Róisín Shortall (Dublin North West, Labour)

I apologise because I was not aware there was a time limit. I thank the House for the extension. I was talking about what is under way to achieve long-term reform. We are waiting for the report from Goodbodys on the health insurance market, which is due within weeks.

In the short term, plans are under way to introduce changes in the primary care area. This relates to the issues raised by Senator Zappone about what needs to be done at community level. Everybody involved in the health service, including the experts and clinicians, say we should significantly move activity out of acute hospitals into the community. We should also move some of the activity from the community to the individual because we need to encourage people to have a much stronger role in taking responsibility for their own health. They should examine their lifestyles, exercise, diet, smoking, drinking and so on. The individual must also take responsibility. Everybody has been saying that for years but it has not happened.

I am conscious that there are powerful interests in the hospital sector such as chief executive officers, consultants, boards of management and so on. We frequently see reports of people marching in support of their local hospitals but we never see them marching for improved primary care services. It is not until we ensure the clout exists at this level in terms of senior management within the HSE and the Department of Health that services and, critically, budgets will switch from acute hospitals into the community. People should receive the vast majority of services in their communities and the aim is to ensure 95% of health services can be delivered at community or primary care level. The commitment to doing this is evident in the programme for Government. The very fact that the new post I am very proud to have been given - Minister of State with responsibility for primary care - has been created is a strong statement that the Government wants this to happen. I am working with the HSE and the Department to ensure priority is given to, and management authority and muscle is devoted to, primary care in order that developments can take place.

In addition, fine work is being undertaken by Dr. Barry White to develop clinical care programmes, which will improve the standard of care for everybody. The aim is to achieve best international practice in the care of chronic illness both at hospital level and, critically, primary care level.

The issue of out-of-hours services was raised. Where there are issues regarding the need to close local hospitals because of safety concerns and because there may not be the critical mass to support them, a range of community and primary care services should be in place. Unfortunately, that is not the case in many parts of the country. Out-of-hours GP services are working well in some areas. I have availed of such a service on the north side of Dublin several times. The DDoc service is very good. I am amazed that every time I have attended the clinic, nobody else has been there. These services need to be promoted. They cost quite a bit of money, they make sense but people are not aware of them. I was in Temple Street Hospital on a Tuesday at 8 p.m. recently and it was packed, yet out-of-hours services are available all over the city of Dublin, which are under used. We must ensure people are aware that good quality out-of-hours services are available throughout the State. We work on the basis of the services in place and building on them. Many services could be provided at community level, which would mean people not having to attend acute hospitals. That is the intention and the Government is committed to honouring the proposals set out in the agreed programme for Government. Work on that is being progressed on a weekly basis and the Minister, the Minister of State, Deputy Kathleen Lynch, and I are determined to see the reform programme through.

In addition, I concur with many of the comments on the provision of training for hospital doctors and on their career structure, which is outdated and not fit for purpose. Reference was made to the fact that this small country has six medical schools. That makes no sense and needs to be addressed. I am also concerned about the low intake of Irish students. Hundreds of thousands of students who would make fine doctors would love a place in medical school. We need doctors in both the hospital and primary care sectors. It is nonsensical that numbers are restricted to the extent they are when there is a shortage of doctors in both sectors. That issue is being addressed and I recently received the go ahead in the Department to undertake a major study on medical manpower planning over the next five to ten years because we have little data in this regard.

It is positive that Irish trained doctors spend time abroad and experience other systems and that needs to encouraged but it is regrettable that many of them feel they have to leave the country because of the lack of satisfactory opportunities to continue their training or the failure to be given an acceptable status within our hospital system. I am conscious that the manner in which the system works could be described as "inhumane", given the hours people and conditions are expected to work in and the manner in which they are treated by their seniors, which is not acceptable. We have to consider the career structure hospital doctors should have and that needs to be reformed urgently. Currently, we have an all or nothing system with people either being consultants or non-consultants. It is as ridiculous as having teachers and non-teachers or architects and non-architects. It has been suggested there should be a middle tier.