Seanad debates

Tuesday, 13 May 2003

2:30 pm

An Leas-Chathaoirleach:

I welcome the Minister for Health and Children, Deputy Martin.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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I am pleased to have the opportunity to speak on the Government's commitment to providing quality health care for all. This commitment is clearly demonstrated through the record levels of funding invested in health services in recent years within a framework for growth and reform as set out in the national health strategy on quality and fairness. This year we are investing almost €9.2 billion in the health service. This represents an overall increase for the service since the Government came to power in 1997 of 162% or an additional €5.7 billion. This extra investment in recent years has brought significant results, including record levels of activity in the acute hospital system and a whole range of additional services provided in all the major programmes of care. As a percentage of GNP, gross non-capital health expenditure in 2003 is estimated at 7.93%, the highest figure in almost 20 years. In four years, 1997-2001, the per capita spend on health services has moved from fifth from bottom in the European Union to just above the EU average, a significant figure in itself. This investment has been matched by increases in the quantity and quality of health care outcomes.

We need to guard against undermining the achievements of all those who work in the health service. It is important to remind ourselves that every day thousands of people have satisfactory experiences of the service, and successful outcomes. A survey carried out in 2000 by the Irish Society for Quality in Healthcare tested the attitudes of 1,800 patients who had been through the acute system. The results indicated that 96% were satisfied or very satisfied with the level of quality of care they received from the system. Other statistics in that recently published survey indicate significant satisfaction levels on a number of fronts from those treated in our hospitals.

The range of services provided within the health system is unique by international standards covering everything from health promotion and disease prevention to acute hospital treatment and a wide spectrum of personal, social and community services. The vision we have for this vast and complex system is set out in the health strategy which describes the programme of investment and reform that will stretch over the next decade. Contrary to popular opinion, the strategy is alive and well. I am pleased to report that 91 of the 121 actions set out in it are being implemented.

While there has been a substantial degree of adverse comment about the health service, no one can deny the system is providing more and better services than ever before. Activity in our acute hospitals continues to rise. In 2002 alone there were 963,000 in-patient discharges as against 785,000 in 1997, an increase of 178,000 in-patients. In other words, we had discharged or treated 178,000 more people at the end of 2002. This must be taken on board when discussing the health service if we are to get some sense of balance and perspective in the debate. The 2002 figure represents approximately 2,600 patients being discharged each day of the year, an overall increase of nearly 5% on the number of discharges in 2001.

There was an increase of 13% in the number of day cases between 2001 and 2002. The number of day cases is an important international benchmark in terms of the modernity of any system. There has been a dramatic increase in the number of day cases over the last decade, the last five years in particular. It is now estimated that in the academic teaching hospitals in Dublin alone 58% of all cases are now dealt with on a day case basis. This is illustrative of the progress made in terms of increased productivity and modernisation.

The growth in acute hospital activity is supported by the health strategy objectives on bed capacity. The strategy provides for the largest bed capacity expansion in the history of the health service. Notwithstanding current difficulties in the system, commissioning of an additional 709 acute hospital beds for public patients began in 2002, an increase in capacity of 6%. Some 520 of these beds are now in operation and the remainder will shortly come on stream. These extra beds were placed in different hospitals and dependent on the capacity of particular regions and hospitals to accommodate them. Hospitals in Galway and Limerick did particularly well as did St. James's Hospital in Dublin because they had the capacity to absorb additional beds last year. This is the first phase of the provision of 3,000 acute hospital beds by 2011 as announced in the health strategy. Some €118 million in capital and revenue funding has been allocated to increasing bed capacity in 2002-03 and to provide for those 709 beds. The Government remains committed to providing the additional 3,000 beds over the lifetime of the strategy.

Despite pressures on the acute hospital system and influencing factors such as the winter vomiting bug, considerable progress was made in 2002 by health agencies in reducing waiting times for public patients. The total number of children waiting for more than six months for in-patient treatment fell by 24% between June and December 2002. 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 fell by 15% between June and September 2002. The House might be interested to note that the total number of patients on the public hospital waiting list represents just 2% of all discharges from acute hospitals in 2002. The Government will continue to make inroads on the waiting lists.

While the waiting list initiative will continue to fund additional elective activity, the dedicated national treatment purchase fund, NTPF, is being used to target those waiting longest for treatment – those waiting more than 12 months. Where this target has been achieved in some health boards we are moving down to six months. Funding of €43.8 million has been provided in 2003 for the waiting list initiative while some €31 million has been provided for the NTPF, the success of which is evidenced through the 4,000 who have received treatment. The 4,000 people concerned are patients who were awaiting treatment for longer than 12 months.

The NTPF has been an interesting experiment in terms of getting a better focus on the waiting list. The ultimate litmus test of a waiting list is when one approaches a person about having an operation and being told by that person that he or she has had the operation or no longer needs one. It is interesting that in its first year of operation the NTPF identified up to 5,000 people who either had had their operations or were unavailable to have one. We are looking to a further evolution of the NTPF concept in terms of the overall waiting list initiative to get a better handle on the statistics that emanate and the waiting list. The NTPF has been a successful experiment, although there is much criticism of it in certain quarters and there were attempts to undermine it from the beginning. As part of a wider approach to waiting list and capacity issues, it has been a successful innovation.

I acknowledge that there are difficulties in the acute hospital sector this year as a result of a tighter budgetary situation that is further compounded in the Dublin area due to significant deficits accumulated in recent years by the Dublin area teaching hospitals. These difficulties can only be resolved within the existing statutory framework, including the 1996 accountability legislation. I must have regard to that process. By statutory framework, I mean the establishment of the Eastern Regional Health Authority that was undertaken by both Houses of the Oireachtas. The legislation in question gave responsibility for the authority to deal with the hospitals under its remit in terms of funding and the purchasing and contracting of services. It is within that statutory context that the current issues must be resolved.

The accountability legislation makes it clear that if an authority overspends in one year, the latter must then be set against the budget, at first charge, the following year. That legislation was approved by parties on all sides of the House. We are working closely with the ERHA and the DATHs and have entered into a process to resolve the difficulties we are facing in this area during the current year.

The improvement of both the quantum and quality of service has been made possible through a highly-skilled and committed workforce, which has grown by over 40% since 1997 from 68,000 to 96,000 whole-time equivalents, excluding home helps. Approximately two thirds of administrative staff are involved in providing front-line services for patients. I refer, for example, to consultants' secretaries, community welfare officers, out-patient and accident and emergency department personnel, ward clerks, medical records personnel, etc. The remainder are involved in general administrative functions such as finance, personnel, dealing with legislative requirements and payroll.

Since 1997, an additional 439 consultants, representing an increase of 34%, have been appointed. In the past three years, an average of 103 doctors per annum have taken up duty in Ireland as permanent consultants for the first time. This compares with an average of 40 in the mid-1980s and 50 in the early 1990s. The number of nurses and midwives employed has increased by 6,800 since 1998. I can provide a range of other figures on the record number of training places available for nursing. In addition, an historic breakthrough was made when we introduced the degree programme for nursing. The latter will be underpinned by funding of €250 million in the coming years.

Since the implementation of the national cancer strategy, which commenced in 1997, there has been a cumulative investment of approximately €400 million in the development of appropriate treatment and care services for people with cancer. This includes a sum of €29 million which was provided in 2003 to ensure that we continue to address increasing demands in cancer services throughout the country in such areas as oncology and haematology services, oncology drug treatments and symptomatic breast disease services. Cancer services throughout the country have benefited from this investment, which far exceeds the £25 million requirement which was initially envisaged under the national cancer strategy. Among a range of other initiatives, this 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.

Activity has significantly increased in this area. For example, the number of new patients receiving radiotherapy treatment has increased from 2,402 per year in 1994 to 3,809 per year in 2000. This means that an additional 1,407 patients are accessing these services, representing an increase of 58% nationally. We acknowledge that we have more to do in respect of radiotherapy services. The forthcoming radiotherapy report will address these issues in a structured and rational way.

The number of new patients receiving chemotherapy treatment increased from 2,693 per year in 1994 to 3,519 per year in 2000. This represents an increase of 30% nationally. Breast cancer is the individual site-specific cancer which has received the most investment in recent years and in-patient breast cancer procedures increased from 1,336 in 1997 to 1,839 in 2001. That is an increase of 37% nationally. We now have far more consultant oncologists in the system than we had three years ago.

When people claim that the health services are worse now than they were three years ago, they need to reflect on what they are saying. For example, there are places outside Dublin – Cork, Waterford and elsewhere – which, up to two years ago, had no oncologists. We now employ a significant number of oncologists who are providing a better quality treatment for many patients than we aspired to in the past.

Heart disease remains the single biggest killer in Ireland and it is an everyday reality for thousands of people and their families. In July 1999, my predecessor in the Department of Health and Children, Deputy Cowen, launched a cardiovascular strategy, Building Healthier Hearts, to address this important cause of sickness and death. Funding has provided for the appointment of almost 800 additional staff to support the strategy's implementation, including funding for 17 additional consultant cardiology posts. We have 109 extra cardiac rehabilitation staff in place which means most acute hospitals treating people with heart disease have a structured cardiac rehabilitation service. These are facilities that did not exist a few years ago.

The immediate benefits of the strategy are evident and include: reduction in emergency call to treatment times; regional self-sufficiency for non-invasive diagnostic procedures; the development of chest pain clinics and cardiac rehabilitation; an almost 200% increase in certain cardiology procedures and a 24% reduction in the waiting list for cardiology procedures; and the increase in the numbers now being detected and treated with chronic heart failure. To this can be added a rapidly expanding budget under the cardiovascular heading in the GMS, under which we are spending many millions of euro on products provided by the Statens Serum Institute, etc. This reflects the impact of the cardiovascular strategy on treatment and prescribing patterns of primary care, in particular, during the past three years. That is a significant and welcome development and it will mean better intervention and treatment and a consequential reduction in mortality rates.

There has also been substantial investment in continuing care services since 1997. For older people, this has meant enhancement of nursing home subvention scheme, 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 in 2002 provided for further new residential, respite and 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, investment 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 guidance and assessment staff positions in the health boards in the area of rehabilitative training.

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 enable primary care to develop the capacity to meet the challenges with which it is faced – including ageing of the population, earlier hospital discharge and care in appropriate settings – as well as the opportunities afforded through modern information and communications technology.

Last October, my Department gave the go-ahead for the establishment of ten implementation projects and funding totalling €8.4 million has been provided in 2002 and 2003 for this purpose. The projects involve putting in place, at ten locations throughout the country, a primary care team which will include GPs, nurses and midwives, healthier assistants, home helps an occupational therapist, physiotherapist, a social worker and administrative personnel. As the ten projects are rolled out, more than 80,000 people will benefit from having direct access to an improved range of primary care services. As the new model is developed, a wider network of other primary care professionals will also provide services as the needs of the populations in the catchment areas dictate. These ten projects will inform the wider expansion of the primary care model as envisaged in the health strategy in the years 2005 and 2006,

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.

Significant progress has been achieved in providing capital funding for the health sector since 1997. Total expenditure for the years 1997 to 2002 was approximately €1.7 billion. This has made considerable inroads into addressing the historical infrastructure deficits that have existed for so long and prevented the establishment of standards of facilities required for modern patient care. Major projects have been completed during this period, across all health care programmes. These cover projects across the State and include, for example, in the acute hospital area, projects in the Mid-Western Regional Hospital Limerick, University College Hospital Galway, Tallaght Hospital, St. James's, Cork University Hospital, Portiuncula Hospital, Mayo General Hospital, as well as over 500 beds under the bed capacity initiative. In addition, a range of important projects – including new community nursing units, child care units, etc. – was also completed in the non-acute hospitals sector.

I have been conscious of the need for better management information systems throughout the health services for planning, monitoring and evaluation, with a view to maximising efficiencies and care provision at all levels. I will be bringing the national health information strategy to Government shortly and seeking its approval to publish the strategy. The strategy sets down the essential framework to begin the process of informing health information, not only for staff and management but also for the people.

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

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, the many layers and intersecting roles, and the lack of consistency in the development of the systems and applications 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 mode 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 has also been established in recent years.

One of the main conclusions in the health strategy was that, while the system has served us well in many respects, some significant concerns remain. These include the need for stronger co-ordination and integration of functions and services, greater consistency in access to services and delivery of services throughout the country, 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 currently being formulated in respect of the health system. The first is the undertaking of an audit of structures and functions in the system. The audit is also dealing 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 that same year. Part of its work is concerned with examining the practical implications of moving to a consultant-delivered hospital system. This is likely to include reference to the future configuration of hospital services in Ireland.

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 that was undertaken on behalf of my colleague, the Minister for Finance, Deputy McCreevy.

I wish to elaborate in some detail on the work in relation to the audit. Action 114 of the strategy was intended to support organisation 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, with no overlap or duplication between organisations, and a proper alignment of the structure as a whole to the vision and objectives outlined in the health strategy. The outcomes sought are to ensure that 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, 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, they found that there are a number of barriers to achieving the improvements sought in the health 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 an acute service delivery, which will come under the hospitals authority, 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 will clarify and create 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 in the strategy in relation to reform of acute hospital services and the likely changes required, in terms of configuration, anticipated in the health strategy. It 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.

There is an important synergy emerging between the three reports, in respect of the unitary system of delivery, in terms of the configuration of services via a consultant-delivered service, and the advances made in terms of both the commission on funding and the audit of health structures. We are working towards a joint position on these, with decisions to emanate from Government following the presentation of those reports.

It would be imprudent to suggest, however, that the gains from changes in systems, structures and functions changes can be achieved without continuing investment in the health system. There are several reasons for this. The principal reason is that health care is expensive. Technological advances, an ageing population and higher levels of public knowledge and expectations, combined with pay and non-pay inflation make it expensive just to stand still.

To make the point, I would have received an extra €1 billion this year in health expenditure compared to last year. It is interesting that in the Estimates around November I received about €690 or €670 million. Between that and the revised volume, which I think was in February, I received an additional €250 million. Senator O'Toole would know where that money went. Less than €150 million went straight into the benchmarking deal, and approximately €75 million went on the pay deal regarding intellectual disability. I make that point to illustrate that one can account for almost all of that €250 million without any incremental increase in service, other than that we obviously have to fulfil our obligations in relation to benchmarking. That is right in terms of bringing up pay and conditions of staff, which is important, but it has to be acknowledged as a significant factor in the overall story of the modern health service. Not only have we dramatically increased the employee numbers from about 68,000 to 96,000, but we have significantly improved pay rates and conditions across all grades. That has clearly had an impact on the health budget.

Technological advances, an ageing population and other such factors will continue to put pressure on the budget. From a cost viewpoint there is a cruel paradox in the fact that the more successful the outcome, the more expensive it gets. I mentioned earlier the oncologists that we appointed. They have driven activity to an extraordinary degree, and that is a good story, but it increases demand and increases the number of people waiting for particular services – services which they simply did not get before. I do not know why people are saying services are worse now than previously – that is rubbish. The bottom line is people did not get some of the services we now have available.

Brendan Daly (Fianna Fail)
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Correct.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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I acknowledge that we need to do a lot more. We have a long way to go in terms of consultant numbers and the like, but much of that will depend on change all around in terms of the Medical Manpower Forum.

Demographic projections for Ireland suggest that by 2011 the number of people aged over 65 will have almost doubled to an estimated 767,300, and will constitute 16.4% of the population. This is a factor of major significance in planning for the provision of acute hospital services into the future, and will clearly have an impact on budget levels and funding. We are looking at the impact of an ageing population on other areas of the economy. Demand for health care is increasing, related to 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, which yield longer life expectancy but also, typically, the onset of further illness later in life.

A second reason for the need for continued investment relates to the current deficits in the system, the addressing of which will be essential in achieving the system changes we seek. Some €500 million has been invested in developing infrastructure under the national development programme. Notwithstanding this 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 and a variety of other facilities, especially those providing care for older people. The full development of information and communications technology capability is identified as a prerequisite to improving monitoring and evaluation of services, improving health impact assessment, and in turn giving better value for money. Report after report has identified this as a major system deficiency.

A third reason relates to the need to give up-front support to structural reform of this nature if change is to be secured. We must continue to invest in the system if we are to keep pace with these 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 the reform of management structures and financial accountability. The first stage is the finalisation of the two key reports that I mentioned earlier. Both my colleague, the Minister for Finance, Deputy McCreevy, and I will be submitting the reports to Government for a 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 that have now been advanced are a considerable challenge to everyone within the system. I will not understate the enormity of the task ahead. There are no quick fixes for the kind of changes we envisage in the coming years. I reiterate that the potential of the system can only be released if we continue to invest as we reform.

Photo of Joe O'TooleJoe O'Toole (Independent)
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I am glad the Minister is finally getting support from his party.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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His Senators are certainly loyal to him. The state of a country's health service is one of the test areas for determining if this is an advanced economy.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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I apologise for leaving as I have to attend business in the other House.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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Apology accepted. We fail the acid test of health provision. That is not to say that there are not thousands of excellent people involved in the health service. We all know many individuals who are totally dedicated, committed and professional in their approach. I have recently been in Sligo General Hospital and admit that there are areas in it where the service is doing well, such as cardiac surgery and hip replacements. However, there are fundamental problems and unfortunately we do not seem to be able to get to grips with them. We are almost in despair trying to do so. The Minister, Deputy Martin, was certainly showing signs of despair under the pressure of the past few weeks. I do not wish to contribute to his malaise but it is my duty to express my views and those of many others who are deeply distressed and affected by what is happening – or more worryingly, what is not happening.

The Taoiseach has given a hollow endorsement of the Minister's performance, suggesting he is doing his best. Of course he has every confidence in that regard. When benign teachers put "He is doing his best" in schools reports, it is not the ringing endorsement that parents wish to see for their children. The absence of Fianna Fáil support during the Dáil debate last week is all too indicative of their anxieties. It is quite obvious that they are avoiding association with a troubled cause and a Minister in hot water.

What happened to the health strategy promise of November 2001, and a pre-election boast that by the end of 2003 no adult would have to wait more than six months for treatment and no child more than three months? The Taoiseach says the Minister is doing his best and he would know. The Minister says there is no crisis in the health service but nurses are in revolt, public health doctors are on strike and major hospitals are shutting down access to beds. Confidence in our ability to cope with a SARS outbreak is minimal. Carers are angry and accident and emergency units are being overrun, while old people are left on trolleys in hospitals. In spite of this, the Minister says that to call it a crisis is to overstate the case. I do not think it is being overstated; it is calling it as it is. He is the Minister and he would know and the Taoiseach says he is doing his best.

What are we in a less influential position to do but to wonder at it all and lament that all is not well in the health service? What will the Taoiseach do? Traditionally the prescription was to change the Minister. That would be radical surgery at this time. Who might be the new Minister of this relegation doom club? What about the Minister for Agriculture and Food, Deputy Walsh, or the Minister for the Environment and Local Government, Deputy Cullen? Other options would be the Minister for Transport, Deputy Brennan, the Minister for Justice, Equality and Law Reform, Deputy McDowell, or perhaps the Minister for Foreign Affairs, Deputy Cowen? He has already served his time. Perhaps it should be the Minister for Finance, Deputy McCreevy. There is a thought – he could combine both ministries. Unfortunately it may come down to the Taoiseach having to eat the cake he baked himself.

Fianna Fáil got back into office last year because among other promises it made, it almost guaranteed it was heading towards the promised utopia of no waiting lists, hips on demand and a cure for every ill. It does not seem that this is happening but the Minister is doing his best and he has the confidence of the Taoiseach.

In 1998 €4 billion was spent on the health service. In 2003 €9 billion was spent. One third of the extra money is going on pay settlements. The chief executive of the Health Services Employers Agency, Mr. Gerry Barry, said that the nurses' pay dispute added 25-30% to the nurses' pay bill. Medical inflation is running at 10%. The cost of drugs for hospitals is a significant factor. I acknowledge that a central purchasing unit, the hospital procurement services group, has helped in this area. It is difficult to understand the cost of blood, which is given freely by donors, yet the cost for hospitals is extremely high. Accident and emergency departments are now groaning under the strain, with up to 30 patients lying on trolleys. A big problem for hospitals is that beds are taken up by people with nowhere to go. The system is riddled with inconsistencies.

Finland has a population similar to ours, although it is four times bigger in area. It has 12,000 consultants compared to Ireland's 1,730. Finland sets great store by screening and prevention, thus saving in the long run, especially in the area of cancer. A big problem in Ireland is consultants working publicly and privately at the same time and in the same hospitals.

Most people familiar with the various health models acknowledge that Ireland has got it right in some areas. We need to do three things; to provide better regional distribution of specialty services; to recognise that hospitals must operate within the concept of total community care; and to increase our bed capacity, as the crisis stems from our incapacity to admit patients to hospital.

The removal of health boards has been mooted but we know this is a problematic area. Could the Minister take the political risk to tackle them? In the Irish Independent last week, Damien Corless gave the historical background to the achievement by consultants of their powerful position in the health service. He said that the consultants have it in writing that no one can monitor their hours. It is most peculiar that consultants can use the valuable services – beds, nurses, office space and so on – while the return to the hospital is that they provide a certain public service for which they are very well paid.

There are three reports due. The Hanly report stated that the management, funding and operation of all public hospitals should rest with one agency. It also recommended that 3,000 additional consultants be appointed and the number of junior doctors be cut. Before so many consultants are taken on board, their powerful position should be regularised. I do not know if that will happen.

In 2001, a value for money report stated that Irish hospitals had lower costs and fewer clinical staff than those in other countries. The report also pointed out that our hospitals had fewer acute beds, yet they appeared to offer value for money, in that they were heavily used.

I welcome the unique approach by the chief executives of five hospitals and their medical boards in coming together recently to announce the closure of beds. This co-operation highlighted the fact that beds are being closed. The Department of Finance sees a black hole in the health services and will not give any further money until that is plugged.

Mr. Stephen McMahon of the Irish Patients' Association recently stated: "Given the scale of the cuts announced by the hospitals, patients are likely to die while waiting for treatment. Accountants are making decisions about people's lives." That is a very emotive comment. In a recently reported case, a woman aged 85 was on a trolley at the Mater Hospital for 75 hours. She was one of 20 patients who had been there for up to three days, although there are empty beds in the hospital. Why is this allowed to happen? On the fourth day the woman, Ms Sylvia Byrne, was sent home without having the tests which had been promised. I do not regard that experience as indicative of a proactive health service.

The Minister may very well say, as he did today, that there is no crisis in the health service. Neither I nor my colleagues can possibly agree with that view. We are told the Minister is doing his best and has the confidence of the Taoiseach. What are we to do? I know what I will do – I will pray that I remain in good health because if I become ill, I will be in trouble.

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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Cuirim fáilte roimh an Aire Stáit go dtí an Teach. I welcome the opportunity of contributing to this important debate on a subject which touches the lives of all of us at one time or another. Irrespective of what may be said, the health services are mainly praiseworthy, though there are some occasions when they deserve criticism.

I am not suggesting that everything in the garden is rosy, no more than it was in any previous Administration. However, the picture has certainly become much rosier since the advent of the Fianna Fail-Progressive Democrats coalition in 1997. The objective of that Government was to ensure, for every patient, a world-class health service in terms of internationally determined standards of care delivered within specific times and on an equitable basis. Undoubtedly, there are difficulties in certain aspects of the health services, but they have improved significantly.

I believe there are certain causative factors contributing to additional pressures on our health services over a number of years. In my view, those pressures have come on four different fronts. There has been an increase in population. In my own county, Westmeath, the population has increased from 63,000 to 72,000 in a relatively short period. The population of Mullingar has increased by 50% in less than 20 years. People are living longer and the age profile of the population is increasing. There is a saying, "Old bones can be cold bones" and they need additional services by comparison with younger people.

There is also a greater tendency for people to seek elective procedures. I recall a time when people were reticent about seeking medical attention. Even if they needed a hip replacement or suffered from a frozen shoulder or an ingrown toe-nail or whatever, they would put up with it. One avoided going to hospital, whatever about going to a doctor. As I said, people are now more disposed towards seeking elective procedures.

Let it also be acknowledged that asylum seekers are an additional segment of people seeking medical attention. I do not intend any disrespect to them – they are a factor in our increase in population and they need various services.

It would be interesting to have a comparison of the working conditions and salary levels in this country as compared to other EU countries. I am informed that a consultant in Spain is paid approximately €30,000 and some of the top surgeons are paid €35,000 to €40,000. That is my information, be it right or wrong. Such a comparison with other EU states would be very interesting.

Since this Government came into office, the largest ever increase in health funding has been accompanied by unprecedented work on planning comprehensively for the future. Quite a number of new services have been brought on stream. In my health board area, in which there are three major general hospitals, it was decided, arising from the Shaw report a few years ago, that there would be one hospital on each of three sites. Each hospital provides a particular type of service, some providing specialties not provided by the others. In the recent past, we have secured the appointment of A&E consultants. People may say that is no big deal, that we should have had them already. Of course we should, but we did not have them until recently. We have also got additional consultants in Mullingar in the area of gynaecology, obstetrics and paediatrics.

In nurse training, for the first time in 21 years there has been an intake of psychiatric students in the Midland Health Board, with a recruitment of 32. In this Chamber a few years ago, in the presence of then Minister for Health and Children, Deputy Cowen, I recall speaking on the re-commencement of psychiatric nurse training. On that occasion, the Minister did not have very good news for us. There was great difficulty in recruiting to the psychiatric nursing discipline. I am glad we have turned the corner in that regard, as evidenced by the recent intake of students to which I have referred. We have had two intakes of general nurses and I recently had the honour of presenting nurse graduates with their certificates. That was since this Government took office, with the college of nursing being established in Tullamore in tandem with the institute of technology. That is another success story.

The health strategy is the core of our programme. There has been a significant reduction in waiting lists. In my health board area, on which, as chairman, I can speak with more authority than in relation to other boards, our waiting lists have reduced by some 50%. I regard that as no mean achievement. The national treatment purchase fund, the uptake of which the Minister outlined, speaks for itself. This is a strategy for fundamental reform, unprecedented in its depth and vision and based on partnership with patients and the professionals who are most familiar with the needs of our health services.

I wish to refer further to the area of psychiatry. The present Minister for Health and Children, Deputy Martin, was the first Minister to visit the Central Mental Hospital, Dundrum. I consider it a shame that it was left to him to be the first one to do so. Such a visit should have taken place long ago. The Minister appointed a project team to consider improvements to the infrastructure of that facility.

There has been much criticism of the health board system. As with any system, it has its strong and weak points. There is no doubt that some boards have performed well by expanding their services within annual budgets. Whatever action is taken to reorganise the health board system – whether they are to be reduced or eliminated – I ask the Minister not to throw out the baby with the bathwater. Some boards got it wrong while others got it right. Although they are well known I will refrain from naming them. The Minister should give a rap on the knuckles to health boards that have not delivered within budget and have not expanded their services.

We will have to examine carefully the treatment of the elderly because additional beds are required in this regard. Up to a few years ago, orthodontics was a particular specialty that caused shivers to run up and down the back of every public representative. I am a member of the Joint Committee on Health and Children, which invited orthodontists' representatives from various areas to speak about the difficulties they were experiencing. In the Midland Health Board area, Longford does not have a waiting list and services are provided pretty well on demand within departmental guidelines. In Westmeath, a new surgery has opened in Athlone where the waiting list is down to one year, although we will have to improve upon that. In Mullingar the waiting list is also one year but the new clinic will improve that situation. In Offaly, the waiting list is down to ten months, while originally it was a year longer. County Laois has no waiting list due to the new dental clinic, which has accreditation for training. Two orthodontists are currently in training there, in addition to one for Longford-Westmeath and another for Laois-Offaly. Two further orthodontists are training in Guy's Hospital, London, and funding for that has been provided by the Department of Health and Children. Nationally, some 20 orthodontists are currently in training.

While much has been done, much more needs to be done. There are exceptions to every situation but as regards health matters, the exception is frequently quoted rather than the rule.

Photo of Joe O'TooleJoe O'Toole (Independent)
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This debate is obviously taking the same route as the recent one on agriculture, like every debate on these subjects that I have listened to during the past 16 years in the House. I welcome the Minister of State, Deputy Tim O'Malley, to the House as it is the first time that he has been in the "hot seat" when I have been contributing. I must tell the Minister of State, however, that nothing ever changes. It is the business of Opposition parties to oppose and criticise, and there is nothing new about that. I am speaking as an Independent Member and, in that sense, I am disinterested in the political engagement between parties but I have heard the same debate down through the years.

I recall seeing the former Deputy Des O'Malley walking the streets of Limerick when that terrible Minister for Health decided to close Barrington's Hospital. The Fianna Fáil Government of the day duly called for the resignation of the Minister. I saw the former Minister for Health, Deputy Noonan, make a wrong decision because he followed the advice of his lawyers in the McCole and other cases. I listened to people on the other side of the House calling for the Minister's resignation. Now I am listening to the same calls concerning the current Minister, Deputy Martin.

I did not agree with the first two proposals and neither do I support the idea that the current Minister should resign or be removed from office. He is as committed and effective as any Minister for Health and Children that I have seen over the years. I would like to see who those calling for his resignation would wish to put in his place. It is one of those cases where people just might get what they want. I would be quite happy to see a change of Government and then we could look at it from a whole new perspective.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Who is going to take over?

Photo of Joe O'TooleJoe O'Toole (Independent)
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As regards moving the deckchairs within the current Government, however, I want to say, "No". There is a caring, responsible and committed Minister in office, although he has made mistakes upon which we should focus.

Senator Feighan gave a strong, engaging and committed outline of the issues as he saw them. I also listened to Senator Camillus Glynn but, as I predicted three months ago, he could not sit down without telling us that it is okay to get rid of some health boards but not his. As long of that kind of nonsense is being spoken there is no point in publishing the report. He should not be allowed to read the reports when they are published because he has already made up his mind on where he stands.

The health boards do not work but that is not because of the people in them, be they good or bad. The boards should work on the basis of a national policy with regional delivery but, unfortunately, that is not what we have done. We set up nine, ten or 14 independent republics, however one counts them, which all replicate each other's activities. They all parallel each other's services and everybody wants a full-scale, fully primed hospital in every small town in the country. It is time for us to deal with that.

I could not get over the debate that took place at Christmas time about the hospitals in Cavan and Monaghan. For a period, a man whose grandchild died tragically became the Minister for Health as far as the media were concerned. The level of debate was appalling. It was the same story two weeks ago with the SARS issue. Every day, I compared what we were hearing about SARS with the headlines of every major newspaper in the English-speaking world. What we were being told here was absolutely hysterical. We need to examine such issues, however, and we need to be clear about them.

I ask the Minister of State to take the message back to his own party and the broader message back to the Government that we cannot have Swedish levels of health care with Texan levels of tax. The reality we must address is that we cannot afford what we are seeking with current levels of taxation. I have been told that, as a negotiator of national agreements, I am perhaps not clear on that issue, but I am 100% clear that we need more investment.

I note the point in the Minister's speech that we have gone from fifth last to above average regarding the percentage of GNP spent on health on a per capita basis. That is a significant issue, although the speech was predictable enough. For the past 17 years I have watched Ministers delivering speeches written by officials in the Department of Health and Children. Today's speech was headed "Achievements" but the speeches are always about achievements. They wrote the same speeches for Barry Desmond and Deputies Michael Noonan and Brian Cowen, stating what had been achieved.

I had a discussion recently with three senior trades unionists, none of whom voted, or will vote, for either of the current Government parties because that is not their colour. They concluded that if somebody in Government had come to them in 1997 and offered to double investment in the health service and increase the number of health service personnel by a figure equal to the current total Civil Service they would have thought they were going to be in clover. The real question, however, is why the health service is not working. I do not know but we will not get to the bottom of it simply by political parties telling each other that the Minister should resign – the same thing that was said about the former Ministers, Barry Desmond, Michael Noonan and Brian Cowen. That is not the answer.

We should examine the problems and deal with them by coming up with answers. What are the answers? Senator Feighan was very clear – he wondered what the answers are. I do not know what the answers are either, although there are things I would love to do. If I were the Minister for Health and Children, I would send a bill to every drunk who clogs up an accident and emergency unit on a Saturday night. Taxpayer's money should not be spent on those crowding our accident and emergency units simply because they cannot hold their drink. I do not see the reason this cannot be done.

I am told that consultants do not have full use of equipment paid for by taxpayers' money after 3 p.m. I do not know why this is, just as I do not know the reason some services close down at 5 p.m. These issues need to be addressed. I do not have the slightest difficulty in paying for somebody to travel to Belfast, Moscow or anywhere else to buy the treatment they cannot get in this country. The location of the hospital is of no relevance whatever. If I was told tomorrow morning that I had a serious difficulty and that I needed to travel to Madrid, Copenhagen or Belfast to have it treated, I would just do it. If that is a more efficient way of treating people, the person who is sick does not need to be part of any philosophy on this side of the world. I do not think it is good but if it is a more effective way of doing it, we must accept that to be the case. I do not know. I certainly believe we need to move forward in such a way.

I have met people who tried to reduce costs in the health service but found it impossible to do so. I have had a three hour conversation with an individual who purchased an RSI scanner five or six years ago. I do not have time to outline, month by month, the difficulties he had in trying to get the machine accepted in the health service, despite the fact that he was providing the local hospital with a machine that could produce first-class, up-to-date RSI scans for about 55% of the cost. The consultants in the local hospital would not refer patients to the fully operational, supported and properly run clinic. I do not know why such people have a grip on the system, just as I do not know the reason we cannot renegotiate the contracts of all the consultants in Ireland. We need a new clinical approach.

I do not want to hear discussions about sacking Ministers or trolleys. If those who make such arguments did not do so when their own parties were in government, they are being unfair and dishonest in their dealings with the House. There have always been such problems – they were problems for everyone. Those who call for the resignation of Ministers are engaging in cant at this stage. Such suggestions would not solve the problems.

The Government is hiding the three reports from us, as I do not know the reason we are not allowed to read them. They should be published to allow us to make up our own minds. I know that Senator O'Meara has called for them to be produced on a number of occasions and will probably will do so again. We should be able to see them and make up our minds in order that we can come to conclusions about them. I hope we will all offer our points of view when they are published but Members of this and the other House with no point of view and nothing to propose simply have a row with each other every single time. We are not making progress on this issue, unfortunately, for that reason.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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I feel a little inadequate in having to follow such a fine performance from Senator O'Toole. He has really put it up to me. I welcome the Minister of State, Deputy Tim O'Malley. I am delighted and proud to commend the record since 1997 of the Minister for Health and Children, Deputy Martin, his predecessor, Deputy Cowen, and the Fianna Fáil-Progressive Democrats Government. I am glad that the Minister came into the House today to put the record straight for us. He was very upfront in recognising that there was a need to do more and in acknowledging that more would be done by him.

There are concerns in relation to the health service. There have always been and always will be such concerns. I am glad, however, that the Government is committed to the elimination of waiting lists. Rome was not built in a day, just as waiting lists cannot be wiped out in a day. The Government has been very progressive in finding new ways of dealing with them. It is also committed to dealing with other problematic areas in the health system.

The Minister mentioned figures. I encountered some departmental statistics during my research for this debate. The Government is spending $2,109 per capita, compared to an EU average of $2,097. The figures, which are in US dollars because the statistics are compiled in a common currency, show that there is very little difference in what we are spending per capita. Ireland spent 3.6 billion in 1997, a figure which has now risen to 9.2 billion.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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Is the Senator still referring to dollars?

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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No, I am gone from the dollar. The delivery of the health strategy, which is only—

Photo of Frank FeighanFrank Feighan (Fine Gael)
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I thought she was referring to Hong Kong dollars.

Rory Kiely (Fianna Fail)
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No interruptions, please. Senator Feeney should not heed those interrupting her.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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It is difficult not to heed them. As the Minister mentioned, the delivery of the health strategy is only 18 months old. Some 91 of the 121 recommendations have been acted on so far, including the reform of the health system, the reduction of agencies and the scaling-down of health boards. Like Senator O'Toole, I compliment the Minister on the innovative approaches he is adopting. It will not be easy to make changes but new approaches are needed because the system is failing us. I am also delighted to see that the Minister has engaged in a wide-scale consultation process with the ICTU and other affiliated unions. The fact that he has brought Congress on board speaks volumes for the type of man he is.

The BreastCheck programme was debated in this House two months ago. We are all delighted that it is now available nationwide, although I did not notice many great media headlines about it. All I read was small paragraphs. The Minister spoke about the increase in the number of oncologists compared to three years ago. When I stood here only three weeks ago, I spoke about the wonderful services we had in the North Western Health Board, through Sligo General Hospital, including a new oncologist and an entire oncology ward. We also had a debate on primary care a few short weeks ago but I do not want to revisit these areas because they were well covered at the time. I would like to point out, however, that every health board has a GP co-op and that €8 million has been put into ten pilot schemes. Multidisciplinary teams will be set up in those areas and 80,000 patients will benefit from an improved range of primary care services.

When I was in Tullamore recently, I was amazed to see the size of the crane outside Tullamore General Hospital. There is a similar crane in Portlaoise. When I pass St. Vincent's Hospital on my way to the House every morning, it looks like a construction site because so much building is going on around it. Surely Opposition Senators have to recognise these facts.

I think we had a debate on services for the elderly about two weeks ago. I hear all the time about the wonderful benefits and money being pumped into this area. I was a member of An Bord Altranais when the nursing degree, mentioned by the Minister, was introduced. Our nurses are receiving a wonderful education. Does the Opposition think this can be done for nothing? There has been an investment of €2 billion.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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Will the Government create enough jobs to allow the nurses to stay here?

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Extra places have been created in all the training hospitals. Senator Feighan spoke of the hollow endorsement given by the Taoiseach to the Minister. The Senator also mentioned the fact that the Taoiseach had said that the Minister was doing his best. I agree with the Taoiseach in that respect, as the Minister is doing his best. Members of Fianna Fáil and the Government are very modest and do not need to sing each other's praises. The two Ministers of State at the Department of Health and Children were with the Minister in the Dáil when the health debate took place last week.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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The backbenchers were all out on the plinth.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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I am sure the rest of his ministerial colleagues were busy. It may have slipped Senator Burke's mind that we are running the country.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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Where is the Government running it?

Kathleen O'Meara (Labour)
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Into the ground.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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The figures speak for themselves. I did not hear any Opposition Senator utter a single constructive word, with the exception of Senator O'Toole, who is an Independent. Senator Feighan acknowledged that he had no answers but found time to sneer, which is typical. It is no wonder that his party is in Opposition and not in Government. Why can the Members opposite not be frank and open with the Irish electorate? They should talk about the investment that has been made in the area of health. Senator Ulick Burke should give people the facts—

Photo of Ulick BurkeUlick Burke (Fine Gael)
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This time last year they were not given the facts.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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—instead of being irresponsible, jumping on a political bandwagon and causing unnecessary anxiety among vulnerable people. The Senator is engaging in cheap politics, nothing more and nothing less.

Kathleen O'Meara (Labour)
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Since this Seanad convened less than a year ago there have been a considerable number of debates on health, which is indicative of people's major concerns about the issue. One must commend the Minister on coming before the House on every occasion he has been asked to do so. Each time he has defended his position and set out what he is doing. That is commendable in terms of accountability, availability, etc. As I listened to him earlier, however, I was struck by the fact that his comments are beginning to sound like a plea. He is saying, "Please believe me, this is what I am trying to do. I am pumping more and more money into the health service."

Photo of Ulick BurkeUlick Burke (Fine Gael)
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Please release me.

Kathleen O'Meara (Labour)
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Perhaps. He also seems to be saying "If I keep saying it is working, it must be working and if I keep saying it is getting better, it must be getting better."

The Minister is in denial – Senator Feeney appears to be in the same position – with the notion that there is a wonderful health service which delivers everything to everybody when required, whereas everyone knows that the reality is different. There is a growing crisis in the health service and that cannot be denied any longer. This was illustrated last week in the joint statement of the Dublin teaching hospitals, which pointed out that 250 beds would be closed and that this would have a number of consequences. It is also stated that:

The reduced availability of beds will directly impact on such critical areas such as A+E, where waiting times for admission are already unacceptable.

High acuity scheduled admissions (the majority of which are urgent), which are already being curtailed, will also be adversely affected, with a direct impact on medical and surgical procedures. This will inevitably mean potential delays in diagnosis of medical conditions, in the performance of necessary operations (such as cancer surgery and major cardio-vascular treatments) and in the treatment of the sick with consequent unnecessary morbidity because they cannot get into hospital, including disability, deformity and pain (with reduced quality of life).

As we embark on major reductions in our bed capacity, forced on us by the funding situation, we are concerned that we are taking actions that will undermine the fabric of our services.

How much clearer can it be? People will suffer, be obliged to wait longer or they will die as a result of these bed closures. However, the Minister stated that there is no crisis. On what planet does he live? The position is that there will be fewer beds, fewer staff, longer waiting lists for procedures, equipment will not be replaced or bought and people will die while awaiting treatment. Such a situation is unprecedented and unnecessary.

Members have inquired about how this problem will be resolved. The Minister is muddled and befuddled. Senator Feeney stated that the Government is running the country and the health service. The Government is running the health service into the ground and it clearly has no answers. Its members are going around like a bunch of headless chickens trying to work out what to do next, while the professionals in the health service are doing their utmost to point out the level of crisis.

The Minister does not refer to cutbacks – he promised last year that there would be no cuts in services – he refers instead to a "tighter budgetary situation". In my opinion, the crisis will only get worse. It cannot get better unless the Government changes its current policy and its attitude towards spending on public services and, in particular, infrastructure.

It is notable that the Minister constantly refers to the amount of resources that have been poured into the health service and to the increased numbers of staff. The latter developments are welcome, but people are forced to ask why a problem exists. It is clear that the management of the health services is wrong and that one cannot simply start on infrastructure building programmes, cancer strategies and so on, send signals to the health authorities to expand and bring forward more services and then suddenly say, "Stop".

Situations where, for example, hospital extensions are half built and the money to finish them must be found from day-to-day spending cannot be allowed to continue. This time last year we were assured that waiting lists would be eliminated within two years. A year later, waiting lists are on the increase and we still await the full story on waiting lists. It is interesting that the Government has not released the full figures on waiting lists for several months. When one wonders why this is the case, one comes to the obvious conclusion.

Senator O'Toole referred to the number of reports that Members have continually asked to be published. There has been much recent media comment about three reports, in particular, namely, the Prospectus report, the Brennan report and the Hanly report. Public representatives in contact with the health services are waiting with bated breath, some anticipation and not a little concern for the recommendations contained in these reports. I understand that the Government plans to issue all three together and present them, I hope, as some sort of strategy for the future. I wish to seek early clarification in this regard. Like Senator O'Toole, I wish to know why these reports have not been place in the public domain. As with the rail strategy review, we are being subjected to a "drip, drip" process of media leaks. The final conclusions and recommendations in that review, as it turned out, were very different to the selective leaks that had presented a fairly positive picture in the month prior to its publication. It may be the case that the recommendations in the reports to which I refer will be met with a fear and trepidation, particularly on the part of representatives of the Government parties.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Not at all.

Kathleen O'Meara (Labour)
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If one is talking about the closure of local hospitals, as indicated by the headline in the Sunday Independent of 11 May—

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Newspaper articles cannot be read out.

Kathleen O'Meara (Labour)
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—which states that smaller hospitals should be closed. It would again appear that this headline came about as a result of a leak or that it was based on some sort of deduction about what will be contained in the Hanly report. If one is to believe the headline, it will mean that a hospital such as Nenagh General Hospital would lose either its acute hospital status or its accident and emergency unit and become a satellite hospital of Limerick or some sort of primary care unit.

We are entitled to know what is contained in those reports. We are entitled to know the justification for what appear to be major reductions in services in local communities. The Government should not believe that people will sit by and let their local services be diluted and undermined.

I hope that, in terms of the operation of the health boards, some sort of automatic decision will not be made by the Government that there should be fewer health boards or that they should be run by business management types. I imagine that such a recommendation would be heavily favoured by the Progressive Democrat element of the Government, in particular. It appears that there are those who believe that the health professionals within the health service are not capable of managing the health boards and that the problem lies at managerial level. If that is the case, reforming the managerial level by introducing an extra layer of managers will not provide a solution. Communities are entitled to know what the future has in store, whether in respect of the operation of the health boards or local health services.

A point made recently in the debate on cancer services is that half the beds in St. James's hospital are occupied by people with smoking-related illnesses. What are we doing to change that? The cost to the public purse of smoking-related illness is huge. The cost to the health service of alcohol-related illnesses is also exceptionally high. Senator O'Toole referred to this. That is something that will take time to address, but we should certainly be working on it to bring down the cost.

Photo of Michael KittMichael Kitt (Fianna Fail)
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I am very glad of this opportunity to contribute to the debate. I welcome the Minister of State at the Department of Health and Children, Deputy Tim O'Malley, and also congratulate the Minister, Deputy Martin, on his address to the Seanad.

The Minister was modest in his quotation from the Irish Society for Quality in Healthcare survey. In the correspondence I received there was a reference to 92.9% of respondents being satisfied or very satisfied with the overall quality of care they received during their stay in hospital. Also, 85.5% of respondents reported being satisfied or very satisfied with the standard of services they received in the accident and emergency department. With regard to communication with doctors, 90% of respondents indicated that the explanations given to them by doctors about their condition or treatment were very easy or fairly easy to understand. That is something we do not hear much about in the media.

We know from the members of the Western Health Board and from conferences such as that held in Kilkenny in March that there is much pressure on hospitals and on their staff. That was pointed out very clearly in Kilkenny by the professionals who spoke there and talked about the extra hospital activity. One theme running through the conference was that they wished to see a single waiting list for public and private patients and also new contracts for consultants.

Senator Glynn spoke earlier about conditions in different parts of the country. Population increase is common to every county now, as well as the fact that people are living to a greater age. In County Galway there was always a huge rush of activity in the summer with visitors to the county. Our region did not just cover the counties of Galway, Mayo and Clare but also the midlands, as well as holidaymakers in summer. There were always difficulties at Christmas with elderly people getting influenza and colds. We now have a considerable number of people visiting hospitals.

Senator Glynn mentioned asylum seekers and economic refugees. In Galway particularly, people arriving for the birth of a baby from difficult situations in countries where they may have had no pre-natal care are obviously adding to the difficulties in the maternity units of the hospitals.

I compliment the Minister and his Minister of State on dealing with these issues and telling us the facts as they are. I have heard about these reports Senator O'Meara referred to – the Hanly, Brennan and Prospectus reports. I have seen the headlines referring to the closure of acute hospitals. I attended a meeting last night in Tuam where there was a request from the local community to have a 60-bed community hospital in the town. The Minister has said, and has put in writing, that a population base of over 30,000 people would be an ideal number in a catchment area for a hospital. This would be the case in Tuam if we include the Tuam and Glenamaddy areas where 14% of the population are over 65, of whom 1,059 people live alone. Whether we are talking about step-down accommodation or a community hospital to go to after being discharged from the acute hospital, it would be an ideal development. I have the support of members of the Western Health Board in asking that the hospital brief for Tuam which has been with the Department since September 2002 should be progressed and that money should be provided for the building design work. I raise this issue again with the Minister of State with a view to getting money for the design of the building.

I understand that the Hanly report, referred to by Senator O'Meara, looked at the mid-west, the area she represents, Limerick, Ennis and Nenagh, and three hospitals in Dublin. It is very difficult to accept that they are suddenly going to close every acute hospital in Ireland from a study of just two areas. That, to my mind, makes no sense whatsoever. I agree with Senator O'Meara that the Hanly, Brennan and Prospectus reports should be published, and we will then in a better position to deal with their proposals. Hopefully, we will be able to give our views on them.

The Western Health Board had some good publicity at the end of 2002 when it was shown that there was a surplus of over €8 million and at yesterday's meeting there was reference to a €5 million surplus. I hope some of that funding can go to keeping beds open. In the area of disability, for which the Minister of State has responsibility, I hope we will also find funding to keep respite beds open, a matter I have raised with him privately and publicly. It is a shame to propose to reduce respite care even from five days to four days, as, for example, in St. Dympna's in Portumna. There are also proposals to reduce the number of staff at Ashtree House in Ballinasloe. Parents have really been very strong and called meetings to make the case that if there is extra funding, it should be spent on disability. I hope the Minister of State will be able to give us a positive response.

I accept that we have a difficulty in the area of orthodontics. We have seen the guidelines from the Department that, in order to qualify, people must have 10 mm malocclusion. There are sad cases of people who have 8 mm or 9 mm malocclusion and do not meet the criterion. They are told there is no service for them. That has to be changed immediately. Obviously we need more and more people to be trained in the area of orthodontics and hopefully those people will spend some time working in Ireland. My information is that many people leave the country as soon as they have qualified to find work in Great Britain or some other European country. That is very difficult for a health board because staff are not available.

I am not very good at public relations and neither are the health boards. The Department of Health and Children could use other means to let us know what it is doing. I obtained yesterday a book entitled Catch a Flickering Light, a collection of stories from residents of a day-care centre in Tuam, which is also a community nursing unit. These are beautiful stories, about – as the blurb says –"the truth and innocence and the tears of joy and pain". This publication did get publicity in our local media, but it is an example of the good things the health boards do and I welcome it. It is similar to what Jim Fahy used to do when he presented the "Looking West" programme, asking people about their stories. This is a very good example of what should be done to commemorate old people, and I hope that the elderly will be a priority for many years to come.

Photo of Martin ManserghMartin Mansergh (Fianna Fail)
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I wish to share my time with Senators Cox and Scanlon.

Rory Kiely (Fianna Fail)
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Is that agreed? Agreed. Is the Senator taking five minutes?

Photo of Martin ManserghMartin Mansergh (Fianna Fail)
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Yes. This side of the House has full confidence in the Minister for Health and Children and we were glad to listen to his contribution. He is one of the most able Ministers of the Government and an able Minister for Health and Children. His humanity is obvious to everyone. Any group which thinks it can whip up some kind of crisis and succeed in forcing his resignation can whistle at it. He has the support of the Government, the Fianna Fáil Party and, I am sure, the Progressive Democrats also. The Minister of State, Deputy Tim O'Malley, is present in the House.

There has been a concerted attempt for some years to persuade public opinion that we are no further forward than we were in the late 1980s in regard to the health service. That is nonsense. It must be remembered that healthy people only have limited contacts with the service and at any given time that is a majority of the population. There have been huge advances in staffing, modernisation of hospitals, operations being undertaken, new techniques and procedures. One only has to look at the Estimates volume to see that expenditure now accounts for 7.8% of GNP. I remember debates in which the Labour Party urged us to achieve the level of GNP Barry Desmond achieved in 1986, something like 7.3%. We are way beyond that point.

All of us recognise the need for more development but no sector – there are many deserving sectors – can simply be handed a set of blank cheque books. While health is a major priority, there are other major social priorities. Education is an obvious one as well as infrastructure, law and order and so on.

I heard talk that some of the unions are looking for a 35 hour week. In an ideal world all of us would like a 35 hour week. France has adopted a 35 hour week but has had a great deal of difficulty with it. Most of those involved in the public sector do not work a 35 hour week and I am not certain that is the most pressing priority in the health service, notwithstanding the magnificent work done by doctors, nurses and others.

We are all taxpayers and potential patients. Almost all the reports I have received about the health service over the past ten years from family and people in the community, whether to do with the public health service or VHI type treatment, have been good. The vast majority of what goes on in the service is good and people are satisfied. We get to hear about the difficulties but that sometimes gives a say to those who are the majority and have limited contact with the service. They give a wholly distorted view in order that when somebody goes into hospital, they are pleasantly surprised that it is not the disaster the media have told them to expect.

We have spent much more money on services for people with a disability but that is an area which will continue to need a very high priority because of the strain it places on families. I am sure the Minister will develop the excellent heart surgery facilities in Cork.

We discussed here on another occasion the fact that not all health problems were unavoidable. Drugs, drink and so on present problems which take up a large part of the attention. There is something to be said for imposing an extra charge on those concerned who seek the help of the health service.

I would not cast aside the idea of decentralisation of the health service. I believe in local and regional decision-making which should be borne in mind. A world class health service should continue to be our goal.

Margaret Cox (Fianna Fail)
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I reject the line constantly thrown out by the Opposition that patients receive a second class health service.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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It is not.

Margaret Cox (Fianna Fail)
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I wrote it down as somebody said it. In my experience the quality of work done by health care professionals is second to none.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Hear, hear.

Margaret Cox (Fianna Fail)
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Nobody is more proud of the work they do. If I was to have a heart attack, suffer from cancer or any other condition that would make me seriously ill, I would not want to go to any other country to be treated. If somebody in need of medical care and attention goes to an accident and emergency department, he or she may have to wait on a trolley – I accept this and wish it was different – but when admitted to the hospital he or she will get the best available care from some of the best consultants and nurses in the world on which I commend everybody involved in the health service.

People ask where the €9.2 billion spent on the health service this year has gone, and we talk about the administrative black hole, bureaucracy, reform and so on. That is a load of codswallop. I will tell the House where the money has gone. It has gone on more residential places for people with a disability. It has gone because people now have personal assistants that they did not have five, six or seven years ago. It has gone because people in the west suffering from cancer now have oncology services that they did not have in the past. My father died from cancer in 1995. At the time there was no oncologist in the Western Health Board area. Since 1995 a whole team has been put in place to deal with cancer patients.

People ask what is happening to the cardiac strategy. There are now four cardiologists in the west. That is decentralisation of the service and an indication of where the money has gone. The money has also gone into the appointment of consultants and on improving the lives of nursing staff. We have many more nurses now than we had in the past. Their wages have increased which I support. The Western Health Board is now providing 1 million hours of home help, not at the 1995 rate of £1 an hour but at above the minimum rate. That is where the €9.2 million has been spent.

Photo of Eamon ScanlonEamon Scanlon (Fianna Fail)
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I concur with the two previous speakers. As a public representative and frequent visitor to hospitals, I am aware that the patients I visit are very satisfied with the treatment they receive. That is because of the work done by the doctors, nurses and other staff in the hospitals concerned.

Since I became a member of the North Western Health Board in 1991, the improvements which have been made in Sligo General Hospital are phenomenal. A new day surgery ward was opened last year where patients can have minor surgery in the morning and go home in the evening. We have a new state-of-the-art oncology ward. I have a friend who, unfortunately, has cancer. He attends the oncology ward every second day. His treatment is finished by 10 a.m. and he can then go to work. Twelve months ago he attended St. Luke's Hospital, Dublin for treatment which took five or ten minutes but because of the journey involved he had to stay in the hospital overnight. He was away from his family for the whole week and could not go to work. While the system is not perfect, it is improving. It is worth noting this.

There have been improvements in care for the elderly. The nursing unit in my home town was taken over recently by the health board. The care provided and the ancillary services available to the people concerned, including the home help service, are excellent.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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I wish to share my time with Senator Bradford, by agreement.

Rory Kiely (Fianna Fail)
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Is that agreed? Agreed.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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I welcome the Minister of State. With reference to his colleague, the Minister for Health and Children, Deputy Martin, it is difficult to understand how a Minister can reform the health service if he does not recognise that there is a crisis. In that regard, it will be very difficult for the Government to initiate any worthwhile reform other than to scramble from one crisis to the next and hope to survive politically. While Members on the opposite side of the House have listed statistics regarding the number satisfied with the health service, there is a failure to recognise that this satisfaction comes from those who have access to services. What about waiting lists, those on trolleys and those who must travel abroad to gain access to services?

We talk about reports, analysis and reviews. I am sick to the teeth of this pussy-footing. It is time the Minister had the courage to reform if he intends to reform, although I am sceptical as to his commitment in that regard. In his address he dealt with the major reform initiatives under way and quoted from some of the reports my colleagues have mentioned. He referred to preparing a plan for medical staffing of acute hospitals and said: "This is likely to include reference to the future configuration of hospital services in Ireland." Leaks to the media have been welcome because they warn people of what is pending. However, when we talk about future configuration, we know that we will have the closure of hospitals. We can call it step-down, downgrading or otherwise but there is no doubt that the professionals delivering the service in recent months in the hospitals listed in the leaked report have been terrified and demoralised. All that they have done and how successful they have been in delivering the service are now questioned and, according to the report, there is no place for them in the future.

As Senator O'Meara mentioned Nenagh, I will refer to Portiuncula Hospital in Ballinasloe. I have reason to believe that since the Department acquired the hospital from the Franciscan Sisters some time ago, there has been a shortfall of €3 million in funding for it. This clearly indicates that the shortfall will be made up in the future by downgrading and making the hospital a step-down facility.

I cannot finish without mentioning a hospital within a stone's throw of this House – Our Lady's Hospital for Sick Children, Crumlin. If ever there was a monument to departmental neglect, this hospital is it. Members should visit it to see this. I have had reason to be involved with it for a long time and know that were it not for the parents and the personalities, sports and otherwise, who fund-raise to keep the paint on the walls and the basics in place, any Minister who survived the Celtic tiger's lifetime while neglecting to fund it should consider his position and disappear as a matter of urgency. There has never been a place in Ireland which has been neglected as it has. That is a shame.

Photo of Paul BradfordPaul Bradford (Fine Gael)
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In today's post-Celtic tiger economy the state of an Irish family's health has become totally dependent on the size of its wealth. That is the biggest indictment of the Minister and his Government colleagues, although it is not all his fault as he is implementing Cabinet decisions. There has been a glorious ten years of economic boom but at the end of that decade of unprecedented opportunity the health service is no better than before.

When the Minister makes his case for the defence either inside or outside the House and when the Taoiseach speaks about the health service, we are given as the golden goal the fact that so much money is being spent and that investment has doubled and trebled. That case for the defence has become the case for the prosecution. The questions stemming directly from it are: what value for money is the taxpayer getting for the money spent and what level of service is being delivered?

I recall the political debates of the mid-1980s when the then Minister for Health, Mr. Barry Desmond, who was trying to bring about genuine reform of the health system, was politically attacked as the man who was bringing destruction to the system. We were promised a better way. One may remember the slogan, "There is a Better Way". However, since then, there has been no political leadership with regard to the health service. Money has been invested, as it should be, but we have not had value for money. Taxpayers are rightly demanding that any extra investment in services produces results. However, that extra investment, particularly in recent years, has not worked.

We hear very little from the Minister about his future plans, only about reports. Every sort of report seems to be emanating from the Department of Health and Children. As we speak, two or three more are shortly due to issue while the situation on the ground has deteriorated. Whether it is a question of disputes with doctors or nurses, patients bear the brunt. Patients are not concerned with whether the delivery of a top class health service comes via the public or private sector – they simply want a service which is working and delivers when needed.

It is now the case that unless people have private health insurance, they have no guarantee of a health service. Members have debated the Health Insurance Bills in both Houses of the Oireachtas in recent years but a stage is now being reached where every citizen will be obliged to take out private health insurance or they will have no guarantee of access to the service. That is not fair at a time when billions of euros per annum are being spent on it. While we are spending world class money, we are ending up with a second rate service.

Huge structural reform is required. I am glad that the Minister is considering the system of delivery. I hope he has the political will and that he will receive the political support from his Government colleagues and parliamentary party to bring about dramatic reform of service delivery, particularly with regard to the health boards which have been a failure over the past 30 years.

The BreastCheck clinical unit for the west will be based at University College Hospital, Galway, and it will have two mobile units. Counties Galway, Sligo, Roscommon, Donegal, Leitrim, Clare and Tipperary will be covered. All these improvements cost money and we, as politicians, are in this together. The problems in the health service will be resolved by the Houses of the Oireachtas and not by an individual Minister for Health and Children or political party.

Mary Henry (Independent)
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I wish to share time with Senator Norris. He says he needs only a minute but I am sure he could have two.

Rory Kiely (Fianna Fail)
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Is that agreed? Agreed.

Mary Henry (Independent)
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I welcome the Minister of State. There is no point in knocking spots off each other claiming this, that or the other about the health service because we have serious problems. The general public, if they manage to get treatment, get good treatment, but a large number of people are not getting the treatment they need or deserve. A huge amount of money has been pumped into the health service but 70% of it has gone on wages. I presume the Minster for Finance was present when the Government decided what the wage increases should be and I do not know why he is so surprised about where the money has gone. More money will be spent on benchmarking shortly. Although I do not question the necessity for or the desirability of the wage increases, considerable money has been invested in them.

Rash promises were made prior to the election about the introduction of services and the retention of small hospitals and people are angry because these promises have not been fulfilled. For example, a number of Senators referred to the improvement in cancer services in the west. They should speak to the oncologist who contacted me recently about the promised radiotherapy unit for the region. The unit will not be provided for several years, even though it was promised almost immediately. A radiotherapy unit was also promised in Waterford, although I do not know about the justification for locating it there.

Photo of Martin ManserghMartin Mansergh (Fianna Fail)
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It was not promised.

Mary Henry (Independent)
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The people there told me that Government Deputies and Ministers promised the unit.

Photo of Martin ManserghMartin Mansergh (Fianna Fail)
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I support the unit but it was not promised by the outgoing Government.

Rory Kiely (Fianna Fail)
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Senator Henry, without interruption. Her time is limited.

Mary Henry (Independent)
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It is terribly foolish of Senator Mansergh to call for local autonomy regarding health issues such as this. That is what happened in regard to Monaghan and Cavan hospitals. It is impossible to provide an accident and emergency unit at every crossroads and it would be wrong to do so. However, the Minister must make firm decisions in this regard.

The worst aspect of the health service is the terrible lack of morale among workers. Vested interests is another description for consultants. It has been proposed that newly appointed consultants should work only in the public service. That is absolutely splendid but what, in heaven's name, is the Minister of Finance doing giving tax relief to private hospitals when the existing ones are between 60% and 70% full? What sort of economic sense does that make? It is absolutely ridiculous.

Senator Feeney is a member of the Medical Council and she will be well aware that we passed with great haste in April 2002 an amendment to the Medical Practitioners Act so that non-EU doctors would find it easier to achieve permanent registration. Nothing has happened, yet there are problems all over the country because these doctors who were shoring up rural hospitals are not being allowed, quite rightly, by the Medical Council to work in them because they were not being trained. The council finally put its foot down and said it would not authorise such doctors to take up posts in hospitals where they would not receive training. There is delay in the appointment of neurologists, even though there are only ten in the State. There is one rheumatologist in the west. Is there no arthritis in Connacht? That is amazing. These problems are bad.

However, major progress has been made in other areas. For example, the survival rate of neonates and babies who weigh under a kilo is incredible, but it must be accepted that not all these children will survive without a great deal of remedial treatment as they grow up. Nothing has been put in place in this regard. I receive letters regularly. One woman asked where was early intervention for her two and a half year old child.

Treatment of heart disease is going well. People are not dropping dead where they stand due to the improved pre-hospital emergency services and intervention by cardiologists and cardiac surgeons. Ireland has a good survival rate but such patients need expensive treatment. Some of our great advances will continue to cost money and that must be accepted.

I am delighted the Minister of State, Deputy Tim O'Malley, is present because mental health is his bailiwick. Despite the investment in the health service, the proportion spent on mental health services has been reduced from 12% to 7%. This is not the Minister of State's fault. While it was decided that mental hospitals would close, which was good, community health services have not been established. I have sympathy for those who work in the community such as psychiatric nurses and social workers. However, a number of psychiatrists who accept posts working with the homeless then refuse to take them up because they have limited support services.

The Minister is correct to examine the cost of drugs. Prescribing generic drugs is not the only action that can be taken because branded generic drugs are only 10% cheaper than some of those produced the principal pharmaceutical firms. These companies must be taken on because we pay much more for pharmaceutical products than people in many other European countries. The reason is the Government makes a deal with these companies. Are we so influenced by our total dependence on the pharmaceutical companies for exports that we must tolerate such a bad deal? I will support the Minister of State on anything he can do with them.

Photo of David NorrisDavid Norris (Independent)
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I thank Senator Henry for sharing time. It is important that we hear voices such as hers because she comes from the professional coalface. Her contribution and that of Senator O'Toole were important because they were made by Independent voices who did not make a political football of the issue, which is one of the problems.

Everybody recognises the health ministry is a poisoned chalice. The Minister for Health and Children, Deputy Martin, has done a reasonably good job. One of the problems is that people's expectations have risen so spectacularly. They are also new techniques, drugs and machines available. People expect the State to keep them alive forever but it is not possible because we are perishable goods.

Like Senator Mansergh I have experience of the health services and I found them quite mixed. They were quite excellent on some occasions, while on others they could have proven fatal to one's health. We should not simply say this is the best health service in the world. We have a mixed health service and we should examine its defects.

I had a disastrous experience here during prostate treatment as a result of which I damn nearly died. I visited Cyprus recently where one receives such treatment almost immediately. They use the latest techniques and drugs, patients feel little pain and they are out of hospital almost instantly. I had a dental problem while I was there. I have four dentists in Ireland attending to one tooth. Over there, I got an appointment the next day and saw a wonderful young female dentist. She gave me an anaesthetic, partly extracted the tooth and dressed it. She gave me a full run down on oral hygiene practices and it cost approximately €35. There is too much specialisation in Ireland.

I support all Senators who said there should be greater investment in services for people with disabilities. I wish to highlight the question of autistic children and children who suffer from attention deficit disorder, which I have raised on the Adjournment and during other health debates. One of the crippling failures in the system, about which I received another letter from an agonised parent today, is the inability of the State to provide speech therapy. This must be looked at as efficiently as possible. It is destructive not to have it available when parents know their children could be helped but for the absence of speech therapists. I know the problem relates in part to the universities but it should be examined.

While I may not have had much time to speak, I have at least had the satisfaction of uttering the last, if inadequate, word in the debate.

Rory Kiely (Fianna Fail)
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When is it proposed to sit again?

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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At 12.30 p.m. tomorrow.