Mary Harney (Dublin Mid West, Progressive Democrats)

It is a great pleasure to be before this new Seanad. I am not yet familiar with the names of the many new Senators and may mix up some names and faces, but I welcome them all. I began my political career here when I was appointed in August 1977 and the Seanad met in October. I thought the first meeting day would never arrive, such was the sense of excitement, and I hope new Members felt a similar excitement. I see some former Members have returned. I will not say old Members because Senator O'Reilly would not like to be described as an old Member.

I am also pleased that there appear to be more women in the Seanad, although I have not checked the statistics. There are still too few, of course, but it appears to me that there are more women than in the previous Seanad, and that is a good thing. In any body that makes decisions a reasonable balance of women and men is necessary because women and men sometimes come to issues from a different perspective.

Health care is a major issue in every country, especially well developed ones like this. There is no country where it is not foremost in the minds of citizens and their representatives. Many of those who sat on the Oireachtas Joint Committee on Health and Children during the term of the previous Dáil and Seanad lost their seats. This included Senator Twomey, for whom I have a high regard and who made a significant effort in that committee, Paudge Connolly, James Breen, Senator O'Malley and many others. This may convey the message that the public does not appreciate its representatives spending a long time dealing with health issues. We had many meetings, some of which lasted between six and eight hours.

I particularly welcome Senator Fitzgerald, leader of the Opposition and of the Fine Gael group in the Seanad. I have known her for a long time and we worked together during the recent general election.

What passes for a health debate here concerns deficiencies in the service and negative points when people often say that if we only had more people and more money, somehow everything would be right. We have learnt, however, in the past decade that investing more money and significantly increasing the number of people in the service without reform will not deliver the kind of benefits people expect. Last year, the health service budget was increased by €1.2 billion, yet people talk about cutbacks.

To put the events of a few weeks ago in context, the Health Service Executive, HSE, is expected, like any other organisation, to live within the budget voted to it by the Oireachtas. Its chief executive officer, Professor Drumm, is accountable to the Oireachtas, which is unusual in State organisations. The legislation I brought through the Oireachtas provides that the chief executive officer should be the Accounting Officer because those who spend the money should be responsible and accountable to those who provide it. In time, this will be seen as a wise decision.

The decision on staffing will affect between 200 and 300 people out of a total of 120,000, but every day when I read the newspapers and listen to the radio I hear about all the patients who will be affected. To give one example, in Sligo, 30 nurses employed while permanent nurses took their holidays, as happens every year, will not be kept on when their temporary contract ends. There are 640 nurses in Sligo General Hospital. In respect of the four consultants let go, one locum was appointed to allow Dr. Healy, an orthopaedic surgeon, do his work on the Medical Council. He has since retired and a permanent orthopaedic surgeon was appointed in his place, so we are not going to keep the locum. Two locums were appointed to clear a long waiting list for ear nose and throat procedures, which they have done, so we will not continue to employ them. The last was an obstetrician-gynaecologist who retired. He was asked to stay on as a locum for a couple of months pending his replacement's start date, which he did. That is the truth about Sligo. I could repeat that example for other places throughout the country.

Those who think that this is all about money and staff need to think outside the box. Hospital managers need to manage their budgets. Senator Twomey mentioned a piece of equipment in Wexford County Hospital that is broken. I am not familiar with the details of the equipment or how much it would cost to replace it, but I wonder have people in Wexford been going to conferences, or travelling overseas to international gatherings. This is a question of priorities. Patients must come first.

We have the highest proportion of nurses to patients of any country in the world. For example, in France there are seven nurses per 1,000 patients. We have 12.2 nurses per 1,000. The EU average for the former group of 15 countries was nine per 1,000. Between now and June 2008 we are expected to take 2.9 million nursing hours out of the public health care system to meet the commitments we entered into some months ago during the nurses' dispute. The working week will be reduced from 39 to 37.5 hours on a cost neutral basis without any diminution in services to the patients. That is a challenge. If people say that the events of recent weeks will cause serious difficulties for patients, will we have the capacity, on a cost-neutral basis without any diminution in services, to reduce the number of nursing hours by 2.9 million?

We spend 8.9% of gross national product on health care. The OECD average is the same, yet only 11% of our population is over 65 whereas the OECD average is 17%. In Germany it is 27% and in the UK 17%. We spend more per capita on health care than France or Britain. Based on purchasing power parity among OECD countries, we spend $2,596 per capita as against $2,500 across the OECD which comprises the world's 30 richest countries. On capital spending we are top of the class with Norway, spending 0.6% of our national income annually.

Often we do not put matters in context. I was asked what I have been doing over the past two and a half years. I have been trying to turn this massive ship around. Unfortunately, one cannot flick it around. The public health service is a large organisation and we have sought to do the right thing. Today, for example, we took four steps to improve cancer treatment. We will ensure that one will get care in the right place, at the right time from the right person, no matter where one lives. That is not the case at the moment, with the exception of paediatric cancer, in which we are top of the class in Europe.

We do badly on other cancers because of the fragmented nature of our service delivery. There are doctors performing breast surgery who are not trained breast surgeons. They are general surgeons and the outcome is poor. People often say we must maintain the service here. We cannot provide triple assessment by a pathologist, a surgeon and a radiologist in every hospital in the country. No country has the resources to do that. Today we announced that 13 hospitals must cease breast surgery immediately because it is not safe. A parent with a sick child will travel almost anywhere to have the child cured, especially of cancer. The same applies to adults. Given a choice between the local hospital or a centre of excellence where one has a better chance of being cured, hardly anyone would fail to opt for the centre of excellence.

Many of these developments did not happen in the past because local institutional, professional and vested interests stopped them happening. Patients were not put first. Senator Healy Eames mentioned the west. A health board had responsibility for that region until two years ago. Many of the shortcomings she criticised were not addressed when local autonomy was vested in a health board comprised mainly of people from the locality, those who worked in the system and those appointed to the health board. The staff-patient ratios in the west are the highest in the country. That is the sad reality. The reform agenda involves doing the right thing, working differently and not just putting more money into working the way we always did because that will not deliver results.

We would have had a consultants' contract two years ago if I had said yes but the test for this contract is that one has equal access to our publicly funded health system whether one is a privately insured patient, has one's own resources or has neither. There should not be a situation, such as arose in Kilkenny, when a woman was told that if she had private health insurance, she could have access to diagnostics immediately, but because she had not, she would have to wait six months. These facilities are funded by the taxpayers and nobody should have preferential access to them. That has been the main difficulty in agreeing a contract of employment.

Those who criticise co-location should re-examine what happens in public hospitals, many of which are hives of private activity in which if one has private health insurance, one group of employees, namely, consultants receive fees, while neither nurses nor anyone else does so. One group of citizens, that decides who is to be admitted to hospital, receives a fee. It is a no-brainer for someone to tell me it is preferable to continue doing this, to have the National Treatment Purchase Fund deal with public patients while letting the public hospitals deal with private patients only.

Those facilities to be funded by the private sector will provide private facilities on site. This is much better than the present practice of converting publicly-funded beds to private beds. A total of 20% of all beds in our hospitals are designated as private beds for insured patients only or for those who can pay for themselves, and I do not consider this to be fair. It is reasonable to convert such beds to public beds to which all have access and to tell private providers to provide the private facility. For example, such a private facility must make services available to the public hospital at a greatly reduced rate, must share diagnostics with the public hospital if it makes sense and must pay for the diagnostics. This makes eminent sense.

While Fine Gael has always supported private investment in health, it seems to take the view it is acceptable to locate a private hospital five miles away but not five yards away. A total of 700 doctors have category two contracts, 650 of whom are in Dublin. They can work in any number of hospitals and some of them work in three or four hospitals. I want to keep them on site and working in the public hospital for the benefit of all the patients. In addition to converting private beds for public use, this is the main reason the Government supports co-location.

As for beds and their use, I refer to Professor Keane's appointment. He comes from British Columbia, Canada, having been educated in Ireland, and has a highly distinguished track record. He has informed me that British Columbia, which has a population of 4.1 million people, has ten radiotherapy beds. Ireland, which has a population of 4.4 million people, has 179 radiotherapy beds. The most expensive bed in any country is a hospital bed and one could obtain a suite in any hotel in this city for less than the price of any acute hospital bed. Clearly, people should only occupy acute hospital beds if they need them and not otherwise. Therefore, many patients will be treated on an ambulatory basis or in hostel-type accommodation. This is more cost-effective and efficient. Members must recognise that Ireland must learn from best practice, whether it is from Canada, the United Kingdom, including Northern Ireland, or wherever. We should not close our minds to the idea of combining hostel or hotel-type accommodation with hospital treatment as some of the best cancer centres in the world do so.

The issue of regional or local hospitals was mentioned in respect of what will happen in different places. Essentially, the Hanly report pertained to ensuring the provision of consultant-delivered services nationwide. At present, if one turns up at most hospitals at this hour of the evening, one will be seen by a junior doctor. This is not good as to be seen by someone with the title of doctor does not mean one is being seen by the right person. The Government wishes to ensure when one turns up at an accident and emergency department, especially if one is a serious case, one is met on one's arrival and dealt with by a qualified person. As all Members are aware, the sooner one is seen by the right person, the better the result, particularly when one is a trauma case.

Recently, a consultant in Dublin informed me of a new blockbuster drug for strokes. Apparently, it must be administered within three hours of suffering a stroke and not all patients are suitable for it. The drug can induce a brain haemorrhage if given to the wrong patient and only a highly qualified person can administer it. If one went to the wrong hospital and spent an hour or two there, it might be too late by the time one got to the right place. I provide this as an example.

We must begin to introduce such practices in a safe way. Safety and quality must be our guiding principles when it comes to choosing where services are provided. More things will take place in smaller hospitals and more local people will be treated in many such hospitals because, at present, sometimes they go into the major centre unnecessarily. Equally, however, some cases will go to the major centre rather than the smaller hospital because the former is the more appropriate place. I ask Members to be flexible, open-minded and innovative in respect of matters such as putting patient safety first. The correct decision will be made if this is done.

As for bonuses awarded in the HSE, the principle of performance related pay has long been a hallmark of public sector pay and to the best of my knowledge, it has received great support from all parties. It was introduced many years ago and both the review group on higher pay and the benchmarking body support it strongly. Staff in the HSE have been employed on the basis of a particular contract on foot of which they receive X salary and Y bonus. I do not believe the suggestion made by some people that such practices should now be stopped suddenly constitutes good industrial relations practice. Rather, I consider it to be a cheap shot. Undoubtedly, Professor Drumm would earn a great deal more were he to work as a paediatrician in this city. He is not especially interested in money. When Dr. Halligan declined the post of chief executive officer of the HSE, I spoke to a number of people to ascertain whether they would be interested in the post. I was amazed by the numbers who replied they earned in the region of €800,000 or €1 million. I refer to those who I believed genuinely would be in the ball park. It is not unreasonable to pay the kind of salary and bonus received by Professor Drumm if one is to be in charge of a budget that is as large as €15 billion and of staff numbering 120,000 people.

The rolling out of population screening cannot be done overnight. One cannot press a green button and state that one has provided population screening for all the groups that are to be screened. It must be done on a phased basis and I know of no country that has done it. While I welcome this debate, we must back the reform agenda. There is no other way to achieve the health service to which all Members aspire and that I believe can be achieved other than if we continue to have the courage to introduce the changes under way at present.