The welcome increase in funding since 1997 has shown clearly how ineffective are the management structures and accountability of the health service. In previous years, when resources were not so available, we could have argued that the problem was lack of resources but that argument is now hollow. Clearly, the problem is not resources but rather how these public resources are planned, managed and accounted for. Is the €9 billion spend delivering everything we can expect it to? Do the 100,000 who work in the health service use their talents effectively and are they well-managed and focused on service delivery? Is there clear and accurate public accountability for this level of public resources? Fundamentally, does the system work? Clearly, the answer is "No". It neither works as we expect it to nor as the public deserves.

This is not a reflection on anyone because thousands of fine people work in all parts of the health service and they want to be effective in their work and the services they provide. It is instead a reflection of what is now a dysfunctional system, a collection of often unrelated institutions, agencies, decision-makers, boards and advisory bodies. The Government has recognised that there is an urgent need for review and action to address the problem of the health system being less than effective.

In 2001 the value for money audit that my party particularly sought identified serious deficiencies in the capabilities of health boards to develop service plans, manage value for money and implement performance management models. A big gap in terms of data and management information was identified. In essence, health boards were often more focused on administration than real management.

Efforts at effective management at national and regional level were dissipated by the proliferation of organisations and the absence of management capabilities on boards. The value for money audit did not make a strong recommendation about health boards and agencies but the issue of what to do about them was highlighted in An Agreed Programme for Government as a matter of urgency. The programme states: "We will seek the completion of the report on health agencies and management structures by the end of 2002 and will move forward on the principle of removing unnecessary overlap of functions and minimising delays in implementing service improvements." The report by Prospectus Management Consultants is nearing completion and I understand its recommendations are likely to come before Government soon. It is vital that this report and others nearing completion in the areas of financial accountability and medical manpower are far-reaching and courageous in their conclusions.

We have too many health boards. They do not provide effective governance or management structures for public money in the health service and are not delivering the valuable local and community input into the service that people want. There is too much inconsistency in health planning and delivery and too many agencies in the service. What we need is rationalisation. The public needs to know who is deciding what and why. The taxpayers and users of the services are paying for this, not the Minister for Finance or the Minister for Health and Children.

Many reports over the past decades have been acted on only partially or minimally. We now have major funding for health and it time for major reforms. The system is not working well. Not only will it be unable to respond to increased funding in future, it is not using well enough its existing €9 billion funding. When evaluating these reports the Minister and the Government should think big and look beyond the pressures from interest groups and individuals which inevitably arise when change is proposed. Change is difficult but it must be embraced. It brings uncertainty and people's fear of change is often greater than their dislike of present problems. Organisations and systems do not welcome change, even when people within them know that something is wrong with the status quo. I have no doubt there will be objections from well-meaning people and organisations, from clinicians, managers, administrators, representative groups and public representatives.

I urge those groups to look at the wider picture, and to regard the Government's proposals, when they are presented, as opportunities for improvement for the people we serve rather than as threats to their position. Above all, those groups should reflect that the health services cannot be sustained and developed if they remain as they are.

A first principle in medicine is do no harm. In policy making it is said, 'If it ain't broke, don't fix it'. Let us agree that the health system is broken and needs fixing. It is futile to argue about how or where it is broken and who is at fault. Doing nothing is not an option. Reform is absolutely necessary and that means reform for us, not only for other people and other groups. I urge the Minister and the Government to implement the required changes rapidly. Delays waste time and money.

In 1996, the then Minister for Health and Children, Deputy Noonan, announced the plan to establish an Eastern Regional Health Authority. It was another three years, however, before the legislation giving effect to the ERHA was passed. This structure has not worked as well as was hoped because it created another layer of governance and management,

I have no doubt that reforming the Health Act 1970, which set up the health boards, and the raft of secondary legislation governing health agencies, will be complex. It must be done carefully and correctly. We cannot afford three years or more of analysis, consultation, drafting and debate. In this motion, we are urging decisiveness in policy implementation. I am confident that the Government will be decisive and that it wants to address the problems identified in the value for money audit, as well as those we encounter in our work and the issues that I expect to be highlighted in the imminent consultancy reports.

The review of agencies and management structures is a key part of the Government's health strategy. Although the strategy set out over 100 actions, the media most frequently judge it by the number of new hospital beds provided. If one looks closely at the analysis of our health system and its numerous anomalies, one will easily conclude that the most important strategic actions on health policy will be reforms of management, financial accountability and medical personnel. These are the areas addressed in the forthcoming consultancy reports.

System change is strategic and we seldom have the chance to implement it but this Government will have the opportunity to do so. In the coming months we can initiate strategic change in our health service. That is what the Government's health strategy and policy should be judged on.

I am confident that the Government has the will and capacity to meet that test. I urge the Minister to embrace the process rapidly and begin the reforms and make the political decisions necessary to flag our intention in this regard. I believe that the Minister has the ability to do so and I hope he will embrace that challenge.

The Progressive Democrats look forward to an intensive and focused debate on these issues in the coming months. Moreover, we look forward to action on strategic change that will make a real difference in the services we provide to the public, funded by public resources.

The health service is the most important service of all but it is also the most neglected. I can recite a litany of its inadequacies. In the last four and half years the Government recruited 4,000 administrative staff but only 2,000 nurses, which demonstrates an unusual sense of priorities. The scandal of the waiting lists is a horror. The state of the nation's health is equally horrific. Ireland has the highest rate in Europe of death from heart disease, which accounts for almost half of all deaths here. The rate is almost twice the EU average. One third of deaths of people under the age of 65 are caused by cancer. This is the third highest death rate from cancer in Europe. Many of those who die are awaiting so-called elective treatment. We can improve our health care in these areas while ensuring that the significant advances we already enjoy are maintained and built upon.

Double standards exist in Ireland today; if one pays for health care, one will live longer and in less pain while those on low incomes will suffer. This is unjust, unacceptable and untenable. There must be a comprehensive, high quality health service available to all based on fair criteria, not the size of a person's bank balance. Citizens cannot be confident of appropriate treatment when they are ill. Major health care service providers have not justified the trust placed in them by citizens. The poor, elderly and many others suffer second-class treatment or no treatment at all.

That the Government has shown a glaring lack of leadership and direction in solving the critical problems of the health care system is obvious. Despite the increased investment in health over the past five years and the various waiting list initiatives, the reduction in waiting lists since 1997 has been a minimal 1,000 persons per year. Add to that the fact that 57% of people on waiting lists are waiting for a bed in one of the Dublin hospitals where numbers on the lists have risen by 16.5% over the past five years. Many of the national specialty hospitals are based in Dublin.

More worryingly, the most recent waiting list figures available are from June 2002, before the post-election cutbacks. We have to wait until mid-May to find out the number of people on waiting lists as a result of post-election cutbacks and the withdrawal of the national treatment purchase fund. It is outrageous that the Department's information systems are so antiquated that it takes four and a half months to establish how many people are awaiting a hospital bed. Four out of ten children who need cardiac surgery have to wait the promised six months, seven out of ten of those awaiting ear, nose or throat surgery have to wait the same length of time, as do eight out of ten children awaiting plastic surgery.

In terms of numbers, the Midlands Health Board was the smallest in the country until recently when it overtook the North Western Health Board. The board of which I am a member has brought a number of new services on-stream while living within its budget. We have heard much about the dental services and I am delighted the industrial relations matter has been resolved. Thanks to the services of our consultant orthodontist, the board has eliminated the waiting list for orthodontics in two of the four counties it covers and is well on the way to eliminating the waiting lists in the other counties.

One of the Senators mentioned staffing. The staff drive and deliver the service, but there is a misconception about them. There were 68,000 staff in the health services in 1997 and 96,000 in 2002. It should be noted that this increased staffing level includes 340 extra consultants, 5,800 nurses – not the 2,000 quoted by Senator Feighan – and over 600 training places. Just over a week ago I was delighted to present the second batch of graduate nurses to the Midland Health Board. The board also has an intake of psychiatric nursing trainees.

The national task force on medical staffing was examining the implications of introducing a consultant provided service and reforming the development of non-consultant hospital doctors to meet EU requirements. The task force made it clear that it will not be sufficient to simply look at the number of medical staff. It must also consider delivery of services throughout the hospital system and have full regard to the interactions with primary care and long-term care services.

In the past Ireland's health service has held up well, given that the system has remained largely the same at its core for over 30 years. However, it is now time to examine the structure. There is nothing so good that it cannot be improved. This motion says, in essence, that the health boards have delivered well in the context of services. Questions are being asked about accountability and services. Many of the administrative positions that have been referred to are for secretaries working in accident and emergency, for consultants and for other services. They are, therefore, front line service providers.

It is not my intention to criticise anybody. Every one is providing a service. The question is whether we can do it better.

We are more than a year into the new health strategy and we have seen little that benefits people. This is particularly so in Carlow, the only county in Ireland with no hospital. The town of Carlow is constantly growing but it has been neglected. There are poor step-down convalescent facilities there. The town has been waiting more than six years for a ten bed extension to the district hospital, which I discussed with the Minister yesterday, and it has also been waiting for a 13 bed extension to the Sacred Heart hospital for many years. This is unfair to families in Carlow who must travel 50 miles to a hospital in Dublin or Waterford to visit relations and endure the stress and trauma this causes. Even when their relatives are recuperating, they must continue to travel long distances. People in Carlow are realistic. They realise there cannot be a hospital in every town and village, but they do expect to have step-down convalescent facilities. They are entitled them.

The previous speaker referred to the health boards. I welcome the Minister's announcement that he will reduce the number of health boards. However, initial reports suggested that he planned to remove public representatives from the health boards. Public representatives are not the problem. Public representatives are elected by the people and are accountable to them. Somebody once said that medicine is too serious to be left to doctors. The last thing we need is a group of consultants in an area looking after their own departments and not keeping the bigger picture in mind. The beauty of having public representatives on health boards is that they will see the bigger picture, both in geographical terms and in terms of human resources.

Money is not the problem in the health services. The current Government and its predecessor proved that by substantially increasing spending on health. Unfortunately, problems still exist. Recently I encountered a lady who needed to have a tooth removed. She was told she would have to wait until November to have it done. That is what is happening. She went for private treatment and had the tooth removed the next day. To expect somebody to wait for 11 months with a toothache is unrealistic.

The Government has failed to address the problems in nursing. I attach great importance to the nurses in the health service. The last speaker mentioned the 96,000 people employed in the health sector. I would appreciate information on the number of nurses and an exact breakdown of the categories of staff. I have a sneaking suspicion that many of them, particularly those employed in recent years, work in administrative areas. They are not needed there. It only creates further layers of bureaucracy. We have greater need of nurses, consultants and doctors.

I compliment the health services on the great work they have done in the area of mental health. Carlow is the location of St. Dymphna's psychiatric hospital, which has done great work with its patients. Many of them have been moved out into the community, which allows them to live a more regular lifestyle. That is a welcome step. However, there are many more new challenges in health. I recently attended a meeting in Carlow on autism. This problem has huge implications for the Departments of Health and Children and Education and Science. The issue of assessment must be examined. Parents are still being forced to have their children assessed privately for dyslexia and autism. The Minister should give this matter particular attention.

Will the Minister talk to the Minister for Social and Family Affairs about the dental dispute and make her see sense? Will he ensure that the people who paid PRSI contributions and had to pay dentists in the last few months are given a refund, to which they are entitled?

The people will decide on this issue when it comes to local, European and general elections. Prior to the previous general election Fianna Fáil Deputies and prospective Fianna Fáil Deputies in every constituency promised that certain services would be made available. The chickens are now coming home to roost. I hope the leak regarding radiotherapy facilities is incorrect because we received more promises from Fianna Fáil and the Progressive Democrats that radiotherapy services would be made available in Waterford Regional Hospital. I hope those facilities will be delivered by the Government because we need them. The regionalisation of such facilities is part of the health strategy and the programme for Government. Will it be another one of those promises that will be forgotten once the general election is over?

I second the amendment moved by Senator Feighan and condemn the Government for its inaction in the management of the health service.

The dogs in the street know our health system is on the point of collapse. The Government needs to wake up and smell the coffee. For once Fianna Fáil should not concentrate on entertaining its builder and developer friends from the elitist sections in society at the hospitality tent at the Galway races. It should come off its high horse and look at the ordinary men and women tricked into voting for a right-wing arch-conservative Administration on the basis of a plethora of lies last year.

I have heard of patients, who have been taken into casualty units at 4 p.m. and are still lying on trolleys in corridors two days later because there are no beds available. The Midland Health Board allocated a complement of 12 beds to the Longford-Westmeath Hospital in Mullingar, but the Minister and his Department failed to provide the staff needed to operate them. These beds would provide treatment facilities for the people of the Midland Health Board region. It is scandalous.

People are appalled by the way they are being treated. VHI premiums have been increased by 18% since the Government was re-elected. I know several people who are due to have hip replacements, yet cannot be accommodated. Having to wait longer is having a serious knock-on effect on their health. They should be looked after. We could all find ourselves in a similar position at some stage in our lives. It is important we care for our sick and elderly.

Since returning to office, the Minister has increased charges for patients attending accident and emergemcy units without a doctor's letter and raised the thresholds for the drug refund scheme. Why, when the number of care staff in most of our health boards runs into hundreds, do the administrative staffs number thousands? Our health boards have chief executive officers, deputy chief executive officers, assistant chief executive officers, administrators of one kind of another, Irish officers, yet they cannot administer community services and initiatives because of shortfalls in certain areas. I plead with the Minister to look after the sick and elderly in society and take action to ensure our current problems do not deteriorate further.

The people are justifiably angry. They were lied to in the run-up to the general election when several Ministers denied that health cuts were being planned. What has happened since? The health service has been eroded left, right and centre. We, on this side of the House, will no longer tolerate it. I can guarantee the Minister that when the Fine Gael Party is returned to office, it will reinstate a proper health service that is the envy of Europe.

The range of services provided within the health system is almost unique by international standards, covering everything from health promotion, disease prevention to acute hospital treatment and a wide spectrum of personal, social and community services. One of the problems in showing effectiveness and outcomes of investment in the health area at the macro-population level is the time-lag between the investment and the measurable effect in terms of life expectancy and/or premature mortality. However, there are improvements to be pointed to in the system and it would be remiss of me, and unfair to our highly skilled and committed workforce, not to illustrate some of these achievements.

The overall aim of the health strategy is to improve the health status of the nation. That means helping people achieve their full health potential. This may mean medical interventions aimed at cure or the putting in place of supports to improve individuals' health, personal well-being or quality of life.

Immunisation is an area where effectiveness is relatively easy to measure and the outcome can be seen in a matter of a few years or even less. Recent successes have included the introduction of the haemophilus influenza type B vaccine in 1992, given its role as a significant cause of meningitis. Since the introduction of this vaccine, the incidence of this condition has reduced tenfold and is close to the point of eradication. An immunisation campaign against group C meningococcal disease was launched in October 2000. The aim of the campaign was to immunise all children and young people up to 22 years of age against the disease. The result has been impressive. In 2002, 14 cases of group C meningitis were reported, compared with 139 cases over the same period in 2000. This represents a 90% reduction overall. However, this success did not come cheaply. The costs of the group C meningitis programmes were in the order of €80 million for initial start-up and €10 million ongoing revenue funding.

This clear and quickly obvious link between intervention and outcome is the exception rather than the rule. There are areas where the full health impact of investment is less easy to measure. However, it is important to understand the impact of investment and the capacity of the delivery system before we begin to talk about system efficacy.

A particular feature of policy development over recent years has been the development of highly focused disease or condition specific action programmes. Leading examples include the cancer and cardiovascular strategies, addressing the two main premature killers.

Since 1997 there has been a cumulative investment of €400 million in the development of cancer services, well in excess of the £25 million initially envisaged in 1996 to implement the national cancer strategy. This funding includes an additional €29 million allocated in 2003 for cancer services this year. That investment will ensure that this year we continue to address increasing demands in cancer services in areas such as oncology/haematology services, oncology drugs and symptomatic breast disease services. This substantial investment has enabled the funding of 80 additional consultant posts, together with support staff in key areas such as medical oncology, radiology, palliative care, histopathology and haematology.

There has also been investment in the development of symptomatic breast disease services. A total of €30 million has been invested in these services alone since 2001. The benefit is reflected in the significant increase in activity which has occurred, with in-patient breast cancer procedures increasing from 1,336 in 1997 to 1,829 in 2001, an increase of 37% nationally. We can also show dramatic increases in chemotherapy and radiotherapy services throughout the country.

The increase in activity levels has been quite dramatic in all these fields over the past few years and one has to ask how we were treating cancer before this level of investment. The bottom line is that previously we were not treating cancer adequately – and that is not to say we do not have more to do. Obviously increased investment is necessary.

We have introduced a national breast cancer screening programme, BreastCheck, on a phased basis and have achieved an uptake of over 70%, which exceeds international standards in programmes of this kind. We are also putting symptomatic breast cancer clinics of excellence in place with attention to geographic spread.

We anticipate that the reports of the National Cancer Registry Board will enable us to show, over time, the link between the type of treatment provided and outcomes in an Irish context. I hope to return to the House to debate the evaluation of that cancer strategy or the formulation of a new one. We will have an evaluation of what happened over the past five years. The critical issue is outcomes, survival rates and reduction of mortality.

Heart disease is the single biggest killer in Ireland. The implementation of the cardiovascular health strategy will have a significant impact on heart disease, an everyday reality for thousands of Irish people and their families. The Government has committed a cumulative €54 million towards its implementation since 2000.

This has supported a wide range of new regional services and initiatives and created almost 800 new posts, four out of five of which are professional staff. The process of appointing 17 of 25 new consultant cardiologists is also under way. This will bring the total number of consultant cardiologists up from 29 to 46. The range of services being sponsored from within this funding is broad, including health promotion, primary care, pre-hospital care, hospital care, cardiac rehabilitation as well as information systems, audit and evaluation.

There have also been substantial improvements in acute services. Of the 3,000 beds committed to in the strategy, 520 were funded in 2002 and the remaining beds will be brought into use shortly. Based on provisional figures provided to my Department by health agencies, for the first 11 months of 2002 there was an average of 12,219 acute hospital in-patient beds available. Considerable progress has been made in reducing waiting times for public patients in 2002. The total number of children waiting for more than six months for in-patient treatment has fallen by 24% between June and September 2002. On the points made by Senator Feighan about cardiac surgery for children, we have made dramatic progress by sending children abroad, with the agreement of the consultant in Crumlin hospital, to Johns Hopkins Hospital in the United States and to England. That has resulted in a dramatic erosion of the waiting list, particularly for children awaiting cardiac surgery, while we are building up capacity in Crumlin in terms of the additional operating theatres.

The total number of adults waiting for more than 12 months for in-patient treatment in the nine target surgical specialties covered by the waiting list initiative has fallen by 15% between June and September 2002.

The hospital system has continued to improve its productivity. A total of 968,000 people were treated last year as either in-patients or day patients in acute hospitals. That is an increase of 5% over the 2001 figure, which was an increase of 6% on the 2000 figure. Since 1997, the number of patients treated in our acute hospitals has increased by 23%. An internationally accepted measure of acute hospital efficiency is the proportion of day cases and the picture in that regard is impressive. In 2002, day cases were up 14% over 2001. Since 1997, day cases carried out in Irish hospitals have increased by 44%. Some of our Dublin teaching hospitals have passed the 50% mark and are now treating more patients in a day case setting than as in-patients. In this regard we are up with best international practice.

While the waiting list initiative will continue to fund additional elective activity, the dedicated national treatment purchase fund is being used to target those waiting longest for treatment. Funding of €43.8 million has been provided in 2003 for the waiting list initiative and a further €30.75 million has been provided for the national treatment purchase fund. To date, approximately 2,300 long waiters have received treatment under the national treatment purchase fund.

In 2002, a primary care task force and steering group were established to drive implementation of the model. In 2002, the task force selected ten locations throughout the country for the putting in place of implementation projects in line with the primary care model. The projects will enable the new model of a multi-disciplinary based primary care team to be demonstrated in action and refined as necessary. Funding totalling €8.4 million is being provided for the projects in 2002 and 2003. As the ten projects are developed, more than 80,000 people will benefit from having direct access to an improved range of services provided by their primary care team.

To complement the primary care model, it was envisaged that in the short term, general practice co-operatives would be established on a national basis so that effective out of hours services would be available in all parts of the country. The funding provided for out of hours co-operatives in 2002 totalled €17 million. Each health board region now has GP co-operatives in place and these are being progressively extended board-wide. Negotiations are ongoing on further expansion this year.

There has also been substantial investment in continuing care services since 1997. For older people this has meant enhancement of nursing home subvention schemes, the provision of additional home helps, improving community-based services and services provided in community hospitals and day care centres, additional respite care and support for carers. For people with intellectual disabilities and autism, service developments provided for included, in 2002 alone, over 100 new residential places, 75 new respite places, 600 new day places and the continuation of the programme to transfer persons with an intellectual disability or autism from psychiatric hospitals and other inappropriate placements. For people with physical disabilities, in 2002 alone investment was provided for the enhancement of home support services, therapy services, up to 100 additional posts as recommended in the sector's service audit, 500 rehabilitative training places and 15 guidance-assessment staff in the health boards in the area of rehabilitative training.

We all know that there are benefits to be gained from investment in the health service in terms of overall economic development. However, assurances that money is being spent effectively and efficiently are crucial. The strategy recognises that further spending can only come in the context of improved efficiency and that investment decisions have to be based on sound information and evidence.

The introduction of the service planning framework has provided an opportunity to enhance the way in which health services are planned in terms of addressing changing needs and ensuring the best possible quality of care is provided for the resources available. This is a major advance in the health system, linked as it is to statutory accountability.

Last year saw a set of performance indicators conjointly agreed between the health boards and the Department being put in place to enable better performance and accountability in the delivery of health board service plans. These indicators will be built on in moving towards a stronger focus on performance at all levels in the health system. A high level steering group and project team made up of representatives from the Department of Health and Children and the health boards were recently established to further develop and enhance service planning and performance measurement in the health service.

This framework provides a foundation for further reform but it needs to be enhanced. In isolation it cannot achieve the order of reform necessary to really improve overall system functioning. Much more needs to be done.

One of the issues which came to the fore during the consultation process on the health strategy was the complex structure of decision-making, roles and responsibilities within the health system – many involved in the national consultation process which led to the strategy commented on this. Other issues included the many layers and intersecting roles, and the lack of consistency in the development of systems and the application of schemes.

It has to be acknowledged that the present structures in the health system evolved from a model developed over 30 years ago. During that time the size, range of functions and complexity of managing the system have all grown dramatically. There have been significant enhancements to the original health board model through the Health Acts 1996 and 1999 as well as considerable changes to the internal structures of the Department of Health and Children and the health boards. A number of new advisory and executive bodies have also been established in recent years.

One of the main conclusions in the strategy was that while the system had served us well in many respects, some significant concerns remained. These include the need for stronger co-ordination and integration of functions and services; greater consistency in access to and delivery of services; and greater clarity around levels of decision-making in the full range of organisations, particularly, vis-à-vis the role of the Department and the requirement for "whole system" effectiveness.

A number of strands of reform are being formulated in respect of the health system – first, the undertaking of an audit of structures and functions in the health system, to which there is a commitment in the health strategy. The audit will also deal with the commitments in the strategy in relation to the establishment of a national hospitals authority and a health information and quality authority.

A second strand of analysis relates to the work of the national task force on medical staffing. This review is concerned with preparing a plan for the medical staffing of acute hospitals based on the recommendations of the report of the medical manpower forum in 2001 and the report of the national joint steering group on the working hours of non-consultant hospital doctors in 2001. Part of its work is concerned with examining the practical implications of moving to a consultant-delivered hospital system that would dramatically change and improve the quality of service to patients. This is likely to include reference to the future configuration of hospital services – in other words, deciding which hospitals will provide what services in a consultant-provided context.

A third strand of reform to be drawn together with these two is the work of the commission on financial management and control systems in the health system being undertaken on behalf of my colleague, the Minister for Finance, who established the commission, on which the Department of Health and Children is represented.

I will elaborate on the work in relation to the audit which is now at an advanced stage. Action 114 of the strategy was intended to support organisational development in helping to clarify roles and co-ordinate the work of different organisations. Specifically, the audit was commissioned in order to ensure clear lines of accountability and communication between each part of the system; no overlap or duplication between organisations; and a proper alignment of the structure as a whole to the vision and objectives outlined in the strategy.

The outcomes sought are to ensure the structures in the system are the most appropriate and responsive to meet current and future service needs; constitute an adequate framework for overall governance of the health system; achieve an effective integration of services across all parts of the system; adequately represent the views of consumers in the planning and delivery of services; and focus on the principles of equity, accountability, quality and people-centredness and the national goals of the strategy.

My Department commissioned Prospectus Strategy Consultants in June 2002 to undertake the audit. The preliminary response of the consultants was to identify the need for the consolidation of structures within the health system. It is important to acknowledge that the findings and recommendations of the consultants must be considered in the context of the considerable achievements of the system I have just outlined. These achievements are an indication of the commitment at individual, professional and corporate level within the system. It is important to be clear that the findings relate to systemic problems and in no way reflect the considerable expertise, skill and dedication of the workforce.

In summary, the consultants found a number of barriers to achieving the improvements sought in the strategy. They also identified the need for strengthened frameworks for governance and accountability as well as the need to develop and enhance supporting processes to secure improved planning, integration, delivery and evaluation of services.

While a final draft of the report is pending, it is already clear that the need to significantly reform the existing delivery structure will be put forward as a major proposal. This will include the development of a unitary delivery system involving considerable consolidation of existing agencies; the configuration of services into two broad pillars, one centred on acute service delivery and the other on primary, continuing and community care; and the development of large-scale shared services. This unitary system is being advanced as the most appropriate way to support the individual strengthening of each pillar within the system, while at the same time providing for a more structured approach to integration processes.

The proposals also include the development of an improved system of governance and accountability which clarifies and creates appropriate boundaries between the delivery system and the Department of Health and Children. This is intended to allow the Department to focus more actively on its role in policy development, population health planning and the monitoring and evaluation of the impact of the delivery system on health status. The proposals emerging will support the commitments made in relation to reform of acute hospital services and the likely changes required, in terms of configuration, anticipated in the health strategy. They will provide a more adequate unitary approach to the delivery of hospital services which, in turn, will support the more even and consistent introduction of consultant-delivered services.

It would also be imprudent to suggest that the gains from changes in system structures and function changes can be achieved without continuing investment in the health system. There are several reasons for this, the principal one being that healthcare is expensive. We need only look at the increased frequency and volume of MRIs in recent years as a classic illustration of technological advances in healthcare There are also an ageing population and higher levels of public knowledge and expectations, combined with pay and non-pay inflation, which make it expensive just to stand still. From a cost viewpoint, there is a cruel paradox in the fact that the more successful the outcome, the more expensive it gets. When we appoint an oncologist, the service will improve and the treatments increase, as will the expenditure. That is what is happening in many of our acute hospitals.

Important factors to be considered include demographic projections for Ireland which suggest that by 2011 the population aged 65 years and over will have almost doubled to an estimated 767,300 and constitute 16.4% of the population. This is a factor of major significance in planning for the provision of acute hospital services.

Demand for health care is increasing as a result of better education, increased expectations, economic prosperity and technological advances in health care permitting earlier and improved diagnosis and treatment. Many successful medical interventions are now made in middle years, yielding longer life expectancy but also, typically, dealing with the onset of further illness later in life.

The need for continued investment relates to the current deficits in the system which must be improved to achieve the changes we seek. Hundreds of millions of euro have been invested in developing infrastructure under the national development programme –€2 billion has been committed between now and 2006. Notwithstanding the significant funding of capital projects in recent years, there is still significant investment required to upgrade facilities such as the Central Mental Hospital, Our Lady's Hospital in Crumlin, radiotherapy services and a variety of other facilities, especially those providing care for older people.

The full development of information and communication technology capability is identified as a prerequisite to improving monitoring and evaluation of services, improved health impact assessment, and, in turn, better value for money. Report after report has identified this as a major system deficiency. There is a need for up-front support of structural reform of the nature being contemplated. A national reform programme will result from the current proposals and that will also require investment. We must continue to invest in the system if we are to keep pace with the changes and at the same time deliver the potential yield from the radical restructuring of the system.

The Government is committed to taking early and decisive action on reform of management structures and financial accountability. The first stage is the finalisation of the two key reports, the audit of structures and functions and the report of the commission. The Minister for Finance and I will be submitting the reports to Government for decision in an integrated manner.

I am confident that there are gains to be made from a radical restructuring of the system in terms of efficiency, effectiveness and value for money. The proposals now being advanced, however, are a considerable challenge to everyone in the system. I will not understate the enormity of the task ahead. There are no quick fixes for the change we envisage undertaking in the coming years. In addition, I must reiterate that the potential of the system can only be realised if we continue to invest as we reform.

One reason why the current health care system is failing patients is that it is not fully utilising the skills and services of the professionals employed. Employment in the health services increased in recent years and currently stands at over 100,000 – a dedicated team of nursing, medical and administrative staff. These people are caring, committed and dedicated professionals who are highly skilled. They work in our hospitals and provide GP services, work as midwives and community care nurses. They are extremely hardworking but the health service as currently organised does not make full use them.

It is important to stress that any reform of the health service is not intended to undermine front-line staff. We want to give them the best possible opportunity to make a real difference in patients' lives. The health service cannot be sustained if we leave them as they are. If we are to get real value for money, use people's skills to the maximum and deliver patient-centred care, the Government must take immediate steps to reform the health service.

Within a framework of reform, we must get the balance right between the administrative set up and medical service provision. When looking at the cost factor, one must remember that we cannot look at it like a business. We cannot get rid of people from the personnel department because it is top heavy. If one consultant does 1,000 hip replacements in Cappagh at a cost of €20,000 and his counterpart performs 1,000 at a cost of €30,000 in the Mater Hospital, the consensus might be to go with the consultant charging €20,000 per thousand, but that might not be good value for money. The more expensive consultant might be dealing with patients in their 90s who have a much higher cost factor in after-care. He may use a better product in the hip replacement procedures he carries out. He may be a better consultant or a better surgeon, putting greater thought and effort into the job. In a medical context, the fact that he is doing so at a less expensive rate is not necessarily the issue. In considering cost factors and cost-cutting measures, we need to be careful how we proceed. We must not always seek the cheapest option.

The total number of people treated in acute hospitals increased by 6% last year. That represents an increase of 48,500 patients in one year, which is massive by any standards. The threefold increase in funding during the past six years, substantially brought about by the current Minister, has made additional demands on resources. A total of €43.8 million will be provided in 2003 towards shortening waiting lists and reducing waiting times. Senator White referred to the fact that she had the privilege of being able to have an MRI scan when she saw fit because she could pay for it. The Minister has gone some way towards dealing with that issue through the treatment purchase scheme by bringing closer to people on public waiting lists the ability to have their operations much earlier than would otherwise have been possible.

A recent television programme showed a prime example of that scheme in operation, with the television cameras following a patient from Beaumont Hospital to England and back and showing the excellent treatment he received. In a subsequent interview, that patient was totally satisfied and described his experience of the scheme as being "as good as it gets". The Minister is to be congratulated on that scheme and not bombarded with criticism.

Between 1998 and 2001, the number of nurses and midwives increased by 6,000. The health strategy provided for an extra 10,000 to be trained during its lifetime, which was another massive undertaking. In addition, there has been a 59% increase in cancer treatments. That is the single most effective tool which has been put in place. Chemotherapy has increased by 86% in overall terms.

On services for people with disabilities, an area which is dear to my heart, the Minister has made a massive commitment. I acknowledge that we are seeking more money from him, but what other sector is not doing likewise? We make our submissions on the basis of sustainable arguments and, on that basis, I hope additional funds will be forthcoming.

If I have any criticism, it would not be directed at the Minister but rather at the system and would relate, in particular, to the reform of the health boards in 1996. I never agreed with those changes. In my opinion history will judge them the result of a poor decision, which led to the creation of a further layer of bureaucracy and made it more difficult for people to get what they need. The changes were unfair to those who were obliged to deal with the new system after their introduction because these individuals were not trained and did not understand the financing of acute hospitals or voluntary agencies. Being left at the coalface without the required understanding, they were unable to grasp our approach in terms of financial requirements.

I will conclude by providing an example. Let us consider a situation where the total payroll in 2001 was €10 million and where standard incremental and national pay increases were awarded on foot of Government decisions. The payroll increased from €10 million to €11 million as a result, but when the additional €1 million was sought from the authorities, an allocation of only €10.5 million was forthcoming. From where would the remaining €500,000 come? That is a crazy situation. It may be that people's focus in the early stages was incorrect, that money was spent in the wrong areas and that difficulties arose as a consequence. That is where system failed and I look forward to the changes the Minister will introduce in order to reform it.

I welcome the Progressive Democrats' motion and I compliment that party on bringing it forward.

The Government is not immune to accepting good proposals from any quarter, as has been demonstrated over a considerable period. The situation has to be viewed in context. It is entirely appropriate for Members on this side of the House, as occurs frequently in the course of debates on this and other subjects, to put forward proposals for future implementation. I acknowledge that the Minister took the substance of the motion totally on board when he stated in that the Government is committed to taking early and decisive action on the reform of management structures and financial accountability. I am pleased that he has fully accepted the thrust and sentiments of the motion. He said he is confident that there are gains to be made from a radical restructuring of the system in terms of efficiency, effectiveness and value for money. We could not have expected more than that in response to the motion.

The national health strategy, which I believe was one of the most innovative and radical documents in the health sector for many years, has been delivered on. The Minister has enumerated the events which have taken place with regard to the adoption of the strategy as well as outlining the matters which remain to be implemented. The Progressive Democrats are pleased that the treatment purchase fund has kicked in and is having a positive effect. The Minister referred to GP co-ops, which have been highly successful. It is clear that progress has been made.

This debate is not about the quality of staff in the system or the quality of care which the system provides for people who are ill. I totally reject the statement made earlier that Ireland has the worst health service in Europe. I suggest we have one of the best health services in the world in terms of treatment of people who are ill and in need of urgent attention. We still have people in the health service who provide a high quality of care and commitment and who, accordingly, should be encouraged. The system within which they have to work is a different issue. That system is obviously unsatisfactory and must be improved, as is the Government's intention.

It is relevant to ask if all stakeholders in this system are willing to participate fully in its reform, in bringing it forward and making sure it delivers. The point was well made by Senator Kate Walsh and others that the focus must be on the patient. If consultants, management and politicians focus on the patient, everything else will fall into place. Senator Minihan quite rightly spoke of the focus being on administration rather than on real management. We have to move beyond that situation in terms of what the patient requires.

Politicians in this House have been just as territorial about this debate as are consultants, administrators, etc., about their areas of expertise. We have managed to see the mote in every eye except our own. Members have repeatedly spoken of the lack of one health facility or another in their respective areas. The focus always came down to a Member's area. That is very clearly indicative of the deficiency in the health board system. We cannot close a hospital or have rationalisation within the system because there are too many vested interests working to ensure that this will not happen.

The Minister went directly to the core of the issue when referring to technology, which is now at a state of development and cost which precludes delivery at every local centre throughout the country. That is impossible in relation to MRI scans, to which particular reference was made. There are more cars in this country than ever before and the people are more mobile than ever. We cannot locate some of these facilities in every area. Would it not be better to buy four helicopters and close down a few hospitals? Would that not be better in terms of delivering the leading edge technology required to ensure that people who are under grave threat can be protected?

I heard a very courageous statement by Professor Bonner of the Institute of Obstetricians of Ireland the morning after a particularly bad tragedy was being used to make nakedly political points. He had the courage, in the teeth of the difficulty, to state that we have to accept that some of these services can only be delivered at national level or at regional level, that they cannot be delivered at local level. That is the measure of the cost of technology that we are dealing with.

Senator Browne was right about this. To be fair to him, he was the one person who said we cannot have one in every town. That is not to say that there should not be post-operative care and that people should not be able to go back to their communities when they are recuperating. That is a different matter. When it comes to acute care and leading edge technology, we must accept that it will have to be delivered in a few specialised centres.

I have a great deal of sympathy for the Minister in his attempts to deal with this complex and difficult situation and in his difficulties in dealing with the stakeholders, but I do not have any reservations about his commitment or his capacity to do it or about the fact that he will do it. When Senator Feighan asks why is there no senior orthodontist in Roscommon, I ask if it is required that there should be a senior orthodontist in Roscommon.

It is appalling that the cynical use of a personal tragedy should be used for nakedly political reasons and that people should be manipulated when they are in the throes of the most appalling personal problems to make political points. That has been done, not once but several times. We must act on the reports. We must accept that in some circumstances public representatives have acted in the same self-serving way as some others who are within the system. There is the question of the influence of personal liability insurance, but that is a debate for another day.

I would make one final appeal, which perhaps is more appropriately directed at the Minister for Health and Children than to the Minister of State, Deputy Callely. If there is one thing I would like to see done in this coming year, it is something concrete for people with intellectual disability. I and the people in that sector accept that an immense amount has been done, but it is the European Year of People with Disabilities and the Special Olympics will be held here, and there must be money for emergency services in that area.

I take this opportunity to refer to a number of points made. Having tabled a Private Members' motion such as this, I am astonished that the Opposition parties could not muster enough people to speak on this issue. Considering that I come in here daily and hear them calling for debates on the health service, where are they?

Níl

Níl–continued.

Tellers: Tá, Senators Cummins and Feighan; Níl, Senators Minihan and Moylan.

Amendment declared lost.

Motion put and declared carried.