Seanad debates

Wednesday, 22 October 2003

National Task Force on Medical Staffing: Statements.

 

10:30 am

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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Last week I published the Report of the National Task Force on Medical Staffing. It completes the package of reforms set out in the health service reform programme announced in June. Its implementation is vital to achieving the kinds of improvements in health care that we want and that the public deserves.

My starting point has always been to do what is best for patients, and this report is about patients. It aims to ensure that consultants are more involved in patient care by taking a hands-on role in the provision of services, that junior doctors are better trained, awake and alert when they see patients and that patients will be treated in hospitals that are fully equipped and staffed to cope with their condition, whether serious or not.

I established the National Task Force on Medical Staffing in February 2002 to devise an implementation plan for reducing average working hours of NCHDs in line with the European Working Time Directive, to assess the implications of moving to a consultant provided service and to address the medical education and training needs of doctors in this context. At present, most front line medical care in our hospitals is delivered by junior doctors, NCHDs, most of whom work excessively long hours. Patients have limited access to consultant care. NCHDs will soon be required by law to work fewer hours.

The task force set out to answer a key question. How do we safely provide hospital services, 24 hours a day, seven days a week, as the working hours of our junior doctors reduce in line with EU law? The task force brought together hospital consultants, NCHDs, doctors from general practice and public health, the nursing and midwifery and the health and social care professions, health educators, the medical unions, managers and representatives of the public interest.

During its work, the task force took particular account of two previous reports: the report of the Medical Manpower Forum and a report chaired by David Hanly on the working hours of non-consultant hospital doctors. Both were completed in 2001 and they highlight a consensus regarding the need for more consultants, new work patterns and fewer junior doctors working shorter hours. The reports pointed to the need to re-examine how and where we will provide acute hospital services in the future.

A priority for the task force was to ensure that, as it studied the measures needed to develop a modern, efficient and patient centred hospital service, sight was not lost of the value of keeping services at the heart of local communities. In order to meet the requirements of the European Working Time Directive and to deliver a better service to patients, the task force has made certain recommendations. It has set out a series of immediate measures to reduce the working hours of junior doctors to 58 hours per week by 1 August 2004. It has concluded that the only way to address reductions in the working hours of junior doctors while providing high quality patient care into the future is to introduce a consultant provided service. It has argued that a full range of acute hospital services should be available within each region, so that patients should not have to travel beyond it other than for services that are best provided at supra-regional or national level. It has recommended investment in local hospitals to provide more services for patients, including elective medical and surgical procedures, out-patient services, pre-natal and post-natal maternity services and better access to diagnostic facilities.

The report also proposed retaining and developing the minor injury and illness services in local hospitals, which currently account for 70% of patients attending accident and emergency departments, and set out a series of principles for the future organisation of hospital services nationally. It outlined measures to reduce junior doctors' hours to 48 hours a week by 2009, improve training and introduce a consultant provided service over a ten year timeframe.

In response to the task force report, I have set out a programme of action which will enable patients to be treated by a larger number of senior doctors working within a reorganised hospital system. Patient care will be the responsibility of teams of consultants, supported by junior doctors working safer hours in an improved training system. Non-consultant or junior hospital doctors have played a key role in service delivery in the hospital system for many years. More than 4,000 junior doctors currently deliver front line services in more than 40 public acute hospitals and numerous other health agencies. Junior doctors work an average of 75 hours a week on-site, while many work considerably longer, often for extended periods without rest.

The task force has proposed a series of important national measures aimed at reducing the average working hours of non-consultant hospital doctors. The immediate target is a reduction to 58 hours a week by 1 August 2004. These measures include replacement of the present system of tiered on-call, increased use of cross-cover arrangements, the introduction of new working and training patterns for non-consultant hospital doctors and a set of measures aimed at reducing the workload of non-consultant hospital doctors in areas in which other staff are better placed to deliver a quality service.

There is one measure which the task force rightly rejected, namely, the recruitment of extra junior doctors. The discussion document, Medical Manpower in Acute Hospitals, also known as the Tierney report, dealt with this issue ten years ago. It pointed out that the growth in junior doctor numbers, which had resulted in two junior hospital doctors for each consultant in the public sector, had adverse implications for patient care, the efficient operation of hospital services and the future career prospects of doctors in training. Since then junior doctor numbers have increased substantially. We have more than enough junior doctors and now need more consultants.

The Tierney report is an important document given that it suggested ten years ago that we should have up to 1,500 senior consultants by 2003. We now have more than 1,730 senior consultants, in other words, we exceeded the Tierney recommendations. I say this to illustrate that what is proposed in the Hanly report is achievable over a ten year timeframe. I have heard comments to the effect that the proposals will not be achieved. Tierney's estimate of the required number of senior consultants has been exceeded.

There will be other issues surrounding the Tierney report which were not advanced at the time, including the reorganisation of acute hospital services. However, there was also the issue that the appointment of a new hospital consultant required the appointment of a new team, which resulted in the number of junior doctors increasing from more than 2,000 to more than 4,000. Hanly proposes a more complete package involving all the various players, disciplines and professions. It also had to consider another imperative, namely, the working time directive which imposed a discipline on the exercise that was perhaps missing from previous exercises.

Our current ratio of junior doctors to consultants limits the extent to which consultants can deal directly with patients. In order to achieve a consultant provided service, we require a substantial increase in the total number of consultants and a corresponding reduction in the number of non-consultant hospital doctors. Significant change will be needed in the current consultant contract. Consultants will be expected to work in teams, sharing responsibility for patients with their consultant colleagues. Agreement will be required to enable consultants to participate, as required, in the provision of on-site cover in the hospital over the 24 hour period and there must be clarity regarding the proportion of a consultant's time appropriately spent on clinical and training commitments. These requirements are essential to the development of a genuinely consultant provided service. There can be no question of moving to this system in the absence of a substantially changed contract.

Reform of our medical education and training system is a vital component of the new service model. Because medical education and training for NCHDs is intertwined with service provision in our hospitals, we will need major changes in how we deliver and organise medical education and training in a shorter working week. Genuine training posts for all NCHDs are integral to a consultant provided service. I look forward to speedy implementation of the task force's wide-ranging recommendations in this area, which include integrating training functions currently scattered throughout numerous agencies; top quality, safeguarded training, oriented to a new model of service delivery; a flexible training strategy; and measures to address the concerns of non-EU doctors in training. The medical education and training group of the task force is currently working on a number of outstanding issues and I expect it to provide me with a final report in the new year.

Earlier I emphasised the challenge facing the task force regarding acute hospital services. How do we safely provide hospital services, 24 hours a day, seven days a week, as the working hours of our junior doctors reduce in line with EU law? The task force has responded by setting out a new way of organising hospital services. Its proposals mean that no hospitals will close. Instead of downgrading hospitals it proposes to bring services closer to patients while ensuring those services are both safe and sustainable.

This was pointed out by a number of consultants who were part of the Hanly group. One can cite the example of a speciality such as rheumatology. There is only one rheumatologist in the entire mid-west region. Until quite recently, there were no rheumatologists in the west. Also, up to quite recently there was not even a neo-natalogist in the Western Health Board region. Everyone focuses on trauma and acute emergency treatment – this is where the debate immediately leads. There is a wide range of specialities and services for which people in the regions have to travel to Dublin or other areas. The Hanly report says this need not be the case. With the exception of tertiary treatment, such as cardiac surgery, liver transplantation and so on – obviously they will take place in national centres – the vast array of other specialities can be delivered in the regions. There is no reason why we cannot give additional services to local hospitals in terms of routine elective surgery. For example, there is no reason local hospitals cannot do routine ENT surgery, or offer a much greater range of diagnostic facilities, pre and ante-natal services and so on. The Hanly report says local hospitals might not do everything they allegedly do. There is a large question mark over what people think happens in emergency services and what actually happens. Hanly makes the point that local hospitals can provide services which they currently do not provide. The type of services provided by hospitals, in the appropriate setting and in a safe context, is at the core of the debate.

A key part of any reform of our hospital services is clearly a reorganisation of emergency care. International evidence, cited by Hanly, is clear on this. Patients do better in hospitals that have the required numbers of specialist staff, are able to provide suitable medical cover 24 hours a day, seven days a week and have high volumes of activity and access to appropriate diagnostic and treatment facilities. At the heart of our reform programme, however, is the recognition that while we need to concentrate emergency care in our major hospitals, reorganisation of acute hospital services offers the potential for a wide range of safe, effective, high quality care to be offered in our smaller hospitals.

Those hospitals identified by the task force as local hospitals are ideally placed for that role. The core of their services will include elective medical and surgical procedures, day surgery, minor injury and illness units, high quality diagnostic services, outpatient clinics, pre and post-natal maternity services, intermediate care and rehabilitation and convalescence beds. These services will be provided by a group of health professionals including consultants, NCHDs, general practitioners, specialist and staff nurses, radiographers, physiotherapists, occupational therapists and other health professionals. In summary, I expect them to provide an increasing volume of elective procedures and the kind of multi-specialist day and outpatient care that is currently performed in the larger hospitals. Far from downgrading, these hospitals should be developed further to give people local access to a wider range of hospital services than they enjoy at present. Managing the changes required will be challenging and I will not understate the magnitude of the task ahead.

I wish to proceed with the implementation of the process. In order to reduce average working hours of non-consultant hospital doctors to 58 hours next August, we need immediate engagement between management and the Irish Medical Organisation. I have asked the Labour Relations Commission to convene a meeting between both sides to agree quickly a process for negotiating the changes required. Closely linked to this process will be the negotiations on a new contract for hospital consultants. At my request, the Health Services Employers Agency has contacted the medical organisations to arrange an early meeting to discuss the format and terms of reference for the negotiation of a new contract.

I also want to implement the changes proposed by the task force in the east coast and mid-western regions. To do this there will be a project group in both areas which will include management and health professionals from the hospitals involved. These groups will engage in a detailed planning exercise, identifying how best to reconfigure services and staffing at local level. With regard to future organisation of acute hospital services, I have asked David Hanly to chair a small group to prepare a national plan in line with the principles set out by the task force. His group will liaise closely with my Department and, on its establishment, with the national hospitals office. The project group which addressed medical education and training issues is now in the process of preparing its final report.

The Hanly group engaged in an exhaustive process of consultation prior to writing the report. It met with approximately 600 people in both pilot areas, including consultants, junior doctors, nursing staff and other health care professionals. There were about 300 meetings. Whatever one's views of the exercise, it was detailed. It looked at the issue from a green field perspective in the sense of examining the best way to organise health services in the future for a population of 350,000. The question of what was the best and safest service for the patient is what ultimately motivated the conclusions of the Hanly group and it is the reason the Government has accepted and endorsed the group's conclusions and recommendations.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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The Minister has a difficult job and I wish him the best of luck with it. One can only suppose that reports such as the Hanly report are aimed at people with a vast knowledge of the health system. For a lay person such as myself, the reports have become complicated documents despite their summaries of the main points. One would have to be an expert to interpret many of the reports. Take, for example, the chart on page 170 of the Hanly report. It is like the circuit diagram for a space shuttle. The interesting question that arises, which is never dealt with, is the costs of these reports and the expenses incurred. I have no wish to undermine the work of the group as its members have obviously worked hard but perhaps they go above the call of duty.

According to my colleague, Deputy Olivia Mitchell, this is the 148th report for the Department of Health and Children in the last five years. The Department could be called "the Department of Reports". Other notable reports in recent times were the Bacon report, the value for money report by Deloitte and Touche, the health strategy "Quality and Fairness – A Health Strategy for You", the bed capacity review of 2002, the Prospectus report and the Brennan report. The Hanly report is envisaged as the first of a series which will continue on the same theme but for different regions. What will happen to these reports? The health service will muddle on with a patchwork quilt of ideas from various reports and none will be used until the various interest and pressure groups are satisfied.

The Hanly report deals with three issues. The first is working hours for doctors, especially non-consultant hospital doctors. The second is a consultant provided rather than a consultant led service. This means there will be many more consultants at the coalface of the health service rather than being on call with the junior doctors doing most of the initial work. The third and most contentious issue is the attempt to rationalise the configuration of acute hospital services. The Minister faces a difficult task in that regard.

Everybody agrees with the effort to improve the lot of junior doctors in terms of working hours, length of shifts and so forth. However, we are not leading the way in this regard but are being forced to introduce better standards by the EU working time directive or EWTD. From August 2004, non-consultant hospital doctors must not work for more than an average of 58 hours per week and not more than 13 hours on-site in a hospital. The historical development of junior doctors having to work incredibly long hours would require another report. Everybody is aware of this practice but it has been allowed to continue until now in the most sensitive of professions where focus, rest and alertness are of paramount importance. At present, there are 3,900 junior doctors in Ireland delivering front line service in more than 40 public acute hospitals and other health agencies. They work an average of 75 hours per week and often for continuous periods of more than 30 hours. In 2003, there were 1,731 hospital approved consultants in public hospitals. The EWTD will have to be implemented or we will be penalised so we cannot take any credit for being imaginative, innovative or reformist in this area.

The report states: "Acute hospital medical services would be consultant provided rather than consultant led". This looks fine but it is aspirational. That is the problem with many of these reports, they are aspirational but there is little meat on the bone. The reduction in junior doctors' working hours will lead to major staffing problems in hospitals with a requirement for more junior doctors or other arrangements. The objective is to have more consultants at the front line of services and one cannot quibble with that, if it is possible. However, I have a quibble with the statement on page 22 of the report dealing with methodology which states:

The Task Force explicitly set aside two forces that inevitably influence the shape of health services: industrial relations issues and political considerations.Finally, the Task Force initially set aside cost implications in order to provide the best possible health service.

If one ignores politics, industrial relations and costs in the health service, one has set aside three key elements in the equation.

While the issue of working hours is guided by the EU directive and the consultant provided service is aspirational and, if possible, fine, I believe the most problematic issue will be acute hospital care and the configuration of acute hospital services. There are probably no huge problems with the report aside from the issue of local hospitals. The Minister faces a serious battle in this regard. One cannot ignore political considerations, although I try not to get involved with them when dealing with something as serious as the health issue, and the ingrained fears in communities who will fight to retain their hospital, be it in Ennis or, in my case, Roscommon. It does not take a consultant to interpret the immediate response of my colleague, Senator Leyden, to the report last week when he said it should be binned. He was being driven by a whole spectrum of emotions.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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He had not read it.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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Senator Leyden, a member of the political party of Government, stated that in the House.

Photo of James BannonJames Bannon (Fine Gael)
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He is also a former Minister of State.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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He had not read it.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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That is not a great argument.

An Leas-Chathaoirleach:

Senator Feighan, without interruption.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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He was driven by the whole spectrum of emotions, fears and needs that are part of the campaign to retain a respectable county hospital. The issue is how to square the circle with the need for multidisciplinary centres of excellence. The report shies away from that, once again kicking issues into touch. It does not mention Roscommon County Hospital, where €8 million has been spent on an accident and emergency unit which has not yet opened. The Roscommon accident and emergency unit will face closure if the report is implemented. I state that now because I believe that is what the Minister has determined for further down the line. The Government is letting the bad information out in a drip effect, with one leak following another.

Photo of James BannonJames Bannon (Fine Gael)
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That is because of the local elections.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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If the Government has no problem with sacrificing a number of Deputies and even Senators, it will take that route. I need not tell Senator Leyden that he has already been sacrificed once on the hospital issue. He is a decent man and I hope that the Government does not sacrifice him again.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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I can see that the patient is looming very large in all this.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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I am a good colleague of Senator Leyden and I would hate to see him lose his seat.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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The Senator would hate to see him lose his seat.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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As I said, those hospitals are already in a marginalised area which the Government has ignored on a whole range of issues, including decentralisation, infrastructure and investment, as it promotes already burgeoning areas of population and urban sprawl. People will fight vigorously and have been doing so for years through action committees to defend and upgrade what are seen as vital services.

The report seems to suggest that an enhanced ambulance service will alleviate some of the problems of emergency cases having to travel long distances for services. The Government must envisage an upgrade of ambulance services, which is recommended. However, it is already a source of criticism because of delays. Then there is the condition of the secondary roads system in the west. I do not know how many people here have travelled on the Boyle to Galway or Roscommon to Galway routes. It is a pretty hazardous trip of approximately 78 miles, taking up to two hours at the best of times. Key message 8 under section 1.8 on page 18 states: "The organisation and staffing of acute hospitals must be restructured to allow for the safe provision of emergency and elective care." On page 45, it mentions "the ability of the hospital to provide safe, quality, accessible patient care, taking account of geographic location within the region". I do not believe that our region fits that description and that undermines the report. Page 65 states: "Each network of hospitals should provide a service which is, as much as possible, located close to patients' homes." While the report has various kinds of aspirational padding about ideas for local hospitals, ultimately, the proposals will once again be seen as downgrading and will be resisted strenuously.

Other questions arise if smaller hospitals are relegated. What will happen to the alternative bed numbers? Where will they spring from in already crowded hospitals? From where will the large numbers of consultants emerge in such a short time? The report admits in 2.3.3 on page 23 that it is trying hard to work on an "'ideal' or 'perfect' model of services". That may be the philosophy of those who present reports, but the nettles of a less than ideal world are the concerns of those affected by this vital, life and death primary service.

Some other points I noted include the tangled web of training as outlined on page 48, with its accompanying diagram on page 49. The task force proposals for a network of acute hospitals have been framed on the basis of the experience in two pilot regions. Further consideration will be required on how best to achieve integration of decision making, planning and effective local management in other parts of the country. They should be addressed in phase two of the task force work, yet on page 61 the report states:

"A consistent message from previous analyses has been the need for clarity of hospital roles, genuine integration of services and the provision of high quality care."

However, "the record in implementing a number of previous reports has been disappointing". It undermines the validity of this report and the pessimism sounded by trumpets in the Minister's own party does not augur well for large slices of it.

I always wish the Minister well because he has a very difficult job. Although the report does not mention certain hospitals, I believe that the future of areas where the Government has spent €8 million, signed off by Senator Leyden as chairman of the Western Health Board less than two years ago, for which the Minister managed to sack him two months later – or let us say that he did not reappoint him—

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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That is a big difference.

Photo of Frank FeighanFrank Feighan (Fine Gael)
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He appointed another man to the Western Health Board. That is more or less a statement that the Minister's commitment to rural counties such as my own, County Roscommon, is limited. However, I wish him well in what he does.

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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Tá fáilte roimh an Aire go dtí an Teach. I welcome the Minister to the House and the opportunity to speak about the Hanly report, the third of recent times, preceded as it was by the Prospectus and Brennan reports. The Hanly report sets out a series of principles for the future organisation of hospital services nationally alongside measures to reduce junior doctor hours, improve training and introduce a consultant-provided service. It recommends investment in local hospitals to provide more services for patients, including elective medical and surgical procedures, out-patient services, prenatal and postnatal maternity services and better access to diagnostic facilities. It states that the full range of acute hospital services should be available within each region so that patients do not have to travel beyond it other than for services best provided at supraregional or national level.

It is important to point out at this juncture that, while we would all like to have a centre of excellence in our back yard or home town, that is not a runner in reality and we all know it. Experience has taught us that in the case of breast cancer. It has been proven scientifically that unless 100 procedures are carried out at a centre in a given year, it is not safe to practise them. Those who have been stating that very loudly are those who would benefit from the change, namely, Irish women. The report proposes developing the minor injury and illness services in local hospitals that currently account for 70% of patients attending accident and emergency departments.

The Hanly report concludes that the only way to address reductions in the working hours of junior doctors while providing high quality patient care is to introduce a consultant-provided service. The Government is committed to putting in place a consultant-provided service harnessing the contribution of all our hospitals and providing a wider range of appropriate services and procedures in local hospitals. Every facility involved in health delivery has a very important role to play and that should not be minimised. However, that will be done if people wish to serve a political agenda. The background to the National Task Force on Medical Staffing was that the European Working Time Directive requires us to reduce the average working hours of non-consultant house doctors from the current 75 hours per week to 58 hours by 1 August 2004 and, ultimately, to 48 hours per week by 1 August 2009.

Most, if not all, Members have, from time to time, been involved with trade unions. There are not too many people in employment who are obliged to work the same number of hours as non-consultant hospital doctors. There is light at the end of the tunnel for GPs because, thanks to the efforts of the Minister, Deputy Martin, my area recently received funding for the out-of-hours GP service for Longford, Westmeath, Laois and most of Offaly. People must recognise that doctors are human and that they cannot work for hours on end. As someone who worked in a particular discipline for many years, I am in a position to say with authority that the working conditions and hours of NCHDs are nothing short of scandalous. I do not know why anybody would want to enter the medical profession and work the hours junior doctors are obliged to work.

The task force also took account of two previous reports, namely, the report of the medical manpower forum and the NCHD hours report which were both published in 2001. Senator Feighan referred to the Bacon report and the various other reports that have been commissioned. In my opinion, reports are important. If individual Members were to carry out audits on themselves, they would certainly tell themselves what they wanted to hear. It is important, therefore, that we have people who will consider the medical sector from a dispassionate point of view. The Bacon report was extremely important because from it flowed schools of language, physiotherapy and speech in Galway, Cork and Dublin. Such reports are not, as is perhaps a popular misconception on the opposite side of the House, left to gather dust.

NCHDs have to reduce their average working time to no more than 58 hours per week on the hospital site by 1 August 2004, to 56 hours by 1 August 2007 and to 48 hours by 1 August 2009. It is interesting that of the 15 EU member states, to date, ten appear to be compliant. Apart from Ireland, four other states – Belgium, France, Germany and the UK – have various measures to implement before they will be fully compliant. It is also worth noting that other countries train their doctors in a shorter working week. Examples of this include Denmark, the Netherlands and Finland. In Finland, doctors in training have, since 1996, worked a standard 40 hours per week. What does this mean?

There has been a call to increase the number of NCHDs. However, I believe the medical profession will agree that there are enough junior doctors and that more consultants are needed. If we take on board the concept that we are going to have a consultant led service, it is axiomatic that more consultants will be needed. Everyone who knows anything about medicine or medical procedures is aware that the incidence of diabetes has increased significantly in recent years. The Midland Health Board has applied to recruit an endocrinologist. The diabetic association in the region is lobbying the health board to have that particular specialty brought on stream. There is also evidence of an increase in the incidence of tuberculosis. The increase to which I refer is not huge, but it must be noted. It is, therefore, that the consultant appointments to those particular specialties will be made. There is also a great shortage of psychiatrists with an interest in child and adolescent psychiatry. If we are determined to have a consultant led service, we will need more consultants. It has been proven that we have an adequate number of junior doctors.

The task force proposes a series of immediate measures to reduce NCHD working hours to 58 by next August. These include the reduction of tiered on-call, use of cross-cover arrangements across specialties, new working patterns for NCHDs and a set of specific measures aimed at reducing NCHD workloads in areas such as radiology, phlebotomy, pathology, pharmacy and surgery. In the longer term, we also need a number of other key initiatives such as a consultant provided service to replace the current largely consultant led system and changes to the existing system of medical education so that doctors can be trained within a 48 hour working week. If doctors can be trained in a 40 hour week in other parts of the EU, I do not know why they cannot be trained in a 48 hour week here.

There is a major need for a consultant provided service. Under such a service, consultants would work together in teams and take a substantial and direct involvement in diagnosis, delivery of care and overall management of patients. The task force believes that this is the only way to achieve high quality care while meeting the requirements of the EWTD. This will entail a significant increase in the number of consultants working in teams, and with revised working arrangements, and a substantial decrease in the number of NCHDs.

I accept that this will lead to a change in work practices for consultants. A vital element in any move to a consultant provided service will be agreeing different work practices for consultants. The task force recommends that consultants will participate in rostered work, night work and extended cover, as required. In some instances, where clinical needs and caseloads require it, this may involve an on-site consultant presence on a 24-hour basis. These proposals are quite stark and careful negotiation will be required in respect of them.

While fundamental change in consultant and NCHD contracts is a central part of the reform agenda, implementation of the task force's recommendations is not completely dependent on contractual change. For example, the following measures can proceed alongside contractual negotiations: a study of the structure and organisation of acute hospital services nationally, national discussions on measures to reduce NCHD hours in the context of the task force's recommendations, actions throughout the country to meet the requirements of the EWTD and developing ways of speeding up the recruitment process, particularly for consultants.

The organisation of acute hospital services will be pivotal to this. The task force report concludes that we need a substantial reorganisation of acute hospital services. Members of the House have been accused, by those outside who do not hold elected positions, of being parochial. I want to meet the councillor, town councillor, Deputy, Senator, Minister or Taoiseach who will not root for their own area.

Kathleen O'Meara (Labour)
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That is the unelected one.

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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The people who are making the comments about Members are the unelected ones. I make no apologies for saying that I am anxious that phase 2B of the general hospital in Mullingar, which is at the design stage at present and in respect of which the development control plan is almost ready, should proceed. I am reliably informed that it will do so. It is to be expected that Members will root for their own areas and I certainly have no apologies to make for doing so. However, there is a bigger picture and people must recognise that all services cannot be provided on a local basis. There will be occasions when specialist services will be provided in a number of centres nationally. Such services cannot all be provided in our own back yards.

The Minister stated that hospitals will not be downgraded. This report is not about downgrading hospitals, instead the task force has pointed to the need to bring services closer to patients. It has stated that local hospitals should be a key part of an integrated hospital service for their regions, providing as wide a range of services as close as possible to the local community. They would meet most of the local population's need for hospital care by providing appropriate diagnostic and treatment facilities and a greatly expanded proportion of election day surgery and elective medical procedures for the relevant region, which would involve an increasing volume of elective procedures that are often performed in larger hospitals. Anyone with experience of medicine is aware that before the advent of day surgery, people were admitted to hospital for minor procedures and took up hospital beds. There was no need for that.

A key part of the Hanly proposals is the need to ensure a well trained and well equipped ambulance service that can provide immediate care for emergency patients. The focus is not on taking the patient to the nearest local hospital, rather it is getting the patient to the hospital best equipped to deal with their condition. Taking a patient as quickly as possible to a well staffed and well equipped major hospital is by far the best course of action. What do we do? We must put patients first – it is all about the patient.

I referred to the locally elected member being an important conduit in the delivery of health services. When one compares them to the monkey and the peanuts, the monkey was terribly expensive by comparison to the locally elected representative. I ask the Minister to include local democratic input in the new structures. This is vitally important and failure to include it would be fundamentally wrong.

Mary Henry (Independent)
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I welcome the Minister to the House and while I welcome the report, I regret it has been so belated. At the end of his speech, the Minister said we must now proceed to implementation. To implement even the EU directive on NCHD working hours before next August will be extremely difficult. It is not true to say we must have EU directives to drive us to do anything that would obviously be for the betterment of the health service in this country. After all, we had the excellent Tierney report in 1993 – would to heaven that we implemented it then. At that stage there were about 2,500 NCHDs. There is now more than 4,000 NCHDs and we will have an even greater problem in paring down this number.

While it is to the advantage of the patient that this report should be implemented, it is also to the advantage of the medical profession. Non-consultant hospital doctors in this country are carrying far too great a burden in the service area. In particular, non-national doctors are dealing with heavy workloads in small hospitals around the country, often with inadequate consultant support. This cannot continue and I hope the Minister manages to implement this report. I am not referring to the Minister when I say that while the political spirit may be willing, the political flesh is fairly weak. It may even be weaker on the Minister's side of the House than on this side of the House. I will do anything I can to help the Minister implement the report.

We have already heard Mr. Hanly saying that the report will be implemented immediately, while the Secretary General of the Department, Mr. Kelly, is not quite so sure. A definite urgency must be found to bring forward the changes in NCHD working hours.

Will the Minister insist that every hospital immediately puts a member of its administrative staff in charge of rostering? This should happen before the end of the month. We know there are already serious problems in some of the big hospitals that have such positions. This must be the first area to be addressed and the report says that getting rostering right is important. It may have to be more flexible than that which is suggested in the report. It cannot be left to consultants and junior doctors to work out private arrangements between them. That will only lead to disaster. Such arrangements must come from management level.

The Tierney report was extremely well written and it is most unfortunate it was not implemented at the time. We have seen that we were making far greater increases in the number of NCHDs than other parts of these islands. For example, between 1988 and 1992 there was a 6% rise in the number of consultants in the State, but a 25% increase in the number of NCHDs. In the same period there was an 11% increase in the number of consultants and a 2% rise in the number of NCHDs in Northern Ireland. The same circumstances prevailed in Scotland, England and Wales. We have continued the bad practice of relying too heavily on NCHDs.

While the report's suggested changes in work practices in certain areas such as accident and emergency departments are good, I wonder if some of them are realistic. At the moment it is suggested that 70% of cases that come to accident and emergency departments, particularly in smaller hospitals, could be dealt with by GPs. The only problem is that we are running into circumstances where we have a shortfall of general practitioners. I am sure the Minister saw the excellent recent article written by Dr. Leonard Condren, an experienced Dublin based GP who recently retired. His words need to be looked at. Even with the improvements the Minister has made in the primary care strategy, we are having trouble attracting people into general practice. I am anxious that we are relying too heavily on GPs taking up the slack from the closure of small accident and emergency departments around the country.

The report rightly suggests that nurses could take over some of the duties doctors are currently undertaking. However, we also have a terrible shortage of nurses. Departments, especially those with specialist nurses, cannot be built up with nurses brought in from abroad for two or three years.

It is suggested that pharmacists within the hospital services can have a greater role. While this would be extremely good, these changes take a while to be brought about. We are talking about having longer working days within hospitals and holding clinics in the evening. Once again, arrangements will have to be made with laboratory technicians, radiographers, physiotherapists, porters, administrative staff, etc. I worked in an acute hospital where the entire outpatient administrative service shut at 4 o'clock. Nurses and I gave notes to patients and told them to telephone the hospital the following day to seek appointments. This sort of thing does not lead to efficiency. It is not really correct to say that everything will be all right if we can get the doctors to work longer. That is not even one-tenth of the problem.

I am glad that Hanly came out against a career service officer grade. That has been a disaster in Britain. This grade is filled by people who, usually due to financial or domestic reasons, had not got the qualifications to get consultant posts. This was fine for a few years but the individuals became extremely dissatisfied seeing junior colleagues with less experience promoted over them and many felt they had wasted the time they should have spent trying to get their exams. It was one of the most dissatisfied groups of people I have ever met.

Hanly also recommends against using physician assistants, as is the practice in the United States. I agree with this. However, he suggests that we should look at surgical anaesthetic assistants, particularly within intensive care and operating theatre units. We should look at this, particularly in view of the shortage of nurses with operating theatre skills. The royal colleges will have to support the Minister in such an initiative as these training courses are normally of four years duration.

I was glad to see a review of the training of doctors being brought forward. There is far too little concern about the quality of training some doctors have received in certain hospitals. In many cases training posts have mainly been service posts. It is very good that the report states non-EU doctors should be treated differently from EU doctors. I was not enthusiastic about suggestions made by the royal colleges about this matter and I am very glad that Hanly came down firmly against it.

Regarding the section on training and medical education, have there been any discussions between the Minister and the Minister for Education and Science about his proposals for changes in medical education? That does not just apply to doctors, radiographers or physiotherapists. The area is enormous and I do not see how it ties in with saying one is anxious about it—

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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A joint working group has been established.

Mary Henry (Independent)
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I know, but the Minister's proposal will cost a fortune. Will radiographers stay in this country if it takes six years to train when it only takes four years to train in England? It is the same for physiotherapists. In addition, the Hanly report also rightly points out how long it takes here to train to become a specialist. The Minister for Education and Science's proposals would add on another two years. We already have a problem with people taking early retirement when we want people at a specialist level to be there for long enough to give decent service. Great consideration needs to be given to the proposals of the Minister for Education and Science. I have heard no costing of those proposals and the Department of Health and Children should have a much greater say regarding those proposals than it appears to have at present.

The area that has received most media attention is the review of acute hospitals, which is very important. However, we have known about this area for years. We could go back to the Fitzgerald report, which recommended much the same as the Hanly report. We are in an age which requires a multidisciplinary approach to medicine so that the patient gets the best possible care. Like other people, I am sick of the word "downgrading". If someone goes into the Bon Secours hospital in Glasnevin, do they say they have gone somewhere that has been downgraded? Yet this hospital only does elective surgery and procedures, so people go in there on a planned basis. I was a patient there once for a day and I could not believe the efficiency. I was saying to the staff how great it was that if one had an x-ray appointment at 10 a.m. one was x-rayed at 10 a.m. and so on. The staff said they did not have to cope with the victims of a major car crash coming in, which would throw everything into disarray. I have worked in acute hospitals for long enough to know that by 9 a.m. or 10 a.m. the plan for the day has gone out the window because something happens which takes over the entire x-ray department. I implore people to stop talking about downgrading.

There are possibilities in the pilot schemes, although they require a great deal of work. For example, people in Limerick will have to get used to going to Ennis if they have a quiescent gall bladder which can be treated in Ennis or Nenagh. They should be saying: "Isn't it great? I can be done in Ennis on 4 November," and know they will be dealt with on 4 November, while at the same time they will get used to terrible car crashes being dealt with in Limerick. The people of Limerick will have to get used to going out to these hospitals, which could become very efficient units. There are very good doctors there as it stands and if an esprit de corps was put into those institutions we would do well.

The problems with Dublin include the infrastructure being in such a state and transport, which is very bad. I would be anxious about downgrading accident and emergency facilities in St. Colmcille's. Now I am using that word.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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The Senator was doing fine until then.

Mary Henry (Independent)
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The elimination, let us say, of St. Colmcille's. That is a very difficult situation because St. Vincent's has a very small casualty department, although it is the only one I have been in for years where the waiting time was not excessively long, unlike the Mater, Beaumont, and so on. That will be more difficult to address.

Huge investment must be made in the pre-hospital emergency services so that those working in the ambulances are properly trained. We will have to make changes in legislation to allow those workers to give out drugs and so forth. Look at how well the situation in Donegal turned out, where general practitioners started giving thrombolytic drugs to patients having coronaries in rural areas. There was a great improvement in treatment with that development. We need initiatives all round as this will be a huge challenge to us and we will just have to get on with it.

I have great sympathy for those around the country who saw money spent in their hospitals but who now feel those units will not be used. For example, a unit in Mullingar hospital has not been equipped but it is there for six to eight years. The last Leader of the Seanad and I had terrible sessions about this, as I was receiving complaints from the area about the unit and he was saying what a splendid place it was. I gather there is no change in the situation there.

We will have to get bed numbers up everywhere. In the 1960s there were approximately 4 million people in the country, but now we have almost 5 million and the population is older. We need more beds, doctors and health workers. If the Minister for Finance wants to know where the money is going, it is mainly going on pay and he agreed to the increases. If he asks the Minister for Health and Children what is being done with the money, the Minister, Deputy Martin, should tell him it has gone to pay people and that the Minister for Finance was at the Cabinet meeting which agreed to those pay increases. I am not saying they are not deserved but I get cross sometimes when I hear about black holes as most of the money I see being used is spent on pay. Some of it is being spent on infrastructure but not nearly enough.

There will be difficulties with the consultants' contracts, as there are always difficulties with major industrial relations situations. However, the Minister needs to hold on to more people on a part-time basis, which could be very important for those with smaller hospitals in their areas. It could help to make up a sufficient quota to cover the time during which people are on call. We have a serious problem with consultants taking early retirement and if they were asked to take on certain shifts and teaching roles in hospitals, we might hold onto more of them. There has also been a great increase in the number of young women consultants being produced and in areas like pathology, anaesthetics and psychiatry sometimes one only needs a part-time consultant. The rate of only 2% part-time consultants at present, is very low.

I wish the Minister success with this initiative. The only problem is that I have seen so many reports come and go. I had to work very hard when the Fitzgerald report was being produced because the man I worked for, Professor George Fegan, was on that commission and put enormous work into it. They were all disappointed when they saw their work come to nothing. Fianna Fáil brought that down but they were not the same sort of Fianna Fáil people that are around now. I am sure the Minister will have great support from many members of the party because the report deserves to be supported.

John Minihan (Progressive Democrats)
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I join previous speakers in welcoming the Minister. Health service reform is long overdue and nobody can defend the status quo. We now have three major reports setting out a clear reform agenda. The Brennan report deals with accountability and improving financial management; the Prospectus report deals with the organisational structures; and the Hanly report deals with NCHD working hours, the provision of a consultant-provided service, improving medical education and training and reorganising the acute hospital system.

The Hanly report, formally launched last week, deals with two pilot areas, the Western Health Board and the Eastern Regional Health Authority. There is broad consensus on what needs to be done now in those areas and implementation should commence immediately. The report also sets out very clear principles and criteria in relation to organising the acute hospital system. These principles and criteria will obviously inform the next phase of Hanly, that is, preparing a report on how to organise hospital services in the other health board areas.

The Hanly report is welcome. We must provide a safe hospital system, harness the skills and expertise of our highly skilled medical and paramedical staff in our hospitals and achieve value for money. Implementing the Hanly report will deliver on these. We are facing some immediate tasks. We must start implementation in the two pilot sites; Hanly mark II which will deal with the other boards must be up and running; the European Working Time Directive in relation to the NCHD hours must be implemented; and we must open negotiations with medical organisations on new contracts. I welcome that the Minister acknowledged this. It will be difficult, but taxpayers and patients cannot be held to ransom. In this regard, new contracts for new consultants must be put in place, regardless of negotiations with existing contract holders.

We have three good reports. However, all will be for nothing if we do not implement them. Implementation is key and it must be a planned and clear process of change with clear accountability for making it all happen. Last June the Government promised to establish the new health service executive and the national steering implementation group, but these two important bodies have not yet been established. I am aware that senior management in the Department of Health and Children and the health boards are progressing certain aspects of the reports. However, we need an independent body to drive the reform agenda. Difficult decisions will have to be made. Current members of senior management of the health system would not be appropriate decision makers as they clearly would have a conflict of interest. We are talking about designing and implementing a new health delivery system, a mammoth task. The change must be centrally driven but with local ownership.

The health service executive should be established immediately and given a clear mandate by Government to plan and drive the reform agenda. There are many stakeholders in the process who must be involved. They must be allowed to contribute but responsibility and accountability for the reform agenda should reside with the health service executive. Taxpayers, other members of the public and the Government must get not only a modern health delivery system but effective management and better value for money. Better management and better value for money are obstacles regardless of the national economic picture. Delivery of these two elements will require a new culture in the health system. Is anyone addressing this matter? Structural change will not deliver it. We must improve the capacity of management in the system.

There should be the immediate appointment of the chairperson and members of the interim health service executive, the recruitment of the chief executive officer of the HSE or, alternatively, initially at least, the chairperson of the HSE could be an executive chairperson and the appointment immediately of the national implementation steering group. The implementation of the HSRP should be led, driven and managed by the implementation steering group and not by the Department of Heath and Children, its officials and health board chief executive officers as now appears to be happening.

With regard to the new governance arrangements, there will be a liaison role between the Department of Health and Children and the HSE and not a direct reporting relationship. In view of that I pose a number of questions. The Government decision of 17 June 2003 indicates that the Secretary General concerned would have responsibility for the implementation process. If that is the case, what will be the role of the HSE, its chairman and its chief executive officer in the implementation process? Implementation of the health service reforms is a defining moment for our future health service. We will get one chance to get it right and it is vital we do not squander it.

I wish the Minister well. We have brought forward a degree of reforms that are on the table. It is now a question of their implementation and making the necessary decisions. Decisions must be made in the national interest, in the interest of all the people and not in interest of those with vested interests. In that regard, I would like to be dissociated from remarks made in the House last week when certain Senators referred to the fact that the Hanly report should be put on the shelf. That is not the way forward. Decisions must be made—

Photo of James BannonJames Bannon (Fine Gael)
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The remark was made by a Member on the Senator's side of the House. Senator Leyden said, "bin it".

An Leas-Chathaoirleach:

Senator Minihan to continue without interruption.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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There is freedom of speech.

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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That is what they call it.

John Minihan (Progressive Democrats)
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I said I would not support that call regardless of the side of the House from which it came. The Government and the Minister have a responsibility to provide a modern dynamic health system in the interest of all the people serves the needs of patients, who must be put first, and not self-political interest. I congratulate the Minister on his initiatives today. I wish him success in the implementation of these reform packages. I hope in the near future we will see the establishment of a proper management structure to drive this change and implement the necessary reforms to provide us with the health service that patients and others deserve.

Kathleen O'Meara (Labour)
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I warmly welcome the Minister to the House for this important and timely debate. I compliment the Leader of the House and others who organised that the Minister would be present for a debate on this report first in the House. I compliment the Minister for making himself available for it. I compliment members of the task force on medical staffing on the considerable work they have done in the public interest and on the public service they have given. I also compliment the Minister on his responsible approach to health service reform. We do not agree on everything but one must give credit where it is due. The Minister has not sat back and said this is too big a problem and he can do nothing about it. He has taken full responsibility in this regard and has asked experts to study the area and to come up with recommendations, which is what they have done. It is up to the Minister and the Oireachtas to implement those recommendations and it is up to us to have an input in that process. This debate is an extremely important and valid part of that process. As Members of this House, representing various communities and interests around the country, we can give our views on the recommendations. I hope the Minister is broad minded enough to realise we are not taking a narrow, party political or parochial stance on this but rather we are making arguments on behalf of the people we represent and the values we represent in terms of the delivery of quality hospital care and a quality health service in our regions and nationally.

Nobody could contest the fact, stated repeatedly, that there is a major problem in the delivery of health services. This problem did not pop up overnight; it has developed over many years and we have not faced the challenges of the modern era. We have not been able to put in place a health service infrastructure which would deliver the quality of care we want delivered locally and nationally. Many hospitals in Dublin are so overcrowded that patients are being treated in car parks, a service over which nobody could stand. Tragedies have occurred in Limerick and Monaghan due to the failure of the health service generally to deliver the care that was required and people have been horrified and shocked by that.

In that context, this report, the Prospectus report and the Brennan report must be welcomed as adding to the body of information and analysis of the current situation we face. I thank the authors of those reports for the recommendations they came up with, although I do not agree with a number of them. One of the pilot areas in the Hanly report is the mid-western area which, from my point of view as an Oireachtas Member and a public representative in the mid-western area, is useful. The pilot area covers north Tipperary, specifically St. Joseph's Hospital, Nenagh. I ask the House to accept that I am not being parochial in this regard. The study examines this area. I live about 100 yards from this hospital and I am well acquainted with it, the issues around it, the people who work there and how the hospital and the health service in the area work. It is part of my responsibility as a public representative in the area. I am naturally very interested in the recommendations of the Hanly report as they have implications for the north Tipperary area in the context of hospital reform in the mid west, in particular the delivery of acute hospital services in that region. I ask the Minister to consider a number of issues.

The report is being presented against the background of an accepted myth that big is better and that big hospitals deliver better services. The Minister asserted this just a week or so ago in Limerick before the publication of the Hanly report. He said that evidence shows that patients receive better treatment in hospitals that have the required numbers of specialist staff, high volumes of activity and access to appropriate diagnostic and treatment facilities. I put it to the Minister that big is not always better. For example, there is only one hospital which has conducted a study and published data on survival rates following acute myocardial infraction. The figures compared favourably with a relevant international trial. That study was conducted by Nenagh Hospital. I have heard it asserted, particularly from medical people, that one could not possibly get good service from Nenagh Hospital. The opposite is the case. The quality of care, delivery of service and value for money in that hospital are exceptionally high. Figures published by the Department of Health and Children prove this. The case I am making is not only that big is not always better, but that in this country "big" has become "worse". Looking at the larger hospitals such as the Mater and Beaumont, it is clear, particularly at accident and emergency level and at acute level, that the care is not as good as one would get in the small hospitals.

Figures from the Department of Health and Children used in the national review of bed capacity show that in 2002 there was a severe deficit of acute hospital beds. In 1981 there were 5.1 acute beds per 1,000 of population, giving a total of 17,500 acute beds. In 2002 the figure dropped to 3.1 acute beds per 1,000 of population, giving a total of 11,832 acute beds. The same report estimated that there was a need to restore between 2,800 and 4,300 acute beds nationally.

The Hanly report will result in a further diminution of the number of acute hospital beds. Consider the mid west region. In Limerick Regional Hospital, which under the Hanly report would be that area's central regional hospital, there are currently 340 beds. There are some 21,000 medical admissions in the hospital annually. Currently, there is a deficit of between 80 and 100 acute beds there. If we close the acute beds in Nenagh and Ennis and in the smaller St. John's Hospital in Limerick, we will be closing 250 acute beds. Between those three small hospitals there are 12,500 admissions, of which 8,000 are medical admissions. If the acute beds in those hospitals are cancelled, it will be necessary to create an extra 350 beds in Limerick. I ask the Minister when that is going to happen and how much it will cost. The Department of Finance has committed no money. Some 50,000 A&E admissions would be added annually to Limerick Hospital on top of the existing 60,000 if the A&E units are closed in Nenagh, Ennis and St. John's in Limerick. What will be the waiting time in Limerick Regional Hospital, which is currently about two and a half hours? Limerick Regional Hospital will see a Dublin-style situation with patients treated on trolleys in the car park. There are currently about 20 patients being treated on trolleys in Limerick. If one adds the 11,000 admissions from Nenagh and the rest from Ennis and from St. John's in Limerick, one has a disaster.

One cannot start closing A&E units without looking at the implications for the central unit. It sounds fine in theory but in practice it would be a disaster. Where in the Hanly report does it say the capacity in Limerick Hospital will be increased to a sufficient level to ensure it can cope with patients from Clare and north Tipperary? I question whether this issue has been thought out. Hanly was not asked to consider this issue but to look at the organisation of the services.

The Minister said local hospitals will, if Hanly is implemented, no longer have emergency services.

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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The Senator should read the full speech and the Hanly report.

Kathleen O'Meara (Labour)
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Is the Limerick speech redundant?

Photo of Micheál MartinMicheál Martin (Minister, Department of Health and Children; Cork South Central, Fianna Fail)
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What does the Senator mean by emergency? We are talking about trauma. We have said that 70% of what is going in to Nenagh Hospital will continue to go in.

Kathleen O'Meara (Labour)
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Let us look at trauma. I appreciate that the Minister is busy and must leave and I appreciate his attendance. There are a number of questions I wanted to ask about Nenagh Hospital and I hope to get answers. What will be the status of A&E there? Will it be a nurse-led A&E? Will it be a 9 o'clock to 5 o'clock or 24-hour service? What will one get there? Emergency and trauma services will go. If there is a major accident on the Nenagh bypass, the victims will presumably have to go to Limerick. Patients cannot be brought to Nenagh Hospital to be stabilised before going to Limerick.

I want to be clear on this. We are told that the day services in Nenagh will be increased, with which I am delighted. What specialist services will come to Nenagh? When will consultants be available there? My understanding is they will be available only for day services. What will happen to Nenagh's acute beds? I presume they will be closed, after which acute hospital services will then be available only in Limerick.

Some 70% of patients currently using A&E in Nenagh will continue to do so, which is fine. However, let us take the example of a broken hand, a classic example in a county where there is a lot of hurling, with a patient presenting on a Sunday afternoon at A&E in Nenagh Hospital. Such a case would not be unusual. The hand will be X-rayed and the patient will have to be sent to Limerick. An elderly relation of mine recently had a minor fall in the nursing home where he is a patient. As the nursing home was giving him excellent care, he was brought from Roscrea to Nenagh Hospital, where an X-ray revealed a hairline fracture in his shoulder. He was then brought by ambulance to Limerick for an identical X-ray. The people attending to him told me all this. I understand the staff in Nenagh Hospital were being cautious, but we must look at the delivery of care in such cases.

I want to look at the issue of value for money. Cost is a very important issue in the current debate and has arisen regularly. According to the Minister's departmental figures, the cost per patient in 2001 in a major teaching hospital was €558 compared to €391 in a county hospital. The amount of time spent by patients in county hospitals is invariably shorter than in major teaching or voluntary hospitals. Nenagh hospital, on a budget of €15 million last year, was able to deliver 3,000 acute medical admissions, 1,500 acute surgical admissions, 2,400 day cases and 11,000 accident and emergency cases. The hospital has a large outpatient service, including ShannonDoc and a primary care unit which could be upgraded and expanded.

One of the inevitable things that will happen as a result of the Brennan, Prospectus and Hanly reports is reform of the health boards. An announcement has been made about the establishment of an implementation body to put into place the recommendations of these reports. Where is the accountability, particularly locally, in regard to decisions on delivery of the health service? It is not good enough to have another NRA style board which none of us, including the Minister, can get near. We in this House had better be careful to ensure we do not create another NRA and then spend the following ten years whinging about it and trying to abolish and replace it with something else. Accountability is essential to the delivery of a good health service and to the democratic process in which Members in both Houses believe. We must ensure local ownership of decisions and local trust and belief in what is being delivered.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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I welcome the Minister of State of the House and thank the Minister for Health and Children, Deputy Martin, for bringing the Hanly report to the House. I wish to put on the record that I was a member of the national task force on medical staffing representing the public interest. At the time I was a lay member and not an elected Senator. I attended in my capacity as a member of the Medical Council on which I represent the lay interest.

I know the contents of the Hanly report well. The group, as the Minister pointed out, was made up of hard-working people who came together for 300 meetings. I did not attend 300 meetings. Membership of the board comprised medics, nursing staff and other health related professions together with medical unions, employers agencies and others. It is a product of a very detailed process. Senator Feighan referred to the costs of compiling such reports. I, and every man and woman on the task force, gave of our time at no cost. If costs were involved they were minimal. Those involved were committed people seeking to better our health service.

The Minister said he was starting from the position of what was best for patients. That has always been his view on such matters. The Hanly report was commissioned for a number of different reasons, one of which was to examine the working hours of junior hospital doctors. It is also about patients and delivering a better and safe service which is consultant provided and does not rely on the services of junior hospital doctors who on occasions are very tired men and women. Some of them work approximately 100 hours and not the acceptable 56 hours now being directed by the EU. The Medical Council – I know this because I am a member – does not favour junior hospital doctors working 60, 70 or 100 hours. One does not get safe practice from somebody working that long. Also, the Medical Council will not allow a junior doctor to accept a post which is not a training one.

Currently, junior doctors are working unsafe hours. The Hanly report recommends tiered on-call for junior doctors, cross-cover, multi-disciplinary teams and a consultant provided service. We now operate at a ratio of one consultant for every 2.3 junior doctors, which is not acceptable. Anyone who had children in medicine would want the best possible training for them. We are seeking to double our consultant places from 1,700 to 3,600 during the next ten years, which is achievable.

I listened to what other speakers, in particular Senator O'Meara, had to say on the downgrading and closing of hospital beds. This report is not about bed closures or downgrading. On the contrary, it is about better utilisation of our hospitals and beds, freeing up beds used by people who do not need them. People have a vision of their local hospital but that vision is not always the reality. That is something with which, hands on heart, we can all agree. It was a breath of fresh air to listen to Senator Henry's contribution. She put her finger on the point when she said we should stop using the word "downgrading" and stigmatising places and should talk things up. The Hanly report takes into account the position of acute hospitals and nobody knows that better than somebody like Senator Henry. While I may not have agreed with other things she said on that matter I say, well done.

Senator Feighan appears worried about political fall-out in certain areas. Yes, we need political goodwill to implement the Hanly report. If Senator Feighan and his party are to challenge this report they should at least come up with an alternative. It is a little cheap to come in here and talk about all the reports that have been commissioned and the costs involved. My colleague, Senator Glynn, has already pointed to what was delivered by the Bacon report in regard to physiotherapy and language therapy. In 1983, the Opposition, in relation to the Tierney report, said the provision of 1,500 consultants by 2003 was madness. I wonder what they have to say now given that the total consultant component of the medical service at 1,730? The Opposition should not knock this unless it has a better alternative.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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Is that the new spin?

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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It is a fact.

Rory Kiely (Fianna Fail)
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Senator Feeney without interruption, please. Senator Burke will have an opportunity to speak soon.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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The Hanly report seeks to provide us with a full range of consultants in centres of excellence, something for which the medical profession has been calling. If we were to engage in how we were to deliver the best quality service for patients in the health system who better to engage with but the people delivering that service. The Opposition can call that "spin"; they can call it what they want, but that is the way forward. The Opposition says we are downgrading local hospitals. I put it to them we are enhancing them. I am in no doubt about that. There will be no downgrading of the Ennis, Nenagh, Ballinasloe or Roscommon hospitals. They will hold on to their consultants.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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That is what the Government will tell the electorate.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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If Senator Burke listened, he might learn something. He will have a chance to speak later. All local hospitals will provide accident and emergency services.

Photo of James BannonJames Bannon (Fine Gael)
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Until the local elections are over.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Between 60% and 70% of all accident and emergency admissions do not involve major trauma.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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The Minister is learning something if accident and emergency services are to be retained.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Change should be embraced, not feared, but I am not surprised the Opposition is fearful. This fine, well thought out document is a workable blueprint for the future but it needs political support and we will support our Ministers and Ministers of State. I thank my fellow members on the task force for the wonderful work they did and, in particular, the staff of the Department, for their expertise and patience. I support Senator Glynn's call on not to remove democratically elected representatives from health bodies on which they can play a role.

Photo of James BannonJames Bannon (Fine Gael)
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I welcome the Minister of State to the House. If the basic principle of benchmarking was reward for increased paper usage and excessive verbiage, the Department of Health and Children would be a model for all to follow. The production of 148 reports in five years must be symptomatic of something but it is not an efficient health service. Following the other 147 reports, the Hanly report must be the worst of the batch. It offers no viable solutions to resolve the rapidly escalating crisis in medical care and, worse still, it offers no guarantee of funding to implement its recommendations.

However, in keeping with the old adage what comes around goes around, it offers another report to follow as one of its key recommendations. This report is conveniently scheduled by the Government not to appear until after the local and European elections. The deferral of the report is laden with self-serving motivation, as unpalatable proposals are not the usual pre-election fare of the Government parties. Just as Nero fiddled while Rome was burning, it should not be forgotten that, while reports are written and action is not taken, people's lives are on the line. The Hanly report puts forward plans that are essentially experimental. They will put the lives of our citizens at risk and that could lead to increased suffering and death.

Given the mounting evidence of Government mismanagement of our health services during the Celtic tiger years and the failure of the Government parties since their re-election to deliver on their promises, I have no faith in their ability to effect major changes to the system without endangering lives. Meeting the EU deadline on the reduction of junior doctors' hours to no more than 58 per week by making a feeble call for pilot projects and future reports is an attempt by the Government to rationalise and close small hospitals under the guise of reform and a promise of better quality services.

Investment will be the crucial factor in the success of new initiatives for our health service. Sadly, when such funding was available in the boom years and the entire health sector could have been transformed in terms of both acute and non-acute services, it was wasted in favour of short-term expediency. If the recommendations of the Hanly report are to be implemented, it will be imperative that regional facilities receive significant funding to provide viable alternatives for the loss of local facilities. A total of 2,500 new beds will be necessary to replace emergency beds lost at local level and major investment will be required to replace facilities at local level. Extra resources will be required in the primary care area and GPs will require skills updating so that they can take on tasks previously undertaken by local hospitals. Ambulance services and the training of paramedics will need to be greatly extended and a countrywide air ambulance service will have to be established as a matter of priority. Senator Feighan referred to the poor health infrastructure and improved infrastructure will be of vital importance, with a specific requirement for major road investment. Local hospitals will require extensive funding to equip them for their new roles in local elective surgery.

Local authorities are cash starved and are forced to generate funds through new local charges which impose unrealistic stealth taxes on residents. To paraphrase Ian Duncan Smith, being a taxpayer has become the hardest job in Ireland. Given the ever increasing burden on taxpayers, whose rapidly emptying purses are paying for the mismanagement of the Government, Fine Gael, which is opposed to the Government policy of closing down vital accident and emergency departments in local hospitals, believes it is imperative the people do not suffer the ill-effects of poorly devised policy.

Rationalising and concentrating services may be a positive proposal in regard to certain specialities but vital maternity services and accident and emergency departments should not be included, given that time is of the essence in many life or death cases dealt with by these services. Emergency services are the deciding factor in life or death incidents. With public confidence in the health services at an all-time low, the people must be consulted and their wishes taken into consideration before their money is once again spent on ill-conceived and unpopular options.

It is important that the views of locally elected representatives are taken into account regarding new health structures because they are the voice of the people. The most significant problem faced by health boards, heretofore, was lack of funding to administer services both locally and regionally and not the appointment of public representatives. Numerous reports have not resolved the funding problem with every health board still struggling in this regard. This is having a devastating effect on the health service. Many community initiatives put forward by voluntary bodies and others have been neglected due to a lack of funding.

The Minister should confirm that phase 2B of the Longford-Westmeath hospital in Mullingar will proceed without delay. People in the Midland Health Board area are anxious about its future and I seek confirmation that this work will proceed.

This is the 148th report produced by the Department of Health and Children and we do not know how many are in the pipeline. Senator Feeney acknowledged that it took 300 meetings to put this report together. What was the cost of those meetings to the taxpayer?

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Why does the Senator not check how much they cost?

Photo of James BannonJames Bannon (Fine Gael)
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The meetings of the health board in my area over the past 30 years will not have cost as much at the meetings of this task force. It is a shame. We want services and facilities for our people, not more reports.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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We are giving the services to the people.

Rory Kiely (Fianna Fail)
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The Senator has one minute remaining. I ask that he be allowed to conclude without interruption in that time.

Photo of James BannonJames Bannon (Fine Gael)
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I would appreciate it if Senator Feeney checked the record with regard to costs.

Rory Kiely (Fianna Fail)
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I ask the Senator to conclude without inviting interruption.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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Senator Bannon is the one who is worried about it.

Photo of James BannonJames Bannon (Fine Gael)
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As I said, this is another bad report. It does not offer a solution to the crisis in the health services. The long queues and serious problems are still evident in accident and emergency departments. Waiting lists are still long and, as Senator O'Meara said, patients are still being treated on trolleys. When the Hanly report was launched, Senator Leyden said that it should be binned.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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That was last week.

Photo of James BannonJames Bannon (Fine Gael)
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This opinion is coming from the Government side of the House.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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It is a sole voice.

Photo of James BannonJames Bannon (Fine Gael)
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Despite Senator Feeney's remarks about support from the Fianna Fáil benches, Members lurking by her side are totally opposed to this report.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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There are more Members in favour of it than against it.

Photo of James BannonJames Bannon (Fine Gael)
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We will see how they will vote when a division is called in this House and in the Dáil.

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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Senators on this side of the House do not have to lurk; they can say what they like.

Photo of James BannonJames Bannon (Fine Gael)
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What about Senator Leyden?

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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"Lurking" is not a word that could be applied to him.

Photo of James BannonJames Bannon (Fine Gael)
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He said that the report should be binned.

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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I welcome the encouraging report of the National Task Force on Medical Staffing, also known as the Hanly report. I applaud the Minister for Health and Children, Deputy Martin, and his ministerial colleagues in his Department for the work they have done to compile this report. I do not mind if there were 3,000 meetings. The fact that the report has been well researched, compiled and produced is evident from the number of meetings mentioned by Senator Feeney. The process bodes well for what I hope will be a speedy process of implementation. If I can find a fault with the reports that have been produced, it is that they are not implemented speedily. There should be an accelerated rate of implementation of the Hanly report. I put that forward as a suggestion and I hope it will happen.

The Hanly report takes account of the EU directive on junior doctors' working hours, the effects of which will become apparent within 12 months. I am heartened by the comments of the Minister, Deputy Martin, this morning. He said that the number of junior doctors will not be increased, but a larger number of consultants will be made available.

I read the report and marked the sections I wish to discuss while I was away for the weekend. The report makes it quite clear that hospitals will not be closed. This area should be focused on and I would like Ministers and spokespersons to discuss it. Although the centres of excellence will be the main hospital centres, every hospital will be a centre of excellence in itself, regardless of its level. Perhaps we are shying away from this aspect of the report. It is possible that we are not concentrating on it.

The Hanly report determines the best options for patients. We should not be debating what should be in the various towns because the most important matter is to determine what is best for patients when they need to be attended to. I do not believe that the people of this country are best attended to by being brought to a hospital that does not have the competence or the staffing to undertake a particular medical regime for them. It is clear that such a system would not be in the best interests of patients. It is important that hospitals should know their parameters, limitations and challenges so they can be staffed and funded accordingly.

The report has outlined where the major centres of excellence will be and what they will have. As a result, patients and their families will know what is on offer in the various centres. They will be able to decide how they can best be served by the hospitals. The various hospitals will be linked by primary and secondary care services, which are hugely important. Those involved in each centre of excellence have been made aware of the equipment, funding and staff provisions at the centres. The link to the primary care sector involves individual GPs diagnosing patients' particular conditions and deciding where they can be best served in that regard.

The services already provided in some hospitals will be enhanced. Rather than considering that the levels of service on offer in other hospitals have been diminished, one should bear in mind that a certainty will exist in respect of the levels of staffing and funding on offer. We should not whistle in the wind and try to ensure that everybody who has something holds on to it. My experience in life has been that a person who becomes ill is best served if the extent of his or her illness is known – this is also true of their family, friends and acquaintances. The relevant GP and consultant are the experts in that regard. Equally, one should know where to send the patient to receive the best service.

Rather than demanding of a hospital a level of expertise it does not have, trying to stretch its budget and holding parades to demand what it should or should not have, one will know under this system what a hospital has. The fact that we will be able to say that a given hospital is a centre of excellence will help to build confidence. The parameters of the hospital will be known and staffing and funding will be allocated on that basis. The process will proceed in stages.

It is time for us to grow up in respect of these matters. We should be honest with one another. We should decide whether we are seeking status for our towns on the basis that a hospital can do certain things. Is it not far better for one to know what one's hospital can do? A certain status is associated with knowing that one can refer a person to a hospital in the certain knowledge that it can offer certain things. This is more important than relying on old diktats and dogmas that have been overtaken by modern life. It should be remembered that while the diagnostic, curative, consultancy and operational requirements of patients can vary, they do not vary in respect of one central tenet – all patients require the best possible treatment. All consumers of the Department of Health and Children's medical services want the best treatment, regardless of where it is received.

I live in a town that does not have a hospital. I outlined the historical reasons for this in the House on a previous occasion. St. Vincent's Hospital, which treats elderly people in a caring way, is very good. The Midland Health Board provides a range of services, for example, diagnostic services, paediatric services, X-ray services and ambulance services. All of these things were laid out in the report and I am seeking their implementation. It is good we should know that such services will be provided. There will be a one-stop-shop, which will mean that consultants will come much more often. One will be diagnosed much earlier and in a better way before being referred to the appropriate—

Photo of Ulick BurkeUlick Burke (Fine Gael)
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There was a time when people thought that there would be an acute hospital in Athlone.

Rory Kiely (Fianna Fail)
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Senator Burke will have an opportunity to speak in a moment.

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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Senator Burke can say what he wants. I am satisfied that I did not seek an acute hospital.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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The Senator was expected to deliver it.

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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I certainly never gave any false hope. I never wished for it. I knew that there was expertise in Portiuncula Hospital, which is 15 minutes from Athlone. I do not indulge in pipe dreams and I never have done.

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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We can leave that to the other side.

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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I think it is wrong to chase rainbows. It is not for Senator Ulick Burke to tell me my electoral duties. I know them.

Rory Kiely (Fianna Fail)
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The Senator has one minute remaining.

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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I thank the Cathaoirleach for that information and for looking after my interests when I was being ambushed.

I hope the remit and programme of services laid out for us in Sustaining Progress will be delivered as quickly as possible. I also hope we will be able to have doctors constantly on call. This is one of the huge issues in Athlone and the very least a patient should demand.

I am very pleased with the report. I wish it an accelerated rate of implementation and hope its very desirable goals will be realised. The Minister, Deputy Martin, who heads the Department of Health and Children excellently, and his two Ministers of State would best serve the nation if they set about the implementation of the report speedily and correctly for the benefit of the health of the people.

Photo of Brendan RyanBrendan Ryan (Labour)
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We, as Members, should value having a debate in this House on something as potentially controversial as the Hanly report. We should not turn it into a replica of the kind of debate one might have in the Dáil. I do not wish to cast any aspersions on the other House, but it sometimes seems to have more heat than light in its debates, perhaps because of the more intense political conflict.

It seems there are different views on the Hanly report in all the political parties. This may be partly attributed to geography and partly to perspective. No rational person could argue with the presentation on the Hanly report made by the Minister for Health and Children, who stated that investment in the quality of service the country needs cannot be uniformly spread among every small town. Nobody could argue about the need to have specialist centres of high quality.

I should have declared an interest at the beginning of my speech, as I do in all debates of this kind, because I am married to a woman who is, at least intermittently, a hospital consultant. I read a headline somewhere about somebody looking for €500,000 per year and I was planning my retirement on the strength of it. However, I never anticipate that sum or believe it will appear before I retire under the normal process of ageing and elections.

I have great belief in the necessity and centrality of a consultant-delivered service. We need to realise that the term "junior doctor" is dreadfully simplifying. It applies to those who are essentially in their first year of internship, straight out of medical school, and also applies to those who have the same formal postgraduate medical qualifications as the consultants for whom they work. If the philosophy behind the Hanly report is realised, junior medical positions will be junior because they will be training posts. The natural and logical progression will be that anybody who is successful in the training programme will have a reasonable expectation of becoming a consultant within a contractual arrangement that delivers service in the public hospitals. We need to refine the whole area of hospital medicine in which "junior" really does mean junior as in "under-trained".

Some of the reports written about the service provided in hospitals imply – sometimes they are true – that certain doctors are insufficiently qualified. It is a well-known fact that one would be wiser not to have an emergency early in July or January because the first line of medical care one encounters in the big teaching hospitals could well involve somebody on the first day of his or her training. We need to rationalise the system so that when somebody is sufficiently ill to require an accident and emergency service, the doctor who treats him will be properly and fully qualified.

To pretend every hospital in the country can have everything is not what we are talking about. My grumbles with the Hanly report do not concern where things should be, because we could argue about this forever, but about sequencing, to use a phrase out of the context in which it has been used for the past fortnight. It would be possible to persuade people who fear they will lose services they have enjoyed of the logic of having centres of excellence if they saw a superb service developed elsewhere first. At the risk of falling out of favour with Deputy Sherlock, I contend that the people in Mallow could be persuaded if they had a centre of excellence with no queues or problems, within a reasonable distance and which could be reached on a particularly good road. This is what the Hanly report is about.

The report is about delivering quality care in centres of excellence, covering the full spectrum of care, and then providing quality of care over a more limited spectrum in local centres that comprise centres of excellence within their capacities. We are not talking about hospitals will fewer good people but about hospitals with a smaller range of specialist services. The way to persuade the public is to develop quality centres that they can see and show them that a traffic jam on the margins of Cork, Limerick or Dublin will not mean that a journey from Naas, for example, to a centre of excellence in Dublin, such as Tallaght Hospital, would not take two and a half hours, as it would have done this morning in an ambulance. It would definitely have taken two and a half hours to get from Naas to St. Vincent's Hospital because of the traffic chaos.

It is a matter of joined-up thinking. One cannot just look at a map and state the distance between two points is only 20 miles when, in some cases, this distance could take two hours to travel. I would love to see Hanly revisited in terms of the time it takes to get from one place to another, rather than speaking in terms of miles.

I once encountered a little problem in the wilds of west Kerry in which the Department of Education and Science wanted a primary teacher to move to a new school because of staffing numbers. It chose another school nine miles away, believing that this was a reasonable distance for the teacher to travel. However, this meant that the teacher had to travel over a mountain, the Connor Pass, which is prone to frost, fog and snow for four months of the year.

Americans talk of journeys in terms of time rather than miles. We need to do this. If we did so and had high-quality services, people would demand to go to the location of these services rather than demand a less good but more widespread service, to which they could gain access in their own locality. This would also be the case if the improved services the Minister described were delivered.

Increasingly, I believe we should not have the Minister for Health and Children in the House when talking about health. Health policy is being dictated by the Department of Finance, not only in terms of funding. The Department of Finance established and funded at least one of the studies we have been discussing recently. Its approach is that having generated the report, it also has responsibility for it. Apart from the extraordinary centralism of that view, it also makes it entirely meaningless for a well intentioned Minister to come to the House and outline policies, with which many of us would not, in principle, disagree, when there is not a squeak from the funding Department about how it proposes to provide the funding needed to offer the type of services that would perhaps persuade people to accept the logic of the Hanly report.

Maurice Hayes (Independent)
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Although I have less involvement with local services than my colleagues in the House, I thought it might be helpful to offer some observations from the point of view of somebody from outside the health service who has worked in the health field. In recent years, I chaired a committee which carried out a review of the acute hospital services in Northern Ireland. Having done our sums, we arrived at conclusions which are not a million miles away from those of the Hanly report. If the Minister wishes a copy of the report in question – it is mentioned in the bibliography of the Hanly report – I would gladly provide it and discuss it with him at any time. I hope the Hanly report will be considered as an opportunity rather than a disaster.

I agree with many of the points made by Senator Ryan who may be interested to learn that our review in the North defined access in terms of journey times and went to considerable trouble to establish journey times for different areas. It distresses me that my colleagues in the media, particularly the electronic media, grab for the word "downgraded" every time they discuss hospital changes. They appear to think of nothing else. Where is the downgrading in looking after chronic conditions, elderly people and other groups?

The Hanly report is the way forward. We should strive for a consultant delivered service. To extend a comment made by Senator Ryan, ultimately training posts should be supernumerary as it would allow us judge the current position.

Acute care is what catches the public imagination and is talked about as if there were nothing else in the health sector. One must consider acute hospitals in the context of the wider health sector. Primary care is extremely important and investment in it and the continuing care and community care sectors could do more to relieve strain than investment elsewhere. The health system must be a seamless continuum in which acute care is only one episode.

Changes are taking place and new patterns have emerged in the way medicine is delivered. If one is to have a consultant led service, one must employ a sufficient number of consultants to have proper rotas. They must also have a sufficient workload to enable them to maintain their skills, and interaction must take place between different places. These requirements drive one towards centres. Other developments, notably in telemedicine, will allow one to decentralise a considerable amount of diagnosis and after care. Changes are also taking place in the pattern of disease. Chronic and degenerative conditions are associated with ageing and, as the Minister stated, those affected by them are entitled to the highest quality of care at local level.

Our review in the North came up with the idea of hospital systems, which are intended to shift people's perception of hospital services as somehow being bricks and mortar located in a particular place. The idea of systems was that each would serve a population of 350,000 to 500,000. Acute episodes would be treated at the centre of the cluster, while it would also be possible to move in the opposite direction. This opens up enormous possibilities for a local centre, whether it is called a hospital, polyclinic or something else, given that a great deal of diagnosis can be performed using imaging and telemedicine.

Significant developments are taking place in day surgery, day treatments and non-invasive surgery. Follow-up services and clinics allow one to offer in local polyclinics a wide range of services backed up by the resources of a system. People will be satisfied with such services. It is important, however, that centres of excellence do not suck all the resources out of the system. In the days when people referred to hub and spoke in the context of hospitals, the hub grew fat and the spoke thin until the rim fell off. People have to be reassured that the provision at the centre is complemented by the maintenance of local services.

A highly efficient ambulance service is also required as it is necessary to be able to move people and information around the system. A proper diagnostic infrastructure in which tests and so forth become immediately available is also needed. If the concept can be presented to people in this fashion, they will accept it as is an improvement on the current service.

As part of the review of services in the North, we carried out a study of accident and emergency departments. The study found that 85% of those who attended accident and emergency had minor injuries which could have been dealt with at a local centre fitted with the proper equipment while around 10% of cases were complicated and required the full resources of a neurosurgical department. It is important to assure people that if they are in trouble they can be brought quickly to the place where they can benefit most.

There is a major question about retaining public confidence in the service and one of the difficulties with discussing this issue is that in seeming to find fault with the current service, we lose confidence in it.

One of the difficulties in the health service in the North – I am sure it is the same here – is that most people who work in it appear to have a vested interest in saying how bad it is. It is necessary to bring the professions along. Changes are taking place in this area. For example, the divisions between the professions are changing, with nurses now performing certain tasks which would have been carried out by doctors in the past. Many functions are now being performed in the community. Many diabetics, for example, who would have been in hospital in the past are now being maintained in the community. We will also need to enrich the jobs of paramedics. If, however, we look at the wider pattern, it is moving in the right direction.

I was particularly impressed by the tone and quality of the Minister's speech, particularly his starting point, namely, the need to show compassion to patients and maintain standards. We all want friends, relations and ourselves to be treated by the best people at the best time. While there will always be a tension at local level, let us please try to stop using terms such as "downgrading". We must stop thinking of the acute service as the only service people need. Let us examine how we improve the service within the resources available to us, which are financial and human – one cannot conjure staff out of the air.

The unrolling of change will take some years. As previous speakers stated, we need two or three good working examples of the quality of the service that can be developed. I commend the report and the Minister's approach to it.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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I welcome the Minister of State at the Department of Health and Children, Deputy Tim O'Malley, to the House. We all know that reorganisation of the health service is an absolute necessity. It is one of the key issues in the Hanly report, page 17 of which states: "The priority must be to provide a safe, high-quality service to all patients at all times." However, this statement is completely aspirational. The Minister for Health and Children launched a new policy document on health, Quality and Fairness, and that document had plenty of aspirational language also, but not a single element of substance of the expressed intentions of that policy has been implemented. If it has been implemented, please tell us where. Otherwise, we will have to look for them.

As a member of a health board for a long time, the only consequence of the policy that I can see is a paper chase. If the Minister of State, his senior Minister and others in the Department of Health are satisfied to go on indefinitely with no improvement, even though the record shows there have been 148 reports on the subject, then the emphasis on patients as the priority for health care in 2003 is extremely rich. We know what has happened and the cutbacks that have occurred. There are people waiting on trolleys in corridors, including old people who are in need of services delivered at community level.

It is a pity the Minister for Health and Children, Deputy Martin, is not here because I was present, as a member of the Western Health Board, when he came to Ballinasloe – Senator Leyden was also there – after the private hospital was purchased. The Minister said on that occasion that it was his and the Government's intention to develop it as an acute hospital and centre of excellence. He was playing to the gallery, just as he is doing now by telling us the patient is the priority – if only we could believe his and the Government's intentions. I remind him of the words heard by hundreds of people on a day of celebration in Ballinasloe when Portiuncula Hospital was purchased. I was glad to hear his comments, but what has happened in the interim? Due to the Hanly report, and the Hanly report mark two, which we are awaiting, there is a possibility of a replication in the other health board areas of what has already happened in the pilot areas. On that basis, Portiuncula Hospital will be downgraded.

Senators on the Government side today mentioned the word "downgrading." They do not want to hear that word because the reality is that there will be a loss of service. The accident and emergency department will be closed, although Senator Feeney said that will not happen. The Minister of State present earlier was mesmerised by the statement. This points to confusion, even within the Department, involving the Minister and Ministers of State.

It is very appropriate that the Minister of State is here because I was present, with the Tánaiste and Minister for Enterprise, Trade and Employment, at a public function in Ballinasloe during an employment crisis in Ballinasloe. She gave a guarantee that there would be no downgrading of Portiuncula Hospital and said that those who were making such a proposal were wrong and should desist. Her statement was supported by the Minister of State and the local Government Deputy. They gave undertakings, but nobody will believe the Tánaiste and Minister for Enterprise, Trade and Employment, the Minister of State or the Deputy in the current climate, especially since they have now deferred the publication of the final part of the Hanly report until after the local elections.

This is cynicism in the extreme as well as an example of political jobbery to ensure that the full extent of the public's wrath will not descend on Government candidates in those circumstances. The public knows that all the cuts proposed prior to the last general election were suppressed. We have no further need to refer to the Minister for Finance, Deputy McCreevy's statement on financial cuts, prior to the last election, compared to what actually happened after the results of that election.

We should consider the vagueness of the language used in the report. It refers to "should", "could", "would" and "might". There is a series of these words on page 17 of the report. No. 4 states that "substantially more consultants should be appointed". No. 6 on the next page states: "In the pilot regions studied, acute hospital services should be delivered by an integrated network of hospitals." If there was any determination on the part of the Minister, the Government and the Department, "should" would not be used. Instead it would state "will be delivered." Definite commitments to what is outlined in the Hanly report would have been given, but there is no such certainty. The same point can be said now of the Hanly report in the light of what happened to the policy document, Quality and Fairness, in that pious platitudes and statements of intent were offered, but not one item of substance has been brought forward.

I am delighted Senator Kitt has arrived.

Photo of Michael KittMichael Kitt (Fianna Fail)
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I thank the Senator.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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I welcome the Senator because he has, like me, a very important interest in Portiuncula Hospital in that constituency.

Will the Minister of State confirm that if the conditions in the pilot areas, including his own health board area, are replicated in other areas, Portiuncula Hospital will be downgraded and we will also lose the accident and emergency and maternity units? These two specialties, among many in the acute hospital, are in themselves centres of excellence. They were developed by committed people, such as the Franciscan Sisters, over the years in the private hospital with their dedication to delivering a service of excellence in its own right. The Minister should not deny that area, where the local community, in the absence of Government commitments, funded the hospital through many fundraising projects to bring it to the standard of excellence it enjoys today.

What is happening now? It has been bought for the purpose of turning it into a five day week, nine to five hospital, and for the remainder of the time it will be a convalescent home with a professional nursing service taking care of people. The report states that 70% of minor procedures are performed at local level. We will have people from Clifden coming to Portiuncula for a minor medical or surgical procedure, bypassing the centre of excellence as they will not be able to get in there. If that is what embracing Hanly entails, on the first day of its implementation something will happen, somewhere in Ireland, that will lead to tragedy because it is a flawed document. With the greatest professional respect to Mr. Hanly, a person with supreme knowledge of aviation and engineering, he was not the person to interpret, with any certainty, the needs of the local communities.

Senator Ryan said he had an interest, because of his spouse's profession, in the development of a centre of excellence in Cork. He also said it was no trouble to travel from Mallow to Cork. It is my suspicion that an inner group made the final decisions in the Hanly report. In the case of the Western Health Board, Dr. Mary Hynes was one of the senior people who made the final decisions along with Professor Gerry Loftus, both of whom are based in University College Hospital, Galway, and whose interests were focused on that. Unless the Tánaiste comes forward once more, I fear for the future of Portiuncula Hospital as an acute centre. It will be downgraded because, as Senator Maurice Hayes said, all the finance, resources and personnel will be sucked into the centre of excellence and the peripheral areas will be forgotten once again. I did not believe that the Minister, Deputy Martin, should allow that to happen.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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I would prefer if the Minister, Deputy Martin, was present to respond to some of the issues I will raise during this debate. I mean no disrespect to the Minister of State, Deputy O'Malley, who has more responsibilities in the Department than I had when I held that office between 1987 and 1989.

In 1968 the famous Fitzgerald report was published. It was compiled by a group of consultants who decided that Roscommon County Hospital should become a community health centre. The man who commissioned that report was the former Deputy and Minister, Seán Flanagan, whose car crashed in Tarmonbarry and whose life was saved in the accident and emergency department of Roscommon County Hospital by the surgeon, Mr. O'Hanrahan. The former Minister realised then the benefits of having an acute hospital nearby and the policy was changed. The 1970 Act was passed.

Now we have decided to remove the health boards, the single avenue for public representatives and others to convey their views. The Minister of State is a former member of a health board. Until 30 June 2002, I was chairman of the Western Health Board.

Photo of Ulick BurkeUlick Burke (Fine Gael)
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We will not go into that again.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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During my time as chairman, tremendous work was done by the board on behalf of the public it served. I stand over that work.

The national task force on medical staffing comprised about 51 consultants and professionals but hardly any consumers to put forward the views of the people of the west and other areas. I would not rely on any paid official, whether it is Dr. Hynes or Dr. Ryan, to put forward the views that I, Senator Kitt or Senator Ulick Burke would put forward. Why were their voices not heard? We should bin the report. It is a disaster both medically and politically. I do not stand over this report and I intend to ensure it is binned.

However, I stand over "Quality and Fairness – A Health System for You" which had a vision and received marvellous input from the health boards. There were no proposals in that report to remove the health boards or to close accident and emergency departments. It also took account of the regulations and directives from Europe. The vision I stand by, which was adopted by the Fianna Fáil Party before the election of 2002, is the vision in the health strategy. It is:

A health system that supports and empowers you, your family and your community to achieve your full health potential

A health system that is there when you need it, that is fair and that you can trust

A health system that encourages you to have your say, listens to you, and ensures that your views are taken into account.

That does not include the removal of the health boards. I attended the meetings in Dublin Castle when the Minister was present. Most of the people involved with that consultative document were in the health services and were from the regions. There were none of these vested interest professionals who want large hospitals with large numbers of consultants. Has the health strategy document, "Quality and Fairness – A Health System for You", been binned? It was to be implemented over the next seven to ten years and was well received by the public.

The Brennan report, the Prospectus report and other reports have been produced since then. My primary concern is that the people in my constituency get a good health service. I signed the contract for the accident and emergency department in Roscommon on 15 May 2002. It will cost about €8 million to complete. I signed it as chairman of the Western Health Board. The Minister said today that he gave the board the money and I acknowledge that. I acknowledge the work he has done for accident and emergency service provision in Roscommon. However, I did not sign that contract to close the accident and emergency department in Roscommon County Hospital.

If this report is fully implemented, the hospital will only open from 8 a.m. to 8 p.m. I passed the hospital this morning and the lights were on in the accident and emergency department. It is a beacon of hope for those who are ill and in need of emergency treatment. Yesterday, there was an 85 year old man and a 92 year old nun on trolleys in the hospital. Would they get a bed in Galway? Will the 14,000 people who are treated in the accident and emergency department in Roscommon be shipped to Galway where there will be no beds available for them? There will be no beds because it is more expensive to provide those beds than to provide the consultants in Roscommon County Hospital.

I signed the contract for Portiuncula Hospital. The Western Health Board bought the hospital for £11 million. We did not buy it to close the accident and emergency department or to close the maternity unit. I owe that hospital a great debt of gratitude. Mary and I had four children in that hospital and it provided a great service. Portiuncula and Roscommon County Hospital work closely together. The hospital in Roscommon in excellent. I might be parochial but it is a referral hospital. When a case arrives, the first priority is to ensure the patient is made safe and if they have to go to an orthopaedic hospital, St. Luke's Hospital, St. Vincent's Hospital or the Mater, they go prepared and, in many cases, they return to Roscommon for rehabilitation.

There is a good working relationship between Roscommon County Hospital and Portiuncula and, in turn, between Portiuncula and UCHG and Merlin Park. They work well together. The model is working well and I have received no complaints about it. Why should I embrace the Hanly report? Why should the Minister and the Department embrace it? I was elected by councillors throughout Ireland and I was not elected to say that everything is wonderful or that the report is wonderful. The Minister and the Government have their view while I, as a Fianna Fáil Senator and councillor, have mine. I will campaign to ensure that the accident and emergency service continues in Roscommon. If that department, the shopfront of a hospital, is closed, the patients will be gone. The bigger hospitals will be strengthened and the patients will not return.

There are 8,000 people aged more than 65 years in County Roscommon. They are in need of medical care on a more regular basis than younger people. That is a fact of life. In many cases, these people might suffer from pneumonia or something similar and they need attention. It is not necessary to go to UCHG to get that attention. You get it in Roscommon County Hospital or Roscommon Acute General Hospital and we have doubled the number of consultants to ensure that they will continue to get this service in the future. We have increased medical, surgical, anaesthetic, radiology and radiography services and we have the best screening room. It is all there. I signed a €1 million contract for new theatres. I insisted that I sign that contract before my term on the Western Health Board was terminated on 13 June 2002. I was the outgoing chairman and I was not even allowed to hand over my chain of office to the incoming chairman. However, I told the chief executive officer that if I did not sign that contract it would not be signed once I had gone. I signed it because I was chairman of the Western Health Board and because I insisted. I also campaigned for, and was successful in getting, St. Colman's ward upgraded. We upgraded the hospital, which will now be perfect. The accident and emergency department will meet the needs of the people of Roscommon and surrounding areas such as Longford.

An Leas-Chathaoirleach:

The Senator has one minute left.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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I need an hour to get through this. How many reports can one get through in ten minutes?

An Leas-Chathaoirleach:

We have another debate.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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I am calling for another more detailed debate. Before I finish on this report, however, I want to say that, as far as I can see, health policy is being controlled by Aileen O'Meara of RTE. The ambulance chasing—

An Leas-Chathaoirleach:

It is unfair and out of order to name people in that fashion.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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As far as I am concerned, she is a respected journalist, but RTE is made up of ambulance chasing—

An Leas-Chathaoirleach:

She should not be referred to. She is not a Member of the House.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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The only opposition, as far as I can see, is being led by journalists who are influencing the Minister. All the top journalists are in Dublin with top medical attention, and they do not care a damn for the medical needs of the west or of Roscommon.

An Leas-Chathaoirleach:

The Senator should conclude.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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They do not care a damn, and every time—

An Leas-Chathaoirleach:

I said the Senator should conclude.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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—there is someone on a trolley, we have Aileen O'Meara or someone else from RTE coming on the scene.

An Leas-Chathaoirleach:

Senator Leyden, I have already pointed out that you cannot name people who are not in the Chamber.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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They will not come down to see the work that is going on beyond that.

An Leas-Chathaoirleach:

Senator, you cannot name people who are not in the Chamber.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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They may not be here but they are well represented here, and the party with whom they are involved is well represented in this House. If they want to defend it, so be it.

An Leas-Chathaoirleach:

Senator Leyden, I must ask you to conclude. You are out of time.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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She is well able to defend herself on RTE. I will conclude by saying that 13,000 accident and emergency patients went through Roscommon County Hospital in 2002 and 1,056 in-patients. As long as I am here, irrespective of how long that is, these people will not be deprived. I will continue the fight, and if we must take it to the streets, we will do so.

An Leas-Chathaoirleach:

Before I call on the Minister, I would like to welcome Councillor Paul Conmy from the North Western Health Board, who is here for the debate. The Minister will conclude.

Photo of Michael KittMichael Kitt (Fianna Fail)
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I had hoped to speak.

An Leas-Chathaoirleach:

I am sorry, but there is no time. The Minister must address the House at 1.50 p.m.

Photo of Michael KittMichael Kitt (Fianna Fail)
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I thought Senator Mansergh and I might have a few minutes.

An Leas-Chathaoirleach:

The next business of the House is ordered for 2 p.m.

Photo of Michael KittMichael Kitt (Fianna Fail)
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That is very disappointing.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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I do not know where to start. I have heard quite a few contributions during the last hour. I fully agree with Senator O'Rourke about the importance of the report's implementation. That is the challenge for the Government. I have listened intently to all the speakers. Senator Brendan Ryan made the very good point that, when people are speaking about access to hospitals, they should be talking about the time taken to get there rather than the number of miles to be travelled. That is a valid contribution. Senator Maurice Hayes shared his experience and his involvement in Northern Ireland politics with us. That was extremely useful, and I was delighted Senator Hayes was so hopeful and supportive of the Hanly report. He sees it as an opportunity for the health services to improve and develop. I agree with his statement about consultant provided services and his mentioning developments in telemedicine. Things have changed, and we cannot continue with the model of health services that we had in Ireland in the past.

Centres of excellence are the way to go, and the Hanly report has certainly very much concentrated on them. I share the concerns of those worried about services being sucked into the centres of excellence. However, anyone who has read the report carefully will see that is not what is suggested. On the contrary, there would be far more services given to local hospitals for the delivery of better day care services and so on. What Senator Hayes said should be repeated.

I have listened to some of the statements made and I can understand people's concerns about their local hospitals. I have listened to a fair amount of the debate on television about the Hanly report. If one stands back and thinks of the people who work in the services, many of whom I have met, one will see that many of them are getting rather fed up. They have spent all their time working in the services, but people are constantly standing up and talking about downgrading those services. They are people who work extremely hard every day of the week all over the country, and they have been doing so for years. Many of those nurses and doctors, and all the ancillary professional services in the hospitals, are becoming demotivated by the constant negative drip effect on the health services. Many people's contributions are negative all the time, as if there have not been improvements in the health services. There have been huge improvements in this country's health services over the past ten years or so.

I listened to Senator Ulick Burke. His contribution was extremely negative, and he saw nothing positive whatsoever in the Hanly report. I am sorry to say that. He stated that Mr. Hanly had deferred phase two, but he has not even done phase two. He admitted at his press conference and in his report – if anyone read it – that he wishes to implement the proposals in the two pilot areas first, after which his team will examine the other regions. To say that the report is flawed is a tragedy when it has only just been published.

There have been huge improvements, including in the number of consultants employed over the past few years. The Tierney report in 1993 led to an increase over the years to 2003. The current Government has gone way over the recommended percentages in employing those consultants all over the country. There have been huge improvements in cancer services and additional services to patients and clients everywhere, in equipment, facilities and the delivery of health care. Waiting lists are down in several health board areas. The national treatment purchase fund has been a huge success.

Primary care is being improved constantly, and the present Government has put a huge amount of money into GP co-operatives all over the country to ensure that many of those who were unnecessarily going to accident and emergency departments are now able to attend a proper GP service in their own community. I have spoken to many of the GPs involved in such services. They are thrilled with it. That service is working in many areas, although not yet all over the country, since in some areas the GPs were not able to organise themselves. However, in the areas where GP co-ops are working, they provide a better service to the patient and cut the numbers going to accident and emergency departments. We all welcome that.

I strongly welcome the report of the National Task Force on Medical Staffing which the Government published last week. The Hanly report is a very significant contribution to the development of health policy in Ireland and its implementation will be to the benefit of patients and health professionals alike. My colleague, Deputy Micheál Martin, the Minister for Health and Children, has set out the background to the report and addressed its main features. From my own perspective, I want to concentrate on some key points which I urge the House to take into account as the debate proceeds.

We must remember that it is a service for and about patients rather than about geography.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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That is my concern too, by the way.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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If we all focus on patients—

Photo of Mary O'RourkeMary O'Rourke (Fianna Fail)
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I agree with the Minister.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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—we will get the results. There are many aspects to the report, including reducing the average working hours of junior doctors. Is anyone suggesting that it is wrong to reduce doctors' working hours? Are we to continue with that system? The Government has been courageous and I am delighted that the Hanly report underlines this fact. What we need is a consultant provided, not a consultant led, service. There is a major difference between the two and I look forward to the provision of a consultant provided service.

There will be much needed changes in our medical education system. These will have to take place, particularly in light of the implications of the working time directive for junior doctors. In addition, there will be a reorganisation of acute hospital services. All of the proposals in the Hanly report are fundamentally concerned with providing a quality service to patients. We must not lose sight of this in the debate during the coming weeks and months.

The report will not lead to the closure of any hospital. Neither will it lead to the so-called downgrading of services.

Photo of Noel CoonanNoel Coonan (Fine Gael)
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Five day a week hospitals.

An Leas-Chathaoirleach:

The Minister of State, without interruption.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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We are concerned here with some key changes in the role of hospitals, ensuring that all hospitals provide the type and level of service for which they are best suited. The Government has emphasised that the recommendations involve not just a transfer of some services from smaller to larger hospitals, but also the other way around. That is extremely important. If the number of consultants is doubled, there will be many more consultants working in the smaller hospitals.

Photo of Noel CoonanNoel Coonan (Fine Gael)
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Five days a week.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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The Hanly report proposes that local hospitals should have substantially increased services in a number of extremely important areas, such as elective day procedures and out-patient work. Instead of having to travel to the major hospitals for many medical and surgical procedures, the report proposes that these would be provided on-site in local hospitals, closer to local communities. This can only improve the services available locally. We must ask ourselves how this can be represented as a diminution of services in smaller hospitals when the report proposes precisely the opposite.

Let us consider more closely what the Hanly report proposes for accident and emergency services. It points to a huge body of evidence that treatments for serious and urgent conditions, including those which may be life threatening, are best provided at a location where there is a full range of specialties available on-site. These include medicine, surgery and anaesthesia as well as a range of important back-up services in such areas as X-ray and pathology. To do this, and to cover a full 24-hour, seven day period within a 48-hour week, we need hospitals with at least 45 to 50 consultants. At present, many smaller hospitals have as few as ten consultants and there would not be sufficient work for 45 or 50 consultants in each of these hospitals. The doctors themselves would become deskilled and this would impact on the provision of high quality patient care.

What is proposed instead? A very workable alternative is put forward, which is based on two key elements. First, local hospitals will continue to cater for approximately 70% of all the patients they currently see in accident and emergency departments. People with minor injuries and minor non-life threatening illnesses will continue to be seen at their local hospital. This amounts to considerably more than the "dressing station" to which some have referred. In fact, local hospitals will continue to treat a substantial majority of the patients with whom they currently deal.

The second element is equally important to stress, namely, that, in the case of emergencies, the best way to meet patients' needs quickly is through immediate intervention by trained ambulance personnel at the scene. The Hanly report stresses the importance of emergency medical technicians, EMTs, who can provide immediate life saving treatment. The focus then, will not be on taking the patient to the nearest local hospital but on getting them to the hospital best equipped to deal with their condition. The immediate intervention of well trained EMTs means that taking the patient as quickly as possible to a well staffed, well equipped major hospital is by far the best course of action.

I wish to deal briefly with an aspect of the report that has not received much attention in the debate during the past week. I refer here to the necessity to reduce substantially the average working hours of junior doctors. At present, non-consultant hospital doctors work an average of 75 hours per week on-site. Some work considerably more than this. Under the European Working Time Directive, we must reduce average weekly working hours to no more than 58 by next August and to a maximum of 48 by August 2009, less than six years from now.

For many years, junior doctors have been vital to the running of smaller hospitals. However, they have been obliged to work extremely long hours. Under the European Working Time Directive, whether we like it or not, this must stop. This again brings into sharp focus the best role for smaller hospitals in a new environment of shorter working hours for doctors. Reducing the working hours of junior doctors is extremely important. Excessive working time can hamper doctors' ability to provide the best possible care. For safety reasons, it would be necessary to reduce non-consultant hospital doctors' working hours even in the absence of the European directive.

Implementing the proposals in this report will no doubt be challenging. However, I am of the opinion that they offer the best way forward. We owe it to junior doctors to reduce their working hours, but, above all, we owe it to patients and their families to implement reform that will improve health care for everyone.