of industrial action commencing this Friday.

Nurses' pay is part of public pay. The Government's public pay policy is negotiated through the social partnership agreement. Recently the Government made an arrangement with trade unions representing hundreds of thousands of workers who have endorsed that agreement. Effectively, it delivers a 10% pay increase over the next 27 months. Separate from the national pay agreements there is a benchmarking process which benchmarks public sector pay against private sector norms. Nurses have a number of issues. We are seeking to encourage them to use the benchmarking process to have these matters adjudicated on. The eight claims have gone to the Labour Court which has recommended that some be considered in the context of benchmarking. I have already put on record that in the area of mental health, those reporting to nurses earn approximately €3,000 per year more. Some 1,000 nurses are affected and clearly that is an anomaly we are open to having adjudicated on and resolved in the benchmarking process.

The issue of a 35 hour week is different matter. I said in the other House yesterday, and I repeat it here, that if it is the case that nurses will do in 35 hours what is currently done in 39 hours, the Government is open to discussing that issue. If it is the case that to reduce the working week from 39 hours to 35 hours we will have to employ an extra 4,000 nurses when we already have more nurses in our health care system than any country in the world, clearly we cannot do that. That is why I have said on a number of occasions recently that we should have a process or a forum where these issues could be discussed with all stakeholders in the health care system.

We need to do with health, in terms of reform of work practice, what we did with the economy in the mid-1980s. At that time the social partners and Government got together, had a shared analysis of the problem and had the courage to come forward with a programme of change that has delivered much of the economic success we enjoy today. There should be a similar approach with all the stakeholders together discussing how they can change work practices so that people can work together as part of teams, and how diagnostics can be used on a longer day basis than under the current arrangement. Effectively, after hours diagnostics can only be used on an emergency basis because of the manner in which people are remunerated and it is extraordinarily expensive. We need to change working arrangements to deliver services for patients when they need them.

Negotiating these changes with individual groups of workers is not as satisfactory as seeking to do the change with all the worker representatives together because people must work in a team. Having a changed circumstance with one group of employees will not work if we do not have another group of employees on side for the process as well.

Recently we provided for nurses to prescribe. I want to empower nurses in our health care system. They are an under-used resource in terms of their experience and expertise. Nurses should be able to order diagnostics. That a nurse in an accident and emergency department cannot order an X-ray for a patient and must wait until the doctor comes to order it is crazy. If the nurse could order it, when the doctor comes to see the patient, he or she would know from the diagnostic results what was wrong with the patient. Under our system we must wait for the doctor to order the diagnostics. These are crazy practices that have built up in our health system for many years that do not exist in other countries.

We must embrace change and empower nurses. I believe the nurses' organisations are up for that change but it must be done in the context of wider reforms reflecting other groups of workers. Certainly the Government will sign up to the idea, first mooted by the Irish Congress of Trade Unions, to be fair, of a forum or a process and I hope all stakeholders in the health care system, including consultants, will do so because it could be an innovative way of delivering the kind of change that reflects the needs of patients, and of genuinely improving the health care system.

The focus in the reform is on moving more services into the community and primary care. Last year we chose to support 90 primary care teams. Such teams include general practitioners, specialist nurses, public health nurses, physiotherapists, occupational therapists, dietitians and so on. These teams, working together, can provide an enormous service to the public. For example, all over the world it has been established that if chronic illness, such as diabetes, is managed, the cost of medication is reduced, as is the need for hospitalisation in many cases. The management of chronic illness must be done at primary care level. We are providing resources to the Health Service Executive to initiate chronic illness management at primary and community care level.

A major issue for society and one that puts enormous pressure on the public acute hospital system is the issue of care of the elderly. We have more than 22,000 people in residential care over the age of 65. International evidence suggests that approximately 4.5% of people over the age of 65 require residential care because they are not in a position to be cared for at home or in the community. We are at that figure. However, one third of those in residential care in Ireland today need not be there if home supports or community supports were in place. The policy is to put in place home supports so that older people will only go into residential care as a last resort. The preferred option of older people, their families and all the representative bodies that represent older people is to provide support at family and community level.

By the end of this year, 5,000 older people will be supported at home through home care packages. These packages are customised around the needs of the individual and average approximately €450 per week. Some are more expensive, some less so, depending on the particular needs. Whether at the €450 level or a lower level, they are substantially less expensive from a financial point of view than residential care and are the preferred option. International evidence suggests that if people can remain at home, they live higher quality lives and, on average, live two years longer than if they reside in residential care. That is the international evidence. We do not have data in Ireland.

Supporting people at home is not just about a home help or meals on wheels, important as they are. It is also about having services at community level. For example, physiotherapy is very important for older people, while chiropody is a very basic service. We still have huge shortages in some of these areas at community level, which is why, in recent years, we have considerably increased the number of therapists we are producing from our education system. This must continue. The new school of podiatry will open shortly in Ireland where we can train our own chiropodists. At the moment, they must be trained either in Northern Ireland or overseas.

Education and training are essential in the health care system. We are producing 325 medical graduates at present. The Government decided some time ago to accept the recommendation of the Buttimer and Fottrell reports to more than double the number of medical graduates. That increase began this year with the provision of, I believe, 60 places at undergraduate level in 2006. This year, an extra 40 places at undergraduate level will be provided and for the first time, graduate entry into medical school will begin. When that process is completed in a couple of years, we will be graduating over 725 doctors from Ireland and the EU. This should be sufficient to meet the needs of our health care system. Certainly, the intention is that we will have enough graduates from our own stock. We will always want to supplement that with the people coming from overseas to work in our health care system, but we clearly need to educate more doctors in our medical schools here. This process has now begun.

Clearly, in many areas, there are negotiations underway with various organisations, including general practitioners in respect of the reform of primary care and, in particular, the GMS. Those negotiations are ongoing and I hope they will be successful. A key part of them is the management of chronic illness at community level.

Equally, we must negotiate with pharmacists. The HSE and my Department had a very successful round of negotiations with producers of medication, namely, the pharmaceutical industry and the medical device sector. When this new contract is fully operational we will save approximately €100 million per year. The HSE then began to negotiate with the wholesalers, of whom there are three in the Irish market. Shortly after these negotiations began the wholesalers produced legal advice sent to them by a pharmacist. This advice suggested that they could not negotiate with the HSE because the outcome of their negotiations would affect the prices paid to the retail sector, namely, the pharmacists, and would therefore be illegal under Irish and European competition law. This was a surprise to us. We were not aware of it.

The HSE obtained its own advice, which confirmed that what the pharmacists said was true, and the Attorney General has so advised. Under EU law it is not open to the State to negotiate prices with pharmacists or any other group. It can negotiate a contract and the nature of what is in that contract, but a different process must be found to settle price. I hope that we will be able to find a mediation or independent process chaired by somebody that is acceptable to both sides to be able to discuss the nature of the contract we wish to have with community pharmacists. I have spoken to the HSE and hope we can put this in place in the coming weeks because it is important. I wish to put on record, because it is misunderstood, that it is not a question of not negotiating with any union. That is not the issue. The issue is that under European law, the State cannot set a price with any group of citizens. It can only negotiate price with its own employees. This is why a pharmacist asked me recently why I was negotiating with the consultants. They are our own employees and are in a different category to people who are self-employed and in their own business. I believe a resolution can be found and we want to work on the basis of being positive and making progress, not on the basis of putting our heads in the sand and saying we will not talk to anybody. That is not my approach nor is it the approach of the Government or HSE.

I will not mention hospital acquired infections because I was here last week to discuss that matter. I say this because I fear Senator Browne will accuse me of not talking about hospital acquired infections.