James Reilly (Dublin North, Fine Gael)

I can understand Senator D'Arcy's concern about Drogheda hospital. It is a serious concern for us too. We have put in place this week initiatives around that hospital to support the earlier discharge of patients and more home care. We are considering one or two other options also. The Senator will see an improvement in Our Lady of Lourdes Hospital in the next few weeks and I will keep in close contact with him.

Each of the hospitals of which there are eight — one of them is Galway hospital — have been asked to put forward their plans to resolve their difficulties in terms of what they believe is needed to address the issue because it is important to ask the people who are working at the coalface what they need. As always in life, unfortunately, there is some gilding of the lily. We have examined their proposals and are supporting those that are reasonable and properly costed, and sending back those that are not. It is quite simple.

I can tell the Senator as an aside, that one hospital spoke about an extra four hours in its acute admissions unit, the medical assessment unit, that exceeded another hospital's pricing for increasing its medical assessment by 12 hours a day. There is a little bit of horseplay going on and that will be resolved but the SDU, special delivery unit — people have gone to all these hospitals — asked them for their plans and have gone through the plans with them. I signed off on the ones that were reasonable two days ago in regard to initiatives that will alleviate the situation. We have left the door open for them to come back with their other proposals, but properly priced.

Senator Kelly raised the issue of medical cards for cancer patients. I addressed that in the context of the issue raised by Senator O'Brien. It is an area that should be looked after. Cancer is a terrifying diagnosis for people although, thankfully, not as bad as it used to be in terms of outcomes. Many more people survive now than did previously, but we will do anything we can do to alleviate the problems for people, given that regardless of how wealthy one is there are certain services one cannot access without a medical card. We are examining that and the discretionary group has been instructed that people who are terminally should be considered. However, we must remember the difference between people who are terminally ill and those with cancer. As Professor Crown will tell us, many people who have cancer will outlive the Senator and me. That is not to minimise the diagnosis, but, thankfully, it is not the death it was previously.

Senator Cullinane asked if we had a two tier system. I agree with him 100%. He asked me what I intend to do about it. We have laid out a five to seven year plan. Senator Crown talked about his matrimonial analogy but I take it the other way. This is the first time we have had political parties and a Government mature enough to say that we would love to fix it in one term but we will not be able to; it may take us two terms. We are being honest about that. If we can do it quicker we will, and there is nobody more keen to do it quicker than me. I abhor the two tier system. The American health economist, Mr. James Tussing, who was here when the capitation came in to the GMS for general practitioners, returned six years later and said he was pleasantly surprised that it had not resulted in a two tier system in primary care, yet we have it in secondary care. We are hell bent on addressing that. We are also hell bent on addressing the issue of waiting times.

I want to be positive. I do not want to ignore Senator Kelly's question which I did not hear properly. I am told it was the restrictive work practices and the bias against people. There is no bias against BUPA or Aviva. We want to regularise the insurance market because there are other people coming into it. We want more competition because we believe competition gives better options for the customer. If we introduce universal health insurance one of the things we want to do is reduce costs. I have made it very clear to the chairman of VHI that this must be the focus this year. There will be new negotiations with hospitals and consultants in the coming year and they must focus on reducing costs, and not just reductions to go 10% across the top or to say that those procedures belong in hospital but we want better value for them. Those procedures should not be done in hospital; they should be done in general practice. What are we paying them — a side room fee as well as a consultant's fee? No. We are not paying a side room fee for those procedures; they can be done in general practice. We might even consider, and this may shock some of my consultant colleagues, that they will be paid less if they do them in a hospital than in a primary care centre. We intend to bring the service to the patient and get the best value for money for the taxpayer as well.

There are positive things happening. I thank everybody for their time and interest in this area. They say all politics is local but all health is local too.