That Seanad Éireann, noting that the proportion of the population in receipt of medical cards is close to an all time low; aware that the non availability of medical cards increases pressure on accident and emergency services; aware that a promise to introduce medical cards for 200,000 more people was made before the last election, condemns the decision to renege on that promise, calls for the immediate reversal of that decision and the introduction of a free GP service for all before the next general election.

I thought about this motion for a long time. As Senators well know, I am good at making the sort of speeches which provoke severe opposition. I would like to speak about this matter in a slightly different tone, for I want to invite the Minister to engage with me and be slightly less defensive than normal. We can do this any time we want, and we will be doing it every six months for the next four years.

There are serious issues of public policy involved in the health care debate. We are in danger of losing sight of certain fundamental issues and making wrong choices because of assumptions about what we are doing or what we have not done. I worry about many things, for instance, about the Competition Authority trying to enter into the debate by suggesting that an increased level of market-based indicators and competition or some such thing would improve the health service. I worry about the degree to which many people have capitulated to the ideological position of the Department of Finance that enough money is being spent on health care.

We see ourselves as an outgoing people, almost half of whom live in a wonderfully healthy rural environment and have a wonderful stress-free life. Ireland's image to outsiders is of a wonderful island of reduced stress. For that reason it is important to state the reality that we are quite a sick country. I will cite statistics from an address given by David Begg, general secretary of the Irish Congress of Trade Unions, in Galway in March 2002. At 65, we have the worst life expectancy in Europe, at 79, the second lowest life expectancy for women. We have the highest rate of premature death caused by coronary problems, the second worst cancer death rate among women, the lowest acute bed ratio, and so on.

Obviously, I could simply attack the Government, but this country needs genuine intellectual engagement about how we are to provide decent health care. Before I finish, I will have a few things to say about the Government. However, I genuinely believe that the debate must move on from my shouting at the Minister, Deputy Micheál Martin. That will not stop me from doing so, but there are issues to address, and I would like to go through them, for I am extremely concerned.

The number of in-patient beds has fallen, even over the last decade. The reduction – less than 1% – was not significant. However, at the same time there was a 10% increase in attendance at accident and emergency departments. The two together suggest that a problem has arisen.

There is a shortage of paramedics, medical specialists, radiologists and others. I know that action is being taken to address the problem, but crises are looming. David Begg says that 80,000 people suffer from heart disease. However, as the population ages, that figure could rise to 150,000 by the end of the decade. That would almost double demands on services. David Begg also makes the disturbing point that between 30% and 50% of people suffering from coronary heart disease require readmission to hospital.

I do not make these points to pretend that I have huge sympathy for the Minister's dilemma. I would love to be in the position to be faced with such a dilemma. It is time for the debate to move from election mode to a level that involves more serious intellectual engagement. If the House serves any purpose, it is probably to try to deal with matters of this nature in a rational manner.

The health service is excellent for those who can gain access to it. Two members of my immediate family required acute hospital services in recent years and both of them could not have been better looked after in terms of the quality of medical care they received. In the case of one of them, I do not believe they could have been provided with better care in any other country. We have good doctors and nurses, but the problem in the health service relates to access rather than care. Many people cannot access quality care because there is not enough available. In many instances, the care provided is excellent. For example, cancer services are extremely good but many who need them find that the provision of such services throughout the country is patchy nationally. That is why there are horrendously high levels of fatalities among women, for example. Not every woman who contracts breast cancer has the same access as others to good quality care. Where the care is available, it is of a superb quality.

The crisis of access manifests itself, in the main, through emergency admissions and the demand for accident and emergency services. It was no coincidence that in the last election the three largest parties in the State made proposals to deal with this problem. Each of them focused on the issue of medical cards. My party promised and remains committed to a GP service which is free to all. The proposal did not include free medicines, but free access to doctors for all patients. The latter would be appropriate and affordable. My only argument with the subsidised drugs scheme – which I, like anyone else in their fifties, use increasingly – is that it is harsh on single people on limited incomes. I have no difficulty with the scheme, in principle. The real problem is that limited access to an affordable primary care service is pushing people in the direction of hospitals.

Approximately one year ago, an extremely reliable authority said that between 90% and 95% of health and socio-health problems could be dealt with through a proper primary care service. As that authority in question was the Minister for Health and Children, I assume it is true. He also described quite well what people want from a primary health service, namely, that it should be community based, accessible at the time it is needed and capable of providing a full range of services. I agree with the Minister that this is what people want and need.

Before the election, Fianna Fáil promised 200,000 medical cards, Fine Gael promised 500,000 and the Labour Party proposed something that was only one step on the way to its eventual goal. The tragedy is that the Government's promise – for which the parties comprising the Administration are responsible – has been reneged upon. As stated earlier, I could easily, and would be well able to, bash the Government. However, I am more interested in discovering what caused the Minister to decide that he had obtained the greatest amount of money possible for the health services from the Department of Finance this year. Within the envelope to which the Minister referred, the 200,000 extra medical cards had to be given a lower priority.

In a Government of collective responsibility, decisions about overall envelopes of taxation and public expenditure are the concern of everybody in Cabinet. While it is easy to say that the Minister for Finance should do this or that, the reality is that he had to make decisions he should not have been obliged to make. He knows that Ireland is not spending as much on health care as do other countries. Based on purchasing power parities, we spend €1,500 per head on our health services while the Netherlands spends €2,000 per head. That means there is a difference of 25% in spending between Ireland and the Netherlands, which is the crunch point in terms of the Minister's envelope. I would like him to indicate why we have decided to spend 25% less on health care provision than the Netherlands, particularly when one considers that we are as rich as them. At a time when it is clear that there are huge needs, that is the choice that was made.

The Minister for Health and Children cannot tell me that a person with an income of €140 per week can afford to pay a GP or to pay €72 per month for medicine or that a married couple, both of whom are under 66 years of age, on an income of €202 per week can afford to pay for medical care. I do not believe anyone is of the opinion that these people should be obliged to do so.

I was correct to decide that I would not become involved in a discussion of an overly political nature. I want the Minister to address the issues of the priorities and choices of Government. He claims to be on the social democratic wing of Fianna Fáil. If such wings stand for anything, it is for decent levels of public expenditure and decent public services.

As the Minister is aware, the Labour Party proposes universal access to primary care and hospital services funded by universal health insurance. While the proposals are not set in stone, their implementation would constitute a radical reform of the system underpinned by funding to meet day-to-day expenditure. There should be major investment in infrastructure because a lot of the problems that have arisen are as a result of cutbacks in previous years for which we all have responsibility. We are now trying to catch up. A similar policy is being adopted now. This will create problems for the future. This is the 21st century and the time to create a modern health system appropriate to our modern economy.

The Government had a budget surplus last year of €5.4 billion in its current account. We should not be financing capital projects out of day-to-day income and expenditure. The Minister for Health and Children should speak to the Minister for Finance about financial policies. People do not pay for their houses out of a yearly budget and leave themselves without food. The Government's financing policy is one of the causes of the problems faced by the Minister for Health and Children.

At the very least, the Government should have kept its promise made at the last general election to extend the medical card to a further 200,000. There should be free primary medical care for everybody. Only one third of the population is currently covered. How can the Government afford to give tax cuts to the well-off while it is short of money to extend medical cards to those who need them? There is also an issue regarding the closing of tax loopholes and ensuring all taxes due are collected properly.

The Government's approach to the economy seems to be stop-start without any continuous investment in the two most important Departments which deal with health and education. When money was available, it was given back to the better-off by way of tax cuts. Then as now it was those on lower income who were squeezed.

During the last general election campaign I met a woman who told me that she could not bring her ill son to the doctor until she was paid. That is outrageous and it put her son's health at risk. Many parents face that dilemma. Older people on very low incomes can be above the income limit for a medical card if a spouse works part-time. They often must decide not to visit the doctor because of the cost involved. The long-term cost implication is that the care of the person concerned will be a greater cost to the health service in the future.

I do not deny that there has been an increase in health funding as stated in the Government amendment to the motion. I appreciate the Minister's efforts in relation to the health strategy but he is working within the mindset of the present which must be reviewed, as Senator Ryan said.

I note in a report I have received from Crumlin Children's Hospital that parents of children on kidney dialysis often spend the night on chairs because there is not enough room to fit a mattress on the floor of the cubicles. The health service is not acceptable. Those suffering from cancer are forced to lie on trolleys for days. Health inflation is running at 10%.

The Government amendment mentions the issue of primary care. If the Government is serious, it should provide funding to allow the new unit in Balbriggan to open. I disagree with the comments made about investment—

The Opposition argues that the number of people covered has dropped and I will not counter-argue because it is a fact but if the number of those covered by medical cards has dropped, there has been a rise in the standard of living and incomes for all of us. Today 1.14 million have medical cards. All of us in the Chamber are spokespersons on health for our parties. I am glad to see that health boards have brought their records up to date.

I am delighted that a Fianna Fáil-led Government extended the medical card to the over-70s. The Minister also made arrangements to ensure elderly people would not have to leave the medical practitioner they knew and choose another from a list. They were accommodated and allowed to stay with the practitioner with whom they were most familiar.

I ask my Labour Party colleagues what their grounds are for saying accident and emergency departments suffer as a result of there not being enough medical cards in the system. The charge is €40, not much more than the cost for a general practitioner. The co-op system will alleviate the pressure on the service which those who do not have medical cards are using. The co-op system will alleviate this and work in tandem with the accident and emergency service. I never thought it was in competition with accident and emergency departments. Let me quote from Dr. Jim Kent's feature in the Irish Medical News yesterday on the WestDOC service. It reads as follows:

I've been working for thirty years and have had to almost change the habits of a lifetime to start a co-op. However, the experience has been phenomenal and all the GPs who are in WestDOC are absolutely bowled over by the success.

It is a wonderful way of life compared to what we were used to. You don't have to be going around like a nervous wreck wondering if your phone is switched on, are you in coverage, is there somebody to mind the phone, is the phone baby-sat?

All those worries are removed now. You don't even have to answer the phone. You don't have to argue with anybody on the phone. Your family isn't answering the phone and being abused by people wanting to know where the doctor is.

The experience for patients [this is the important piece for me] has been equally positive. They think that this is the best thing since sliced bread and they compare it with their experience in casualty. Coming here, they get an appointment but when they go to casualty they wait for five hours. The difference is just unbelievable. They think this is fantastic . A lot of people said at the beginning that it was like a train leaving the station: 'It's a wonderful idea but we are not sure if the train is going to go or not, we would like to wait until the train is actually moving before we jump on'. But, the train has now definitely left the station and we're delighted.

This paints a very positive picture of how the co-op system will work. It gives a clear picture of change and how it is being embraced, not just by practitioners but by patients also.

Senator Tuffy referred to primary care. We are all aware that the health care environment is changing and moving at a pace where general practitioners will have to work as part of a multidisciplinary team. I referred previously in the House to the huge changes in the health sector. I welcome the Government's commitment to primary care. When launching the primary care strategy, the Secretary General of the Department of Health and Children said it was the only show in town. It is the only show in town which will continue to be the case while it has the Government's backing and commitment. I wish the Minister well with it.

There is no justification for increasing the income limit by €6 or 4.5% as the Government did. It is a sham. The paltry increase does not carry weight. It reflects the need for budgetary restrictions in health care spending. Given the spiralling costs in society, not least the current inflation rate of 5.1%, and the fact that wage increases have not kept pace with inflation, the reality for many families is that medical treatment has become a game of chance. Families just hope to get by without having to avail of necessary medical treatment or treatment in accident and emergency departments.

The increasing cost of medical care bears out this argument. I visited the doctor last week at a cost of €40. Anyone who attends an accident and emergency department without a letter of referral from a general practitioner must pay the same amount. The result of this is medical neglect among a large sector of the population. The most worrying aspect is the medical neglect of children whose parents cannot afford to pay for medical treatment. In a society which has experienced the fastest growth rate in the developed world it must appear strange that one of the basic principles of human existence, health, and most alarmingly, the health of children, is being neglected.

The facts do not lie. Current medical card limits are so low that a husband and wife with two children will lose eligibility if their income exceeds €250 a week. In the absence of a medical card it would cost a parent €70 in total to visit the family doctor –€40 for the doctor and a minimum of €30 thereafter for the purchase of prescribed drugs. This would represent 30% of the weekly household income. This is a conservative figure, given that those suffering from long-term illnesses and parents with children often visit their general practitioner more frequently and encounter higher drug costs. For a single person just above the income threshold of €138 per week, one trip to the general practitioner and the purchase of prescribed drugs to a combined total of €70 would represent more than 50% of his or her weekly household income.

The plight of the people concerned has become worse as a result of the recent changes in the drugs refund scheme. In 2002, the Government increased the burden placed on those on low incomes who need to purchase prescribed drugs. Prior to August 2002, the income threshold under the scheme allowed people to claim costs incurred above €90 per quarter. Now they can only claim a maximum of €70 per month and there is no clawback.

Ordinary couples are struggling on a daily basis to ensure that they and their children receive even the most basic medical care to maintain their health. The Government has reneged on its promise to provide an extra 200,000 medical cards. The Taoiseach said it has been delayed. The scheme should be increased. I, therefore, call on Senators to support the motion and vote to reverse the current Government strategy on the allocation of medical cards.

This year we are investing almost €9.2 billion in the health services, which represents an additional €5.7 billion in funding, or overall increase of 162%, since the Government came to power in 1997. When the revised Estimates volume, published in February, is taken into account, the allocation for this year will be 12% above that of last year. The significant increase between the original Estimates last November and the revised volume in February has arisen not least because of pay increases connected with intellectual disability and the impact of benchmarking. Benchmarking will cost the health service this year approximately €185 million. That includes 25% of the benchmarking award plus the arrears. It illustrates how 70% of our budget is directed towards pay.

Senator Ryan raised the question of funding. Any intellectual engagement on the issue of health must acknowledge the significant increases in funding. While it may be argued that they are building on a historically low base, we can demonstrate improvements in a range of areas. When I last attended the House to debate the health services, I said the way forward involved a combination of investment and reform. This year alone, an additional €1 billion has been allocated to the budget. Following the revised Estimates volume, health spending should approximate to 8% of GNP. Before the revised Estimates, gross spending was approximately 7.93% of GNP, or a net figure of 7.63%, but that did not take account of the most recent increases between the original Estimates last November and the revised Estimates volume early this year.

The national health strategy makes clear the Government's commitment to health as a key priority area. It is a long-term programme, but it sets out a clear plan and vision for the future. In setting out such a comprehensive and large scale plan, it is inevitable that prioritisation of actions must take place. This is a seven to ten year programme and there is no magic, overnight formula for putting right all the deficiencies in the system. However, the strategy represents a clear plan for moving forward, which is based on a step by step approach to improving and targeting health services, maximising the enhancement of health status and, in this context, reducing inequalities in the system and building the necessary capacity to meet the growing needs of the population. It is in this wider context that the issue of the extension of eligibility must be considered.

Entitlement to health services in Ireland is primarily based on means. Under the Health Act 1970, determination of eligibility for medical cards is the responsibility of the chief executive officer of the appropriate health board, other than for persons aged 70 years and over who are automatically eligible for a medical card because of a decision taken by the previous Government.

Medical cards are issued to persons who, in the opinion of the chief executive officer, are unable to provide general practitioner, medical and surgical services for themselves and their dependants without undue hardship. Income guidelines are drawn up to assist in the determination of a person's eligibility and these are revised annually by the chief executive officers in line with the consumer price index.

A range of income sources are excluded by the health boards when assessing medical card eligibility. Many allowances, such as carer's allowance, child benefit, domiciliary care allowance, family income supplement and foster care allowance are all disregarded when determining a person's eligibility. The guidelines are not statutorily binding and even though a person's income exceeds them, a medical card may still be awarded if the chief executive officer considers that his or her medical needs or other circumstances would justify this. The health board chief executive officers have been reminded annually by my Department and me that medical card holders should not be disadvantaged as a result of budgetary increases in social welfare allowances.

A number of schemes provide assistance towards the cost of medication to those who do not qualify for a medical card. Under the long-term illness scheme, a person suffering from a number of conditions can obtain without charge the drugs and medicines for the treatment of that condition. Non-medical card holders and those with conditions not covered under the long-term illness scheme can avail of the drugs payments scheme. Under this scheme, no individual or family unit pays more than €70 per calendar month towards the costs of approved prescribed medicine. The vast majority of members of the public who do not hold medical cards are entitled to this service. There has been a dramatic increase in the cost structure of the scheme – up by 50% to 60% in terms of volume and expenditure – since the change was introduced in 1999. I will obtain the figures for Members later. Many more have benefited as a result of the changes. For many it represents an important support subsidy of the cost of medication.

The overall percentage of the population covered by the medical card scheme now stands at 29.2%, representing well over 1 million people. The drop in the number of medical cards has arisen partly as a result of the growth in the economy and employment levels. Between 1997 and 2000, we increased the numbers in employment by 300,000.

Actions to reduce inequalities include implementing a programme of actions to achieve the national anti-poverty strategy and health targets for the reduction of health inequalities – specifically, targets to reduce gaps in premature mortality between the highest and lowest socio-economic groups and between Travellers and the rest of the population. That is the reason we have devised, formulated and published a specific strategy for Travellers which we have funded accordingly. In talking about equity, we are getting to the core of the matter when dealing with lifespans of particular ethnic groups in society. They have a much lower lifespan than others and there is much inequality. We have decided to target these areas. In addition, there are provisions to eliminate barriers for disadvantaged groups, both in terms of making healthier choices easier and supporting them at community level to understand and access services. We also have specific programmes of action for groups such as Travellers, the homeless, drug misusers, prisoners, asylum seekers and refugees, all of whom have a real risk of poor health status.

Our targeted measures are far more effective than a global increase in income thresholds to allow a greater number have medical cards. I agree with the aim of providing more medical cards but if we are to get at some of the critical groups, we need to use this approach. Despite criticisms in regard to our approach to the homeless, we have for the first time brought medical services to the homeless, including general practitioners, mental health nurses and consultant psychiatry services. A multidisciplinary team goes out to meet the homeless in our centres. Previously, we expected the homeless to try to locate these services independently and separately.

Structured programmes are developing. We have comprehensive progress to report over the last five or six years in many of the drugs task force areas in regard to intervention programmes for drug abusers and misusers. There are high success rates in terms of rehabilitation and people returning to work compared with European drug strategies. Our performance in the eastern region compares well with that of our European counterparts.

The health strategy recognises that, important though it is, health service access is just one of the determinants of health status and that efforts to improve access must take place against the background of health supporting public policies in other areas. That is the reason it makes a commitment to the introduction of health impact assessment as part of the public policy development process and will seek to ensure the statements of strategy and business plans of all relevant Departments will incorporate an explicit commitment to sustaining and improving health status.

Senator Ryan mentioned David Begg of the ICTU. I ask the Senator to use his influence with the ICTU to get members to embrace enthusiastically the idea of taking an increase in cigarette prices out of the CPI. The ICTU is one of the barriers to removing it from the CPI.

Comhairle na nOspidéal has undertaken a detailed review of the structures, operation and staffing of accident and emergency departments. The report entitled, Report of the Committee on Accident & Emergency Services, not only deals with the staffing of accident and emergency departments at consultant level it also links reform of accident and emergency departments with the need to look critically at hospital processes and patient flows through hospitals. The report provides valuable advice on the structure of our emergency services and the necessary linkages which will be required to eliminate delays in emergency departments. The provision of accident and emergency services must also be seen in the context of a range of additional initiatives being taken by the Government to significantly enhance the treatment capacity of the hospital and community sectors.

Following a comprehensive review of acute hospital bed capacity needs, the Government decided in the context of the health strategy to provide an additional 3,000 public beds in acute hospitals over the next ten years. My Department provided funding for the Eastern Regional Health Authority, ERHA, and the health boards for the commissioning of 520 of these additional beds in 2002. A further 189 beds will be commissioned this year to bring the total number of new beds commissioned to 709, which exceeds the health strategy's commitment. These additional beds should take some pressure off of accident and emergency departments in that there will be extra capacity to admit patients.

I prioritised the issue. When I received my envelope in 2002, I said I would put increased numbers of beds before other issues. I put beds before the issue of the extension of medical cards. I believed it was critical and there was consensus in the debate on the issue. I am confident that hospital management and staff in hospitals providing accident and emergency services will continue to work together to respond to any difficulties presenting and ensure a high quality service is provided for patients in the best conditions possible.

The national treatment purchase fund, NTPF, is being used to purchase treatment for public patients from private hospitals in Ireland or international providers where it is not possible to treat them within a reasonable period in Ireland. Here again we prioritised expenditure. Public patients waiting longer than 12 months or two years for treatment represent a core equity issue. To date, 3,337 patients have been treated under the fund. Some €31 million has been provided in 2003 for the NTPF, the target of which is to treat 600 patients per month. The fund is also getting to grips more effectively with the statistics behind the waiting lists. We have got some interesting returns in the lists we get from the health boards. Of the 11,000 on the long waiters' list in 2002, the number is now down to 3,000. Some of the numbers were reduced through validation, the process of offering an operation to a person and then discovering that he or she may have had it or no longer needs it. I can provide the figures later for the House. They are a sign of the progress we are making on the issue of equity and quality of life.

Health for disadvantaged groups is a complex issue which needs to be tackled in a number of ways. We must ensure first of all that people are healthier and are less likely to need health and personal social services and secondly, that when they do and once they are deemed eligible that no other barriers, such as transport or opening times, prevent them from accessing the services they need.

In addition to these measures, while having regard to overall resource considerations, the Government remains committed to extending medical card coverage within its lifetime to more people on low incomes, including targeted increases to ensure more children, in particular, are covered. We restate that commitment this evening. Such actions always have to be considered in the light of the whole range of priorities which arise in relation to health services. Prioritisation must be carried out with a view to having the maximum effect on improving the health of all. The introduction of all the elements of the strategy action plan must also be considered in the context of the prevailing budgetary situation.

The strategy also recognises that extending eligibility will not guarantee that people get the services they need. There are other barriers in the system to equity and these have been prioritised to ensure that the eligibility framework in the future can support equal access for equal need. The strategy includes a series of initiatives to clarify and expand the existing arrangements for eligibility for health services, including recommendations arising from the review of the medical card scheme carried out by the health board chief executive officers under the PPF. These include: streamlining applications and improving the standardisation of the medical card applications process to ensure better fairness and transparency; providing clearer information to people about how and where to apply for medical cards; and proactively seeking out those who should have medical cards to ensure they have access to the services that are available.

The health strategy emphasises fairness and the objective of reducing health inequalities in our society. A number of initiatives are outlined to clarify and expand the existing arrangements for eligibility for health services. Shorter waiting times for public patients are prioritised, with the expansion of bed numbers and the introduction of a treatment purchase fund. In addition, there are clear commitments to targeting vulnerable and disadvantaged groups, including: continued investment in services for people with disabilities and older people; initiatives to improve the health of Travellers, homeless people, drug misusers, asylum seekers and prisoners; and implementation of the NAPS targets relating to health.

The primary care strategy, Primary Care: A New Direction, contains the template for the development of primary care in Ireland in the coming decade. Its key objective is to move from the current fragmented system of delivering primary care to one where services are provided by integrated, multidisciplinary teams. The primary care team will include general practitioners, nurses, physiotherapists, occupational therapists, social workers, home helps and health care assistants. As the new model is developed, wider networks of other primary care professionals will also provide services to the populations served by the primary care teams.

This strategy is being implemented on an ongoing basis. In April 2002, a small primary care task force was established within my Department to drive forward the delivery of the reforms of primary care contained in the strategy. The task force reports to a wider national steering group which includes representatives from primary care professional groups, unions, the community and voluntary sector and other key stakeholders and which will give national leadership and guidance as the implementation plan is rolled out.

A national primary care conference was convened in Galway in October last year. It was the first conference organised at a national level to discuss, in partnership with the stakeholders, the implementation of the strategy. Translating the new primary care model into reality will require a partnership approach and the conference provided a forum for the key stakeholders to meet and discuss the main issues involved.

In October last year I gave approval to the establishment of an initial ten primary care implementation projects, that is, one in each health board area. Funding totalling €8.4 million has been provided for this purpose in 2002 and 2003. I prioritised that in terms of obtaining money to get it started. The projects will involve putting in place in ten locations around the country a primary care team in line with the model described in the strategy. 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. The objective is to have these teams in operation and delivering an enhanced range of primary care services to their populations later this year.

The primary care strategy takes a long-term view. It is not possible to transform a health system overnight, nor would it be desirable to try to do so. Change will be achieved incrementally. The strategy recognises that there are many structural changes which must occur in order for the new primary care model to be implemented.

In the context of Senator Feeney's remarks, approximately €42 million has been allocated since 2000 for the GP co-operative, which provides a 24 hour, seven day out-of-hours service in almost all areas of the country, with the exception of Dublin. The co-operative in Dublin does not provide a 24 hour service; it tends to be of a shorter duration. That is something with which we must deal. We hope to move on that again this year, although we have made rapid progress. This will give a quality out-of-hours GP service to people across the country. That is an issue I have prioritised in terms of the allocation of funding. Access for mothers and people with children to good quality primary care in the middle of the night is as important in terms of access to services as income is in terms of getting the right treatment.

As we move forward, it will be necessary, at regional and local level, for existing primary care services to be restructured and refocused so that care can increasingly be delivered in accordance with the principles and the concepts set out in the strategy. The public and the providers of the services have told us what a modern health system should provide – a first class continuum of care, close to home and available around the clock. The primary care strategy provides the blueprint for that kind of care.

Last year was the first year of the implementation of the health strategy. In reviewing its progress to date, I am happy to be able to record significant progress on a number of fronts, including the development of capacity, developments in primary care, legislative developments, the restructuring agenda and so on. At the end of last year, up to 70% of all the actions detailed in the strategy had commenced. We also set out in 2002 to make a tangible difference to the experience of individuals in their interactions with the health system.

Last week saw the launch of the results of the latest survey undertaken on behalf of the Irish Society for Quality and Safety in Healthcare into patient perception of the quality of health care. Interestingly, and contrary to much of the media coverage of this issue, the results of the 2002 survey are positive in many respects. Patients perceive the quality of the care and service received to be very high. Some of the findings mentioned in the survey include: the fact that 92% of patients reported being satisfied or very satisfied with the overall quality of care they received during their stay in hospital; 85% of patients reported being satisfied or very satisfied with the standard of service they received in the accident and emergency department and 90% were dealt with within three hours; 90% of respondents indicated that the explanations given to them by doctors about their condition and treatment were either very easy or fairly easy to understand; 90% of patients who experienced a procedure reported having it adequately explained to them; and 92% of patients expressed a high level of overall satisfaction with the hotel aspects of the hospital's service. Against a background of 95% of patients declaring themselves as being generally satisfied, the challenge now is to build on our successes and address those areas that require improvement.

I thank Senators for their contributions this evening. The Department of Finance presents Estimates every year to the Government. Debates take place on a bilateral basis between Departments. That has happened every year since time immemorial. The Department of Finance progressed issues this year in the context of existing levels of service. We received an envelope. It is interesting to note that of all the increases this year in all Departments across the public service, the Department of Health and Children received approximately two thirds of the full amount allocated. We got an extra 12% in addition to what we got last year.

This year we prioritised GP co-operatives and the primary care strategy on the primary care side. As regards acute beds, we got the full year costing for the 709 beds because many of the beds would have come on stream later in 2002. We have also prioritised areas relating to the elderly and the heart and lung transplant unit in the Mater Hospital.

Every year tough choices must be made in health. One would appreciate a greater envelope. I regret that we are not able to extend medical card eligibility this year, but the funding envelope does not stretch that far. I want to get the other structural changes in place as quickly as possible.

The Minister has pointed out that various allowances are not taken into account such as the carer's allowance, child benefit, domiciliary care allowance, child income, family income supplement and foster care allowance and that there are special groups such as Travellers, the homeless, drug misusers, prisoners, asylum seekers and refugees for whom special latitude is given. There is a certain group who must wish they were not leading such upright lives because they cannot afford to take proper care of themselves and they just exceed the income level. The Irish College of General Practitioners has expressed concern to me about this group, who see doctors less frequently than they should. Often they self-diagnose and self-prescribe. Also they present less frequently for routine checks in the event of chronic illness and do not become involved in preventative health care and health advice which, as the Minister has said, is extremely important. They do not present with social and psychological problems. The longer psychiatric problems remain untreated the more likely they are to be serious. In their report on the stark facts the other day, psychiatrists pointed out it was those from the least affluent backgrounds who had the highest level of psychiatric problems and the least psychiatric services. There is a large group who are losing out badly.

The current level of costs definitely affects those who attend accident and emergency services and the College of General Practitioners supports that claim, as do the accident and emergency consultants. It costs €40 to attend accident and emergency departments and it costs probably less to visit GPs, some of whom charge about €25. However, a large proportion of people do not pay in accident and emergency departments. It is much easier to refuse to pay the anonymous receptionist who has the misfortune of trying to collect the money or the strange doctor whom one is unlikely to see again than one's own GP, whose receptionist may be a neighbour. There is also a problem with people giving false names and addresses in accident and emergency departments when they cannot pay so that they cannot be traced. This is a serious issue which needs to be addressed.

I am pleased that so much more money is being spent on the health services. It is important that a huge amount of that money is spent on well-deserved pay increases for the staff working in the health services, but it is not of much benefit to the group being discussed here. The primary care strategy has been an excellent initiative. I agree with Senator Feeney. It is not just WestDOC that is pleased with the situation. I have not heard people from any of the co-operatives say they were displeased and at the same time single handed practitioners appear to be facilitated. All in all it looks good.

A serious problem which all general practitioners encounter is access to diagnostic services in hospitals and access to physiotherapy, occupational therapy and so on. It would be cost effective if it was possible to reduce the number who have to be referred to a consultant before becoming involved in services such as physiotherapy or have much-needed X-rays.

I noticed in the investigation into all the self-regulatory bodies a suggestion that people should be able to refer themselves directly to specialists in hospital rather than go through general practitioners as at present. Direct access to specialists, as in the United States, has led to its being the most expensive and least efficient health service in the world. It spends well over 14%, possibly 18%, of its GNP on a health service which serves only a certain proportion of the population. There are some aspects of our service which are not bad.

That such progress has been made in the health service over the past 30 years is marvellous. I have been in practice long enough to remember the real two-tier system when there were dispensaries and those who could go to their own general practitioner. It is wonderful that everyone is served by the same people now. The extensions provided for in the primary care strategy are well worthwhile and I support what the Minister is doing. General practice is trying to do what it can in the area of preventative medicine but it is very difficult to get through to the general public that it would benefit. I was fascinated recently at the difficulty in getting people to have their children immunised against measles, mumps and rubella, which is a very safe vaccine.

There are demands that the Minister have smallpox vaccination ready for everyone when the bio-terrorism strikes. America has already had one death as a result of it. We know that three in every million die from vaccinia even in the best of circumstances with smallpox. The New England Journal of Medicine has published several excellent articles saying the United States would be better off if it tried to barrier nurse anyone who got smallpox and to vaccinate those who might be dealing with them, yet there are those here who say we must be ready to vaccinate everyone against smallpox. What would be the cost to the health service?

I have a certain sympathy with the Minister who is trying to control spending in the right direction, but I suggest there is a group who are not getting the services they need.

I strongly support the provision of medical cards for children with disabilities. It is an area that needs to be addressed because such children need more medical attention. Some families who have children with special needs cannot afford medical treatment. I commend the Minister on the provision of medical cards to everyone over the age of 70. Tight budgetary constraints did not allow the Government to deliver the 200,000 extra medical cards this year. We must remember this Government has four years left in office and it will implement these measures as soon as it is economically possible.

It is important to note that this Government cannot create a world-class health system over night. In the years 1995 to 1997 a Labour Party Minister for Finance raised health spending to more than €400 million. That compares to €4.7 billion since. We all accept the country has improved economically since then.

We should recognise the major improvements made by this Government in the health services during the last five or six years. I do not say everything is perfect – it is not. There is a great deal more to be done. This is an expensive business and is a difficult area to deal with. Senator Ryan said we should not make this debate political. I am not making it political; I am merely making a point.

The vast majority of people who went to the polls last year believed this Government would extend the medical card scheme to an extra 200,000 people. We now know, regrettably and unfortunately, that that is not the case. It will not happen. That is something of which this Government will be eternally ashamed. It is wrong to give a commitment in a pre-election pledge that an issue will be tackled with great vigor and sincerity and then say when various Ministers take up office that we must tighten our belts, cut funding and do everything but deliver what was promised. That is precisely what happened and this Government cannot be proud of it. While some will say the Government is making inroads in that regard, regrettably, that is not the case.

The Labour Party spokesperson on health in the Dáil, Deputy McManus, recently requested the Minister to furnish information regarding the number of expert review groups established in this area. That information was not forthcoming for five weeks. Deputy McManus then inquired of the Minister again. She was told there was such difficulty collating that type of information that it would not be possible to do it in five weeks. That tells us that many expert review groups have been established.

Are we lacking policy in regard to the health service? What we need is real action in terms of Government policy, not reports from expert review groups. We need policy that will deliver a health service on the basis of medical need, not what people can afford to pay for.

The chief executive officer of the Children's Rights Alliance called on the Minister for Finance, prior to the budget, to extend the medical card scheme to all children and put forward a good case in support of that demand. The Minister for Finance, Cheltenham Charlie, should take cognisance of this request.

(Interruptions).

That we are debating in the third millennium extending medical cards to a wider population as a follow-up to a pre-election commitment speaks volumes about the manner in which this Government has treated the people. It is shameful, wrong and disgraceful.

The problems encountered in vast areas of the service are ones of frontline management as opposed to resources. This Minister has taken huge strides to tackle this, as have previous Ministers. The level of consultation and discussion between the Department and the service providers is unprecedented. I do not agree with Senator McCarthy that there should not be expert groups and that we should not talk to people on the ground. That is the only way to tackle these problems. Initiatives such as the waiting lists and winter initiatives, the treatment purchase scheme and the national cancer strategy are all a result of close contact with the people working on the ground. This progress will be maintained and enhanced and I am sure the Minister will succeed in dealing with the many issues which arise in this complex and important area.

I contacted the Medical Services Payments Board out of curiosity today. The figures it provides are startling. Almost €360 million was spent on the GMS service in 1997. In 2001, €635.739 million was spent, a huge increase despite the fact that the numbers claiming had reduced, as the Minister pointed out, mostly due to economic success.

Senator Feighan mentioned the drugs payments scheme. In 2000, the number of people covered under that scheme was 942,000. In 2001, that has increased to 1.1 million at a cost of €177 million. These figures point to the total commitment of this Government. It is a long-term plan. The issues, as the Minister pointed out, must be tackled on an individual basis, one after the other, and that is how it is being done.

For the information of Senators on the other side of the House, I will quote from the excellent publication, An Agreed Programme for Government. The only mention of medical cards in the manifesto is as follows:

We will extend medical card eligibility in line with the recommendations of the national health strategy and, further, review cases for the extension of both the medical card and the long-term illness scheme.

The plan is in place and under way. I commend the Minister and his Minister of State on the progress made so far. I fully support the amendment.

I was amazed to read in the Sunday Independent recently that the Department of Health and Children spent a huge amount of money kitting out the Minister's offices. I can now understand the reason for that; it was because of structural damage due to all the reports stuck on bookcases in the Department. I would love to put down a question under the Freedom of Information Act, while I still can, on how many reports are sitting on bookshelves in the Department of Health and Children. It must be an astounding figure. There are reports about reports and expert review group reports about other expert review groups. The Minister might arrange a tour of the Department.

The Labour Party motion before the House highlights the medical card issue, which is a small element of care, albeit an important one. The health system is not about one element of medical care, but about the entire structure. The funds spent in the health system should bring about a package that caters for the needs of all people, not just a certain segment of society.

The motion goes on to state that the Government has reneged on the commitments it made in its manifesto prior to last year's general election. I read the manifesto and at no stage does it state that the Government will deliver a certain number of medical cards within the first eight months of its coming into office.

People have benefited more from sustained funding in the past four years than in the lifetime of any Government. Staff numbers have increased from 68,000 to 96,000. I would not necessarily hail that as one of the greatest feats in the world because some of those staff should never have been appointed in the first place. A small percentage of them, not all, comprise another layer of bureaucracy in the health system and I deal with them on a daily basis. I am delighted to see that the new health structure is being examined with a view to changing it. Some staff are falling over each another trying to find positive things to do.

In 1996 the present system was configured by the then Minister, Deputy Noonan. I am not necessarily blaming him because we took the ball and ran with it.

The myth that there is no money to do things now is precisely that. If I needed to do an emergency job on my house, it would not stop me sending my children to the doctor. I would borrow the money to pay for it. That is what sensible people do. The idea of funding a massive infrastructure programme out of current revenue is ideological nonsense, carried on by a Minister for Finance who is out of control. He leaves the country to follow the racing at Cheltenham and returns to tell us we are overspending. This is extraordinarily and intellectually offensive. This is the fundamental problem with this debate. The Government refuses to engage with the issue and, instead, produces a collection of nonsensical claims that does no service to itself or to this House.

Amendment put.

Tá

Níl

Tellers: Tá, Senators Minihan and Moylan; Níl, Senators O'Meara and Ryan.

Amendment declared carried.

Motion, as amended, put and declared carried.

An Cathaoirleach: When is it proposed to sit again?

Ms O'Rourke: At 10.30 a.m. tomorrow.