John Crown (Independent)

I am trying to compose myself and to wrestle with a dilemma I face in respect of this legislation. The rational side of me accepts it must pass if we are to have doctors in our hospitals next week, but the dreamer in me wonders, after 18 years of screaming about the problems in our health service, whether anybody is listening. This latest example of Ballymagash forward planning, where we are being called in on a Friday to pass emergency legislation for a problem that was glaringly obvious 18 years ago, makes me wonder about the processes of government and public governance in this country.

We are used to planning according to the politics of the last health care atrocity. When we have a sufficient number of major cancer scandals, there is an undertaking to fix the cancer service. When we have a little girl who misses a liver transplant, there is a commitment to put a proper service in place. When cystic fibrosis patients are dying because they are not receiving the right treatment, we are promised it will be addressed. This is not the way to run a health service. What is required is fundamental reform. The Government's proposal, which led me to support it prior to the election, was that there would be fundamental reform of how the health system is structured, financed and run. We are now told that will not happen until after another election. All the fiddling around the edges, all the bureaucratic adjustment in the world, will not deal with our core problems.

The core problem we are dealing with today sees yet another attempt to apply a Band-Aid to the gaping, malignant wound that is the health service. To appreciate how little sense the proposal makes, Members should replace the word "NCHDs" with "trainees". The Government is seeking to attract trainees - apprentices - from India and Pakistan. If any Fianna Fáil or Fine Gael Member lost his or her wedding ring or gold fáinne down a drain, he or she would call a fully qualified plumber, not an apprentice, to retrieve it. However, if the same Member's precious daughter has pneumonia, a blood clot or a belly ache, there is a high chance that the person who attends to her in one of our hospitals will be an apprentice specialist.

That is the core problem. Attempting to fix the problem by hiring more apprentice specialists exemplifies catastrophically bad planning. With great respect to the Minister of State, Deputy Jan O'Sullivan, I dispute her contention that the problems we face are not unique in Europe. The reality is that the context in which they exist is unique. There may be a shortage of junior doctors in other countries, but no other country depends on the labours of junior doctors in the way we do. It is a virtually unique Irish phenomenon. If it were not for the fact that Her Majesty's National Health Service has a similar structure to ours, though a little better resourced, it would make ours look truly deplorable. By setting the second worst country in Europe in terms of medical staffing as the bar, we make ourselves look slightly better than we are.

In addition to our incredible reliance on the efforts of junior hospital doctors, no other country in the world has six medical schools for 4.5 million people. We have twice the European average for the number of medical schools per head of population and nearly three times the North American average. It is crazy that we have so many medical schools but insufficient doctors to staff our hospitals. A Government back bench colleague of the Minister of State remarked yesterday that most of the training he received in medical school was, in the absence of consultants, provided by nurses. The reason consultants were not available to deliver his training was that there were insufficient numbers of them. In many of the hospitals in which this Deputy trained there may only have been one county physician and one country surgeon. If one is already doing the work of six or ten of one's European colleagues, how much time does one have left for training junior doctors?

I was invited to appear on "Prime Time" last night, although some hours later the invitation was withdrawn. There are no conspiracy theories here; the producers simply received a late acceptance from the Minister which was deemed more attractive than the contribution of this poor mumbling Independent Seanadóir. After accepting the invitation, I sought the assistance of colleagues to compile some figures which will be of use to the Minister of State in understanding what she is being told by her officials. I regret I was not in the Chamber for her introductory speech. Being one of those overworked doctors I had work to do this morning before coming into the House.

The Minister has stated there has been an increase in the number of consultants. That is correct, but what else has increased? The answer is the number of people. The population has increased dramatically during the past decade. Let us put some flesh on the bones of the increase in the number of consultants.

Malignant melanoma is the most lethal form of skin cancer. Sadly, it is often one of the most lethal forms of all cancers. The incidence of the disease has risen from 400 to 800 cases per year. The number of patients with spread malignant melanoma which is fatal in most cases has risen from 100 to 200. The people who carry out early diagnosis are dermatologists or skin specialists. Yesterday a dermatologist informed me that the HSE was very proud that the number of dermatologists in the Republic was increasing from 25 to 33. In Northern Ireland which is one third the size of this jurisdiction there are 22 dermatologists, while in Scotland, approximately the same size as the Republic, there 60. We are again seeking to be the poor relation of the United Kingdom which is aiming to have one dermatologist for every 80,000 members of the population, whereas the European average is one for every 30,000 to 50,000. We are setting the bar really low for ourselves.

What is the position on urologists, the people charged with making the early diagnosis of prostate cancer? They also deal with elderly gentlemen who have this disease and ladies who have urinary problems. The European average is one urologist per every 30,000 members of population. In Ireland, there is one urologist per very 180,000.

There are six paediatric surgeons in the Republic. The position in Northern Ireland is the same, whereas in Scotland there are 22 such surgeons. There are 80 consultants at Our Lady's Children's Hospital, Crumlin, whereas there are 200 at Birmingham Children's Hospital and 800 at the children's hospital in Denver. The argument is advanced that we cannot increase the number of consultants in this country because they are paid too much and we cannot afford to hire more. We do pay our consultants too much, but I did not negotiate the contract. I remained on the old one. I am still operating on the same contract I signed when I returned to this country in 1993.

Let us consider the arithmetic. When the old contract was in place, there were as few consultants per head of population as there are on the renegotiated contract. Before the old contract - in the days when consultants worked almost for free in the public service because it was expected that they would make their living from private practice - there were still almost no consultants and we also had the lowest number of specialists per head of population. Is this because there has been a medical cartel blocking the appointment of doctors? As a previous speaker indicated, all of the professional organisations have been pointing to the manpower deficiencies. The only ones who can create consultant jobs in this country are the Department of Health, the HSE and Ministers.

Let us consider the nature of the jobs in question. We have been informed that some of the positions are unattractive because they are non-training, junior jobs. They should not be available. The only basis on which a junior job should be available is as a training job. If a job is not available for training purposes, it should not be available at all. If a hospital is not sufficiently muscular in the context of being academically resourced or if it is not adequately comprehensive in the clinical, academic and research services it can provide for potential trainees, it should not have such trainees. One would not license a school if it could not provide for a proper standard of teaching; why, therefore, would one license a hospital which could not do so?

All that I have outlined is part of a bigger picture. We have a real problem with way we do public governance in this country. We also have a real problem with leadership and listening to people who actually know what they are talking about. We have a colossal problem with bureaucracy. It is extraordinary that, at a time when we have such staffing shortages and trained people who could occupy the positions for which there is a need, we still have PR consultants in the Department of Health, corporate affairs officers in our hospitals and large PR contracts for each of the multiple quangos-----