Paddy Burke (Fine Gael)
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I welcome the Minister for Health and Children, Deputy Harney, to the House.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I am happy to be before the Seanad to speak about the issue of patient safety. A new era has arrived in the Irish health care system. It is an era where patient safety is central to everything we do. The journey of ensuring the setting of standards and the enforcement of those standards has begun with a couple of key milestones. The first was the establishment of the Health Information and Quality Authority, HIQA, a State body independent of service providers whose sole remit is to set standards and monitor their enforcement. I will speak more on this later.

Patient safety is central to the manner in which we regulate health professionals. Just over a year ago, we brought through the Oireachtas major legislation which reformed the Medical Council. At present, elections to the new Medical Council are taking place. In particular, the fact that the new council will have a lay majority is a significant step in ensuring the profession does not regulate itself. Ireland is the first country in the world to embrace a lay majority but I am aware of several jurisdictions following in our footsteps.

The same applies to the changes made to the legislation governing pharmacists, which was almost 200 years old. The new Pharmaceutical Society of Ireland, which I established last summer, also contains a lay majority. I understand from the society that it is working incredibly well in terms of the regulation of the pharmacy profession.

As part of the patient safety agenda and journey upon which we have embarked, we must ensure that when errors and mistakes occur they are properly investigated so we can minimise the capacity of those mistakes ever happening again. We must learn from errors and not in a culture of blame. If I have learned anything over the past three years from a number of key conferences I attended under the auspices of the World Health Organisation, during the British Presidency of the EU during which patient safety was central to the agenda — the chief medical officer heads the world alliance for the World Health Organisation — and in conferences I attended in this country, it is that those health systems which seek to investigate when errors occur and to learn free from a culture of seeking to blame an individual are those which improve fastest.

We have a history of serious errors occurring without being investigated. We know that for 25 years in Our Lady of Lourdes Hospital in Drogheda people knew that what was happening in the maternity unit was wrong yet no audit or investigation took place. Audit will be a common feature of how services are provided in the Irish health care system. From here on in all community and hospital health care settings and even within hospitals themselves, standards of patient care will decide where and how things happen.

Perhaps one of the best examples of this is the new cancer control programme. We have learned not only from our own experience but from strong international evidence on symptomatic breast cancer, for example, that unless this is treated in a unit dealing with at least 150 new cases a year and by a surgeon dealing with at least 50 individual cases a year, we will not obtain the best possible outcomes for the women concerned. We know from at least 250 medical publications that the chances of a woman treated in such a centre are improved by 20%. This means one in five women who would die otherwise survive and have a good outcome. This is compelling evidence for moving with the cancer control programme adopted by the Government and which is now being implemented by Professor Tom Keane.

The change driven from a standards of patient safety perspective is far more powerful than change driven by budgets, industrial relations or staffing issues. Change is often driven by these factors. One of the issues highlighted in the Irish health care system, as it is elsewhere, is the issue of hospital-acquired infections. A national plan is now in place and being implemented by the HSE to reduce the incidence of infections acquired in the Irish health care system. We want to reduce the overall incidence by 20% over the next five years. We want to reduce the incidence of MRSA by 30% and that of antibiotic prescribing, which is a major contributory factor, by 20% over the same period. Unless we know the starting position, we will not be able to measure progress.

Later this month, the HSE will publish data, hospital by hospital, on hospital-acquired infections. This will give us a baseline from which to measure progress. Thereafter, the data will be published every quarter. We saw the results of an investigation by the HSE on the outbreak of c.diff in one hospital. I recently made this a notifiable disease. If we are to improve standards from a patient safety perspective, it is important we audit performance, know what the base is and that we measure performance against it. With regard to MRSA in particular, the countries which do best, such as the Netherlands, are those with a much lower level of antibiotic prescribing than we have in Ireland.

It is equally important that we have appropriate isolation facilities in place, especially in our acute hospitals. I wrote to the HSE several months ago and directed it that private beds in public hospitals which were heretofore ring-fenced for privately insured patients had to be made available as a matter of priority for those patients requiring isolation and that there could be no situation where a private patient in a publicly funded facility could take precedence over a patient who required an isolation facility. This is important. In the context of the co-location proposal, where we will have 1,000 more public beds in our public hospitals, many of which will be in single rooms, we want to ensure these rooms are used to improve the much-needed isolation facilities we require in our acute hospital sector.

I stated at the outset that the establishment of the Health Information and Quality Authority was a significant step. At present, this authority works with clinicians and managers on putting in place appropriate procedures and processes at every health care setting to minimise hospital-acquired infections, especially but not exclusively MRSA. Obviously, c.diff and other infections now commonplace are also included. It is important to have a standards body which can work with the individuals whose jobs will be to implement the change locally.

Hygiene audits are a new feature of our performance measurement for hospitals. They will be carried out in a wider number of health care settings. We have had three audits to date and they indicated a major improvement, particularly as far as cleanliness is concerned. Hand washing is one of the most important things we all can do to minimise the capacity to pass on infection. Hand washing is important for visitors to hospitals, family members and especially important for health care professionals.

On a recent visit to a family member in an acute hospital in Dublin I was very impressed at how prominent the notices were at the entrance of the hospital. Many people did not know I was there because I stood way back in the corner and I noticed that virtually every visitor who came in washed their hands because the signs were so prominent and because they saw other visitors do so. I found that very encouraging and I hope every hospital can adopt the kind of prominent postering used by this hospital to advise visitors as they enter the premises.

The setting of standards is important but so too is the monitoring of standards. The Health Information and Quality Authority recently produced draft standards as far as nursing home care is concerned. Heretofore, nursing homes in the private sector were inspected but those in the public sector were not. From here on, all nursing homes, whether in the public or private sector, will be monitored. Not only will stronger standards be in place but each patient will have his or her own care plan, which is important because the care needs of older people differ hugely. It is important that each patient is required to have his or her own care plan so that those inspecting the facilities can ensure the care plan is being implemented.

The setting and monitoring of standards must be applied across the board in the public and private sectors and not only in public and private sector nursing homes. We have no licensing or accreditation regime as far as private healthcare provision is concerned. On my appointment as Minister for Health and Children, I said I regarded that as a major deficit in our regulatory framework as far as health regulations were concerned. No work had been done on accreditation or licensing and, therefore, we established a patient safety commission to make recommendations around the patient safety agenda but especially as far as licensing and accreditation were concerned.

That commission is chaired by Dr. Deirdre Madden and includes healthcare professionals, experts from other industries which have very high standards of safety in their sectors, patient representatives and family members of those who have had an adverse experience in our healthcare system. The commission is due to report to me in July and the report will be published immediately. I will act on the recommendations of the report as far as accreditation, regulation or licensing is concerned. When that happens, the role of the Health Information and Quality Authority will apply to the private setting as it does to the public one. That was not possible in advance of legislation and regulation.

I refer to a number of the inquiries which, I suspect, led to the request to have this debate. We have had a period of unprecedented inquiry, which is a good thing. For too long the only way people could establish what happened was by litigating. One of the first people I met on becoming Minister for Health and Children was Margaret Murphy from Cork whose son Kevin died as a result of a series of errors in hospitals in Cork. She wanted to find out why it happened. She knew she could not bring back her son but wanted the system to learn from the mistakes that had been made. She could not get any answers to the questions she raised so she had to litigate. She won and received compensation which she donated to a charity. She was not interested in any financial compensation but simply wanted to establish what happened. The remarkable thing was that I met her in the UK. She had been identified by the chief medical officer there as a champion of patient safety and he had involved her in a world health alliance for patient safety. I subsequently appointed her to different bodies, as I have other patient representatives.

That was the era when one had to litigate to find out what happened but we are in a different era now. We must be brave and courageous enough to inquire and learn from those inquiries. After the inquiries into Portlaoise, a number of measures were taken. In the first instance, we established that the failure to have multidisciplinary care in cancer care leads to bad outcomes for patients.

We also learned that there were serious governance issues as far as the Health Service Executive was concerned. I wrote to the chairman of the HSE following receipt of the Fitzgerald report, which I asked it to commission, asking it to take a number of steps. The first one was to put in place a protocol to deal with serious errors when they arise and I am happy that an interim protocol is now in place.

However, it is not enough just to have a protocol. We need to make sure somebody is responsible for its implementation. The HSE has appointed an individual at national level who must oversee the implementation of that protocol. Among the features of the protocol is that patients must be informed in the first instance. As often happens in healthcare settings when information is put or leaked into the public domain, every patient of that service worries that it applies to him or her. That was one of the major problems which arose in Portlaoise. Huge panic sets in and the system cannot respond to inquiries made. That was the experience in Portlaoise.

A recommendation in the Fitzgerald report was that the patient must come first instead of me, other politicians or journalists. We must make every reasonable effort as quickly as possible after an error, or a potential error, is identified to contact patients and to make sure we engage with them. In cases since Portlaoise, that is the procedure in place which I very much welcome.

Reporting in itself is not sufficient if the mistakes identified are not put right. Everybody here knows that as long as we have roads and cars, we will have accidents and that as long as we have healthcare and hospitals, unfortunately, we will have errors. The best hospitals in the world make errors and sometimes very simple things can cause very serious errors. An X-ray read back to front can often lead to the wrong procedure happening. I attended a conference in the UK last year at which a surgeon from New York with 25 years experience said he removed the wrong leg from a colleague because he was in a theatre which was turned the other way from the one to which he was used. It sounds very simple but sometimes such errors can have fatal consequences, depending on the form of surgery. Therefore, we cannot be careful enough, especially as far as surgery is concerned.

Two years ago I launched a booklet by the Health Information and Quality Authority, which Senator Twomey attended, that contained a patient guide to best care. It advised patients to be vigilant in asking the hospital to mark the left leg or the left side of the brain, depending on the side being operated on. I remember thinking as I launched the booklet that one would want to be a very brave patient before one went to the theatre to think of that. Experts in the area inform patients and their families to do as much as they can to minimise the capacity for error making.

When errors occur, we must make sure we learn from, and minimise, them. I say "minimise them" because we will never have an error free healthcare system. No matter how many staff we have or what procedures and protocols are in place, unfortunately, errors will occur. Human beings will make errors no matter what we do. However, we must minimise the capacity for error making because errors in healthcare, unlike many other areas such as law, accountancy or engineering, can have dire consequences for patients and their families.

Members of the House will no doubt have questions. We are embarked on a massive transformation of healthcare. In particular, we are seeking to make sure acute services are provided in a safe environment with the multidisciplinary care that is not only important in cancer care but in many other areas of care. With a population of 4.3 million, that means we will not be able to have the expertise everywhere. There are 52 acute hospitals in the country. Many of the experts are sought after globally and they are in scarce supply. Therefore, when we acquire expertise, we must put it to best effect as far as patients are concerned.

I very much welcome the new contract of employment we have agreed with the Irish Hospital Consultants Association which represents 80% of practising consultants. I hope that the Irish Medical Organisation will, in time, be in a position to recommend the acceptance of the new contract. Central to that is the appointment of clinical directors. Doctors will work as part of a team rather than work as individuals and they will work under the direction of a clinical director who will have specific responsibility for risk, patient safety and so on.

Although many other aspects of the contract, including longer working days, equal access for public and private patients to outpatients and a one-for-all list instead of the separation we have at present, are fundamental changes, the clinical directorate model where clinicians are centrally involved in a leadership role within the hospital will act to improve patient safety in the healthcare system.

Frances Fitzgerald (Fine Gael)
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I wish to share time with Senator Healy-Eames.

Pat Moylan (Fianna Fail)
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Is that agreed? Agreed.

Frances Fitzgerald (Fine Gael)
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I welcome and thank the Minister for her attendance in the House today. I regret we do not have more time to discuss with her the many issues of the health service which Senators would like to raise. We should not have to request the Minister's presence in this House. We should not yet again have had to ask her to come to the House owing to deep-rooted and genuine concerns in respect of patient safety in our hospitals and health system.

As I stated earlier at a meeting of the Joint Committee on Health and Children during which the Health Information and Quality Authority presented its report, HIQA is undoubtedly a beacon of light. There is great concern about quality and standards in our hospitals and the care patients are receiving. There have been seven reports in the area of breast cancer care alone. The Minister said she welcomes that there have been inquiries and reports. One could equally say, however, that failure to deliver for patients on the frontline over a ten year period, a time of unprecedented wealth and the Celtic tiger, is the reason our services are in the state they are in and the reason these reports were commissioned.

I have referred already to services in respect of breast cancer care. However, if one looks at the spectrum of health care in terms of MRSA levels, over-worked staff, maternity services, cut-backs in community care, children at risk of not getting services — as reported on Friday last — and the closure in many counties of mental health waiting lists for children with effectively no service available for children with mental health difficulties, one could not be complacent but could predict the commissioning of many more reports on the current delivery of service to individuals in every region. Something has gone seriously wrong in the delivery of frontline services.

While I understand the vision outlined by the Minister, I must question her about delivery during the past ten years and during her tenure as Minister for Health and Children for the past three and a half years. The names add up to a tally of disgrace and betrayal for many people. I will speak in a moment about what the Minister for Finance, Deputy Cowen, said in the Dáil last week. Names that come to mind are Tania McCabe — Members will have seen the recently published report in that regard — Patrick Joe Walsh — we all know what happened to that elderly gentleman — Beverly Seville-Doyle's experience in the Mater Hospital, Peter McKenna, Susie Long and Rebecca O'Malley. Each of those names represents a person brutalised by the system of care he or she tried to obtain, each of whom was crushed by the system. While the Minister's words and the initiatives outlined are fine, the day-to-day experience of many people in our health service has been one of upset and death, deaths that should never have happened.

I am concerned that last week when Deputy Enda Kenny raised the case of Mrs Peg McEntee, the 76 year old lady left on a trolley in the Mater Hospital for 48 hours, the Minister for Finance, Deputy Cowen, did not apologise to the family for their ordeal but criticised Fine Gael for raising the issue and referred to the matter as facile. I do not believe patient care and safety and raising individual cases to illustrate the experience of many people is facile. I hope the Minister does not believe that and that she will say so. If she agreed with Deputy Cowen's statement she would then also be suggesting it is facile to raise the issue of the distress caused to the women given the all clear from cancer only to find out later the tests were unreliable and they had a cancer that was advanced due to misdiagnosis. These are emotional nightmares for the people concerned.

The Minister apologised to the women concerned and I have no doubt she meant it and that she felt deeply for them. However, that in itself, as the Minister has already stated, will not protect women from future errors. The Minister needs to outline for us the changes being introduced to deal with these situations. There have been many reports such as the Fitzgerald, O'Doherty and Doherty reports. Though there was no collusion between the authors, they all reached the same conclusions and listed problems in respect of governance, communication, delays in responding to patients' concerns and to what can only be described as general confusion among some staff in respect of their roles and responsibilities. I would like the Minister to respond to the problems identified in these reports which are compromising patient safety day in and day out. If people do not know what are their roles and responsibilities in delivering health services, how can they deliver them?

The Minister said in 2004 that we needed clarity of roles and accountability, political responsibility for the Minister and management responsibility for management. Has this happened? The reports clearly show nothing has happened three and a half years after that statement was made. Why is there confusion in respect of roles within the health service? Does the Minister accept that confusion and lack of clarity poses a risk to patient safety and damages the level of efficient care afforded to patients? The buck has to stop somewhere. We must know what action is being taken in respect of governance and accountability within the health service. Many of the reports have addressed this issue. The Minister needs to clarify it; it is not new but has been commented on in many reports.

I would like if the Minister could respond to Senators' concerns about the move to specialist centres. Let us take for example the closure of maternity services and the redirection of expectant mothers to other services——

Pat Moylan (Fianna Fail)
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Senator Fitzgerald indicated earlier she wished to share her time. The Senator has only one and a half minutes remaining.

Frances Fitzgerald (Fine Gael)
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What is the plan of action in respect of the removal of local services before specialist services are in place? I do not have to time to deal with issues such as MRSA or mental health services for children but I ask that the Minister address some of the points I have raised. Clearly, we need more time to discuss this issue.

Pat Moylan (Fianna Fail)
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Senator Healy Eames has less than one minute.

Fidelma Healy Eames (Fine Gael)
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I thank Senator Fitzgerald for sharing her time with me. I welcome the Minister to the House.

I wish to raise with the Minister today the pharmacy crisis in the west. The Department and Health Service Executive is currently swamping pharmacists with litigation injunctions. It was confirmed to me yesterday by senior sources that there is no contingency plan for the distribution of medicines as of 1 May. We are talking about an estimated 4,000 to 5,000 people descending upon community care and accident and emergency at Merlin Park Hospital for medication. Only one pharmacist remains standing in Roscommon and there is a question hanging over Sligo.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Standing where?

Fidelma Healy Eames (Fine Gael)
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All of the pharmacies are pulling out of the community services contract. I am informed the HSE in these local areas have been told to order in medications. Where will they be stored and who will dispense them safely? Where are the labels and computers required for labelling? What is required is a controlled professional environment. Who is familiar with patients' allergies? What will happen to those patients allergic to aspirin or penicillin?

Pat Moylan (Fianna Fail)
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I must call the next speaker.

Fidelma Healy Eames (Fine Gael)
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Anecdotal evidence suggests the civil defence forces will be used to try to mobilise medication.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I do not know from where the Senator is getting her information. This is the first I heard of it.

Fidelma Healy Eames (Fine Gael)
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That is the anecdotal evidence. I ask that the Minister confirm today her contingency plan for the safe distribution of medication as of 1 May.

Pat Moylan (Fianna Fail)
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I call Senator Feeney who has eight minutes.

Geraldine Feeney (Fianna Fail)
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I, too, welcome the Minister to the House and compliment her on her excellent presentation. The Minister had no notes and spoke on this issue for 22 minutes which tells me she is at home with her brief and knows it intimately. It is obvious it is very much part of the Minister's day to day working life. I do not know of any other Minister who comes to this House and deals as adequately with issues arising from his or her brief.

I am delighted to have an opportunity to contribute to the debate. As the Minister has said, it is timely because unfortunately we have seen an unprecedented amount of negative fallout. We went from the cases in Portlaoise hospital to those of Ms Rebecca O'Malley and Ms Susie Long to the MRSA infections and, in recent days, to the case of the young child in Crumlin who had a kidney removed in error. That last case is the first time that I have heard of so-called wrong site surgery. Apparently there have been only two confirmed cases of it in the UK. It is most uncommon worldwide and I would say that the present case is a first in this jurisdiction. It is terrible and there are no words I can imagine that would console the parents, the young patient or his family concerning what has happened, never mind finding words to try to explain how it occurred. It is most unfortunate. I have no doubt it will be dealt with accordingly.

The Minister mentioned the Medical Practitioners Act which this House passed and which provided for a lay majority for the first time. The Minister was very brave in the face of much negativity from medical personnel and despite receiving a great deal of abuse. Everyone told her she was wrong but she went ahead and pushed the legislation forward. Elections are due to be held which will provide a lay majority. I commend the Minister on that. It was the way to go.

We would not have a hygiene audit were it not for the terrible fallout from MRSA. Again the Minister was brave enough to put this audit in place. She is blamed for everything that goes wrong despite the fact she is not in any of the 52 hospitals on a daily basis and cannot be held responsible for all that goes wrong. For all that, she does try to put things right when things go wrong. She is a woman of actions rather than words. She will say the words but she will also put them into action.

I am glad to see that the Coroners Bill, which was debated in the House in 2007, has classed MRSA as a reportable death. I am even happier that from 4 May, what I would term the new disease, c.diff, will also be a reportable disease and is now listed on the infectious diseases reporting system. We can see now what cases are showing up and which ones are being monitored. It was a shame that the recent cases in Ennis showed the presence of this terrible disease when the post mortems were done. It was a contributing factor in the deaths of those people.

As Senator Fitzgerald remarked, the Health Information and Quality Authority, HIQA, earlier today met the Oireachtas Joint Committee on Health and Children. Everyone was greatly impressed by its presentation, the more so because that organisation is less than a year in operation and had wonderful work to show us. I take my hat off to the people concerned who are all hard-working, committed members. They explained the different areas where changes can be seen. Regarding the placement of children under 12 in residential care, there will be an inspection of each residential unit before a child in that age group is placed in it.

It seems only yesterday but it is two years since this House debated the fallout from the Leas Cross nursing home situation. I was greatly impressed to see what is in place now to monitor and set standards for nursing and residential homes. The residential care people with disabilities receive is also being monitored. All these matters are part of the major reform that is needed. I have no doubt the situation will improve.

The Minister said at the beginning of her presentation that she would like to see us learn from our errors rather than enter into a culture of blame. We always appear ready to jump in and blame someone. Perhaps that is human nature but it would be much better if we could stand back without jumping in and pointing a finger of blame. As the Minister rightly points out, if we adopt this approach and learn from our errors, we will improve much more quickly.

The Minister and referred very briefly in her presentation to the Dr. Neary case and she was in the House for the debate on the repercussions of that. It encompassed more than 20 years of terrible practice but as the Minister pointed out, everyone knew about it yet no one wanted to point a finger. That situation was allowed to occur because of a culture of silence. I do not know what one needs to do to try to break down that culture but I believe the Minister is well on the way to ensuring such a culture is eroded. The Medical Practitioners Act was passed by the previous Seanad, the first such legislation in almost 30 years. Competence assurance was brought in. Had there been such a component before, with requisite medical education for doctors and compulsory professional development programmes, the Neary situation might never have happened and the damage done to all the women who came under his care in Our Lady of Lourdes Hospital in Drogheda might never have occurred.

Phil Prendergast (Labour)
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I extend a warm welcome to the Minister for Health and Children, Deputy Mary Harney. Health remains and will continue to be the single most important issue for many families. As we get older we become all too aware of our increased need for involvement with the health service in acute hospital settings and in long-term nursing care. Above all, we need to know that when we engage with the health service we do so in a safe manner. With the current staff embargo the Heath Service Executive is working with a reduced pool of employees. As a result, those already employed are suffering from the effects of having reduced staff through unreplaced sick leave. This undoubtedly will result in increased sick leave and burnout among remaining staff. It is a vicious circle and cutting frontline staff is not the answer. Patients will suffer and so will the standard of care. Managers in the HSE must go back to the drawing board on this.

The present state of the health service does nothing to reduce the anxiety of families. We hear constantly about the lack of hospital beds and hours spent on trolleys in draughty accident and emergency departments, with accompanying lack of privacy and dignity. Such a situation is full of opportunities for mishap. Patients who are nursed on trolleys are at increased risk of contracting infection because such areas are over-populated. There is a further problem with the dangers of MRSA and other hospital-acquired infections. Frontline staff are vigilant but their proximity to infected people means that it is difficult to reduce the risk of contracting infections, with the constant flow and activity and the increased numbers occupying such hospital areas. Trolley use also reduces access for staff, with the possible worst case scenario of a resuscitation trolley being unable to pass through in an emergency situation. When emergency equipment is needed at a particular location, time is of the essence. This has a direct impact on the outcome for the patient. If beds and trolleys must be moved to facilitate movement of patients it is certain that there will be delay in delivery of vital care.

Waiting times and delayed access to mainstream health care continue to be a problem. While the Department of Health and Children prides itself that waiting times are reduced, my experience is that this is not the case. Instead of a long delay inside a hospital setting, the delay now happens between initial referral from a general practitioner and the first appointment within the hospital. I know of a particular lady who urgently needed a hip replacement. Her mobility was severely affected and she was in constant pain. Her GP referred her to Waterford Regional Hospital in July 2006 and by the time she contacted me in April 2007, she had heard nothing regarding an appointment. When I contacted the patient services manager, I was informed that as this lady was categorised as a "routine" patient, she could be waiting up to four years for an initial appointment with the consultant. This is not good enough. It is an insult to people to refer to this inadequate response as a "service". Service implies that a level of care and standards is being upheld. Again, this is not the case.

I am particularly concerned at the level of summer bed closures that are planned. In South Tipperary General Hospital, we will see the loss of gynaecological beds over the summer months, with an associated reduction in surgery. Having worked with women in the hospital setting, I know all too well that many women will plan their surgery around their families' needs. Many wait until the summer when it is easier to make provisions for the care of their children without the usual school routines. It is dreadful to see that year after year, women's services are reduced. It is unsafe and unfair to target a particular group and it should be possible to rotate these bed closures between medical, surgical and gynaecological services in a fairer way to ensure that one particular group is not overly disadvantaged.

Psychiatric care services also fall far below acceptable standards. On 26 February 2008, a parliamentary question was put to the Minister in respect of the number of psychiatric beds available to adolescents in the HSE system, whether there is a waiting list for such beds, the waiting times if this is the case, the numbers on such waiting lists and the geographical spread of those awaiting beds. It was further asked what plans the HSE has to provide beds and the areas in which these beds will be located. The Minister replied that this was a matter for the HSE, citing the Health Act 2004. The HSE has not yet responded with an answer to this question. Telling people that there is no bed or service available is not good enough. I would like the Minister to tell me who is responsible for giving the information and the reason for the lack of response on such an important issue. I know somebody who cannot let their child out of their sight. They are on 24-hour suicide watch.

When a parliamentary question is put to the Minister, there is a specific timeframe after which one is assured of a response. However, there does not seem to be any duty on the HSE to provide a timely response. While I appreciate that the HSE is an independent entity, I assume that since this organisation was created and moulded by the Minister, it is ultimately answerable to her office. If a response is slow in forthcoming in respect of such an important issue, I would expect the Minister to seek a timely and comprehensive response.

I would also like to see the provision of stroke units throughout the country given priority by the Department of Health and Children. Each year, of the 10,000 people in Ireland who suffer a stroke, 2,500 people die through the lack of essential stroke services. A recent national audit of stroke care by the Irish Heart Foundation in conjunction with the Department of Health and Children found that an estimated 350 to 500 lives could be saved through the rollout of such units. Dr. Brian Maurer of the Irish Heart Foundation said that:

[T]he report confirmed what is widely known by professionals working in front line services — stroke services in Ireland are appalling. People are dying unnecessarily simply because they cannot access the optimal treatment.

He also stated that "at the moment, people's survival is determined by chance and location with the virtual non existent service provided". While the involvement of the Department of Health and Children in this audit is welcome, we need to see it implement the report's recommendations without delay.

Once again, I wish to highlight the plight of cystic fibrosis sufferers in Ireland. We have the highest incidence of this chronic disease in the world, yet it is widely known that the treatment received by such patients in Ireland falls well below the accepted European standards of care. In February 2005, this was highlighted by the publication of the Pollock report. Since then, the Cystic Fibrosis Association of Ireland has been tireless in its efforts to lobby for an improvement in the level and quality of care to patients. It is clear that dedicated beds are needed for these patients, who are highly susceptible to lung infections, with associated facilities to allow for isolation and segregation to, as the Minister stated, reduce the risk of cross infection.

Owing to the unique nature of the condition, it is essential that a process be put in place to minimise hospital contacts by arranging for direct admission to the hospital room. This would ensure patients have a reduced risk of acquiring infections which, ultimately, would result in reduced demand on the health care system. I call on the Minister to release the findings of the Pollock report and to implement its recommendations without delay.

I would like to know the status of the review of ambulance services that was due for completion last year. In south Tipperary, Carrick-on-Suir is especially disadvantaged through the lack of an ambulance service based in the town. Instead, the people of Carrick-on-Suir have to rely on an ambulance being dispatched from Clonmel, which is a 50-minute round trip, or Waterford, which could be a 58-minute round trip, depending on the time of day, the level of traffic and whether the bridge is up. This timing does not include time spent on the stabilisation and preparation of the patient for transfer on site. It is clear that the halving of this transfer time would support a positive outcome for patients, particularly those suffering from heart attacks or stroke where time is critical

Ultimately, addressing each of these issues is inherently associated with improving patient care and safety. The HSE and Department of Health and Children seem to be eternally involved with assessing standards, highlighting problem areas and developing strategies and standards. However, when it comes to translating all of this into providing a safer service to patients, both the Department and the management of the HSE are notably inadequate.

I have the highest personal regard for the Minister. I was present on the day when the report on services in Portlaoise was given to us. I could see that the Minister was deeply upset by that. I have no doubt that she is very upset by recent events, including errors that have happened, especially the case we heard about this week and the case of the lady who lost her life. None of my remarks is personal. The embargo is having a serious effect and I continue to be very concerned about psychiatric beds and services, particularly ambulance services, that are not provided fairly throughout the country. I conclude by thanking the Minister for her time and for giving us the opportunity have this debate.

Maria Corrigan (Fianna Fail)
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I also welcome the Minister to the House and thank her for the time she so freely makes available to the House. Patient safety and quality of service are central to our health care system. Every patient should feel confident in the service provided to them, whether it is provided in a major regional centre or a local nursing home or whether they are a patient in the community, in the acute hospital setting or in long-term care. The establishment of the Commission on Patient Safety and Quality Assurance and the Health Information and Quality Authority is a vital step undertaken by the Government to ensure quality and safety of care for patients.

The implementation of quality and safety standards in nursing homes, the development of infection control standards, the monitoring of symptomatic breast disease standards and the development of core acute hospitals standards, including adverse event responses, are immediate priorities, together with work to be done in intellectual disability and child care. The Commission on Patient Safety and Quality Assurance has set out to develop clear and practical recommendations to ensure that quality and safety of care for patients is present. I look forward to its recommendations, which will be reached later this year. One of the commission's terms of reference is specifically to examine and make recommendations in respect of a statutory system of licensing for public and private health care providers and services. The current system where anyone can open a hospital or a clinic is not in the interests of patient safety and I urge the Minister to establish a system of licensing as soon as it is practicable.

As part of the health reform programme, the progression of the Health Information and Quality Authority ensures that there will be a national independent inspectorate for all nursing homes for older people, both public and private, as well as for centres for people with disabilities. This includes centres for children with disabilities who, up until now, had been exempt from the inspectorate for residential facilities for children. A core function of the authority is to set standards on safety and quality of services and to monitor enforcement of these standards in an open and transparent way. The Health Information and Quality Authority is committed to developing a supportive culture for supporting patients, families and clinicians when adverse events involving patients occur. The alleviation of a culture of blame and practical improvements in the reform of the system are paramount in producing a service of quality and safety where trust between the patients and health care provider can be fostered in a healthy way.

International research in countries such as the US, Canada, the UK, Australia and Denmark has shown that between 7.5% and 12.9% of patients admitted to the health care settings will experience an adverse event or patient safety incident. Ireland is no different and mistakes do occur but ensuring provisions are in place to prevent or deal with them is where the focus should lie.The recent case involving a young child in Our Lady's Hospital for Sick Children in Crumlin, which came to light in recent days, is devastating. It is essential that a comprehensive review of this case and the procedures employed from the moment the child left the ward be undertaken to enable us to fully understand what happened and how a mistake of this gravity could occur. As a matter of absolute urgency, we need to ensure lessons are learnt and applied immediately to prevent such an occurrence in the future.

On a national level, the Commission on Patient Safety and Quality Assurance and the Health Information and Quality Authority will be invaluable in ensuring the establishment of the necessary frameworks and the accompanying implementation of policies that will ensure the strongest best practice in the interests of every patient's safety whether he or she be based in a community, hospital or long-term care setting. However, at local level in all these settings, it is essential that attention be paid to issues such as staffing, the environment and adverse incidents.

In addressing staffing issues, it is essential that optimum staff mix be achieved, that staff competence be attained, maintained and monitored, that safe practices be undertaken by all clinicians, including adhering to hygiene standards in between contact with patients, and that adequate staff complements be identified and adhered to. Issues in the environment such as the number of beds, space, hygiene, cleaning and maintenance are all necessary factors for the maintenance and enhancement of patients' safety.

As stated previously, research and experience has shown that, on average, 10% of patients will experience an adverse event or patient safety incident. It is essential at a local level that clear procedures exist and are implemented to report and record such incidents, to investigate them and ensure immediate application of all lessons to be learned from them. I ask the Minister to consider extending such procedures beyond hospital settings to community and long-term care settings where such adverse events occur and where patient safety incidents have occurred.

An immediate challenge to the safety of patients in the community is the pending withdrawal of services by the pharmacists. I ask the Minister to address that issue if time permits.

Liam Twomey (Fine Gael)
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When it comes to patient safety the Government has been, what could be described as, a very slow learner. Even though a great deal has been said about the Health Information and Quality Authority and the great work it is doing, it should be noted that it was established as a result of a great number of disasters, including that of the Leas Cross nursing home and the cases of P. J. Walsh, Bronagh Livingstone, Susie Long and Rebecca O'Malley, that came to light during the Minister's tenure of office. All these incidents occurred before HIQA was set up. It was due to be established at exactly the same time as the HSE but because of all those disasters, there was a rush to bring forward its establishment. HIQA was established in response to the number of disasters that were occurring in the health service and not because the Government had any clear commitment to patient safety in the way we understand patient safety.

Clinical accidents occur in all our hospitals and in primary care services. As a doctor, I know those who work in the health services and in Government are human, but when it comes to patient safety, we need to be clear about what we want in that respect. Fine Gael published a policy on patient safety more than two years ago. I am sure the Minister has read it. It was clear in pointing out that we need a patient safety authority to act as a counterpoint to the vested interests who have a stranglehold over how the Government reacts. Patient safety and patient issues are not at the centre of our health service. These types of mistakes and exposures will continue to happen until we put the patients at centre of health services. That is not happening at present.

Many administrators, the Minister, doctors and nurses hold the same core beliefs when it comes to protecting patients. We want to treat people with dignity, to be compassionate and respectful in how we look after them and to give them proper treatment. However, while we continue with a system where health strategies and reports are published and fine words are said about looking after patients' safety but nothing is done in that respect and no central authority is established with responsibility for protecting patients' safety, we will continue to find ourselves in the mess we are in.

I do not like to demonise those who work in the HSE, as many of the problems in that organisation have occurred because the Minister has not reformed the health services. Most hospitals throughout the country are examining clinical governance issues and such issues are also being examined by most HSE administrators in regard to the services they provide. Will the Minister indicate the number of management or administrative governance issues under examination in the HSE to ascertain if money is being wasted? We are constantly being told by Fianna Fáil representatives that the HSE is in a mess and that it is top heavy in terms of bureaucracy. Where do those problems exist? How many millions are being wasted in that bureaucracy that should be invested in looking after patients? Those representatives mouth off about something they believe will get them a byline but they are not genuinely interested in providing health services for patients.

The Minister has often started off well, as in the case of the Pharmacy Bill and in regard to the Pharmaceutical Society of Ireland and the Medical Council. Although, I disagreed with some of the points she raised during the Dáil debate on that legislation, hopefully, in essence, it will improve matters. A core issue in regard to the Medical Council and the Medical Practitioners Act is the issue of competence assurance. The competence assurance process does not focus on the doctors who need it. The process is in place in a general sense in terms of identifying a few doctors who might tick boxes, fill out the forms and send them back to the Medical Council. That does not constitute patient safety; it merely amounts to being seen to do something because there is a problem in this regard. If we are serious about being compassionate and respectful towards patients and ensuring they have proper treatment, we need to have a proper debate on these types of issues. We need to be able to speak about what is happening in, as the Minister said, a "no blame" way. When the Minister experienced problems in negotiating the consultants' contract in January 2006, I, as the then Opposition spokesperson on health, offered to back her, but for some reason she went all quiet about it for over a year. That contract has still not been finalised, regardless of what the Minister says about it.

Has the Minister signed off on the standards for nursing homes about which she spoke? Are they now legally enforceable in public and private nursing homes throughout the country? I do not believe they are.

What Senator Feeney said about Dr. Neary is wrong in that people are not afraid to speak out. However, because of the way the system is set up, his practices were identified only by accident by two midwives.

Geraldine Feeney (Fianna Fail)
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His colleagues were afraid to speak out. They remained silent.

Liam Twomey (Fine Gael)
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It is important to have these types of debates. Senator Feeney knows my views on Dr. Neary. I was extremely critical of the way some people tried to let him off the hook. We must be fair in acknowledging what people did. When his malpractices were identified, Finbar Lennon, Ambrose McLoughlin and the senior nursing director in Our Lady of Lourdes Hospital went into the hospital one weekend and gathered enough information to make the allegations stick. They acted when they were informed by two midwives working in Our Lady of Lourdes Hospital who were in contact with a solicitor for the health board. That is how it happened. This is the type of debate we need in this House, one in which we give the facts and inform the people about what is happening. While at times I would like the Minister, Deputy Harney, to be accountable and transparent in her contributions in these debates, we need more such debates. We are not serving the patients of this country. We blather on about money, statistics and how to reduce things. Services have already been restricted in my local hospital in Wexford and community care services in Wexford have been cut back. That also applies to services elsewhere throughout the country. It is not getting any better. We need to be more honest about what we say inside and outside this House.

Déirdre de Búrca (Green Party)
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I welcome the Minister to the House. I thank her for addressing the issue of patient safety. There is little disagreement in the House that patient safety must be the top priority for all our health care systems. The importance of the issue of patient safety was recognised in the current programme for Government in which the Government is committed to initiate a periodic review of legislation to improve patient safety, to continue to ensure all new health legislation makes provision for whistleblowers where applicable and to examine the implementation of an advisory charter of patients' rights similar to the European charter of patients' rights. The programme for Government also committed the Government to progressively introduce patient guarantees of what people could expect from their health service and to bring forward and implement the recommendations of the Commission on Patient Safety.

I did not fully understand Senator Twomey's remarks on the Health Information and Quality Authority because he seemed to criticise the circumstances in which it was created.

The Green Party welcomes the establishment of the HIQA——

Liam Twomey (Fine Gael)
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It did not do so before the general election. I was in the Dáil when it was being debated. Senator de Búrca was obviously not paying attention.

Déirdre de Búrca (Green Party)
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It is an independent authority established to drive improvements in the quality, safety and accountability in this country's health and social care services. The authority's priorities include establishing a standards framework for health and social care, implementing a comprehensive programme of monitoring, measurement and, where necessary, enforcement, against the standards, as well as providing a comprehensive information framework to support safe and efficient health and social care. It is a matter of concern that the HIQA does not have jurisdiction over private providers but hopefully this will be the case in the near future.

Patient Focus, which is one of the leading groups representing patients' interests obviously shares many of the concerns that were expressed here today about patient safety. It has enunciated several important principles concerning patient safety. The group points out that lessons must be learned from the past, a point which has been affirmed by other speakers here today. I will not mention the cases which have been already mentioned but improvements must be made. Proper safety systems must be put in place and Patient Focus supports the establishment of a patient safety authority. It also suggests that patients need constant reassurance that services are safe, that they will be at the centre of service provision and that their safety is paramount. The group believes that everybody has a role to play in ensuring patient safety and that it is not just the responsibility of risk managers. It also argues that proper communication and record keeping is essential.

Patient Focus has called for the establishment of a health service ombudsman. It has also pointed to the need for more education for the general public and staff on the importance of good hygiene. It particularly stresses the need to inform the public as to why good hygiene is so important in hospitals, particularly in the context of hospital-acquired infections such as MRSA and clostridium difficile.

In terms of systems reform to achieve higher levels of patient safety, Patient Focus emphasises quality assurance, risk management and advocacy. The group calls for greater investment in ongoing education and training. It urges that peer review procedures become standard practice and calls for the incentivising of clinical audits and research as normal professional activities.

In the area of risk management, Patient Focus wants to encourage a risk reporting culture among staff and patients. It has suggested establishing a national risk resource centre for collection, benchmarking and dissemination of data on good practice. The group also encourages the promotion of systems where savings can be negotiated from insurers for implementing risk prevention measures. It has called for the monitoring of medical litigation and the evaluation of all cases for prevention potential.

Patient Focus has called for the introduction of advocacy services, which it claims are often needed by members of vulnerable groups and occasionally by even the most articulate, when they find themselves in difficult circumstances as patients. It also emphasises the point the Minister made regarding the importance of promoting a culture of disclosure and of recognition and validation of those who take the difficult step of naming and drawing official attention to some of the problems that can occur in our health care services.

In the past, there have been real problems experienced with complaints in our health service. These have often arisen because of an absence of procedures in handling complaints within the service. Another cause has been a form of what has been called "institutional arrogance", which has been characterised by delayed formalised communication or, in some instances, no communication, an unwillingness to believe a complainant and an unwillingness to accept responsibility for problems which arise. Patient Focus has also pointed to the existence of an approach in the past where complaining has had a negative influence on patient treatment.

The group has pointed to the fact that the circumstances and conditions in accident and emergency departments have given rise to problems because of delays and overcrowding. It believes that conditions in these departments have increased the possibility of medical error.

Patient Safety has examined proposals for improving regulation in the area of patient safety and has focused on the role of the Medical Council. It has suggested that the new council structures should include at least 50% lay people, as well as those in various sectors of the health professions and those involved in patient advocacy. It has also called for the new council to have new powers and the ability to impose penalties. It wants the council to be enabled to temporarily remove a doctor from the register during its assessment of a case without resorting to the courts. It has also called for those investigating a case to be fully and properly trained to do so. It further suggests that any fitness to practise hearing should be held in continuous session over a maximum of six months from the date of the complaint. It has called for other convictions to be made available for transgressions other than serious professional misconduct and for penalties to reflect these changes and to include fines, further training or limitations on the practice of a doctor. It has also asked that the council be obliged, where appropriate, to refer a case to the Garda Síochána or to the Director of Public Prosecutions.

Patient Focus has called for the council findings to be made known to the complainant and for appeals to be made available and accessible. If a complaint is rejected, the group believes that the reason for the rejection should be explained to the complainant. In general, the council should become more accountable to the public, provide regular reports and show that it is capable of assessing its own effectiveness and reviewing its procedures regularly.

The health care system has been much slower than other information-intensive sectors to exploit the potential of information and communication technologies, especially in support of the direct delivery of patient care. Health information technology has been demonstrated to have a positive impact on patient safety across many areas of health care, for example, in electronic prescribing. There appears to be a need for improved co-ordination and leadership in the implementation of a national strategy for health information technology.

I thank the Minister for her presence in the House and look forward to her response to this debate.

Feargal Quinn (Independent)
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I suspect the Minister has a death wish because anybody who undertakes what she has undertaken in the past few years and agrees to go ahead with it is pitting himself or herself against such an impossible task. In recent times in Ireland we have tended to turn the spotlight on the negatives rather than accentuating the positives. An enormous amount of good work is taking place with patients with hospitals. While there are failures — the Minister referred to them earlier — and there probably always will be mistakes and errors made, we must concentrate on the positives, of which there are numerous examples.

I was chairman of a hospital at one time and tried to have the use of the term "patient" discontinued because people are not very patient when they go into hospital. They are anxious and concerned. I tried to encourage the use of the term "customers" instead but found it very difficult. Doctors, nurses and other staff found it difficult to call patients "customers". However, I must admit I always believed that the objective of every enterprise is to ensure the customer comes back again. Then, last year when my own cardiac surgeon released me, shook hands with me and said he hoped he would never see me again, I realised that while that was not very good business, I was very glad to hear him say it.

People are stressed when they go into hospital. There is an enormous amount of stress attached to health concerns. When I had a cardiac operation two years ago, the surgeon came to me before I was wheeled in to the operating theatre and said, "I am obliged to tell you that 99% of these succeed and 1% don't". I was already nervous and when I heard that, it was a reminder of all of my concerns——

Phil Prendergast (Labour)
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What if one is the 100th patient?

Feargal Quinn (Independent)
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Yes, one is certainly concerned about that. There are many different kinds of patient care we can undertake. In the past, we assumed care had to take place in hospital and I am delighted to see the changes that are taking place in that context. I remember an experience I had in the former Hume Street Hospital. Staff at the hospital realised that large numbers of those patients who were attending for dermatology and cancer treatment did not need to be in hospital for an entire week to receive one or two treatments. The switch to a day care system was an enormous operational success because it meant a patient could plan to go to the hospital in the morning, receive treatment at 10 a.m., leave by 12 p.m. and return to work. In previous times, patients had to stay in hospital all week long, particularly if they lived outside Dublin.

I learned of a system that operates in the United States from a man who was a patient there. He had to undergo a very important operation but he did not go into the hospital. He stayed in the hotel beside the hospital and he was brought over by the staff to the hospital for the operation. The cost was much different from what it would have been in Ireland. It also resulted in a hospital bed not being used. There are occasions when good patient care can be provided without necessarily using the traditional costly hospital service.

Confidence is very much needed when a patient enters hospital. Many people are afraid to go to hospital because they think they may contract a disease such as MRSA, which is a major concern currently. I am not sure how the Minister will solve this problem.The Health Service Executive and the Minister are doing everything correctly to succeed against MRSA but they have not succeeded to the extent others have elsewhere. I have huge confidence in Professor Drumm. The support given to him by the Minister needs to be backed up. It is easy to knock someone in charge when something goes wrong. I have confidence in him and he needs to be supported with that confidence.

Those who work in hospitals should be reminded of another aspect of care. I had an accident which required a hospital stay. The chief surgeon, doctors, matron, nurses and other staff came into the ward and approached each bed before we were released. However, they referred to each patient by the disease he or she had, not by name. Sometimes attention needs to be paid to little details such as that. That is an aspect of patient care because when patients go to hospital, they are concerned, nervous, uptight and stressed and little things like that can help.

The Minister is getting the support she needs and the support she is giving Professor Drumm is worthy of everything we can do to support that. I have confidence in her and I have confidence we can achieve what we have set out to do. I welcome her contribution.

Terry Leyden (Fianna Fail)
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I am delighted the Minister is present to discuss patient safety. As she will be aware, issues have arisen in County Roscommon again. A report on services at Portiuncula Hospital, Ballinasloe, and Roscommon County Hospital was presented on 10 April at a briefing for members of Roscommon County Council and the Health Service Executive west regional health forum. No courtesy was shown to myself, as an Oireachtas Member, or my colleague, Deputy Michael Finneran, regarding a briefing on this issue. The HSE has issued this report in a cavalier fashion. As a former Minister of State at the Department of Health and former chairman of the Western Health Board, it would have been courteous at least to have been given a copy of the document. I obtained a copy of it which was presented to the management team of the HSE. I hope it will reach the Minister's desk eventually for a decision on the future of acute services at Roscommon County Hospital and services at Portiuncula Hospital.

This issue has gone on for too long. I felt it had been resolved by the Minister in September 2006 when she was well aware of the issues and the proposals that had been put forward. The matter was discussed last night at a meeting of the Fianna Fáil party attended by senior members of the Dáil ceantar, councillors and Oireachtas Members. Having gone through the document carefully, we felt it was not in the best interests of the continuation of acute services at Roscommon County Hospital. The proposal is that all acute services should cease at the hospital and anaesthetists and surgeons should transfer to Portiuncula Hospital.

I was chairman of the health board when we signed a contract for a new state-of-the-art accident and emergency department at Roscommon County Hospital, which was opened by the Taoiseach. Assurances were given by him and other senior political figures at the time that the hospital would be retained as an acute general hospital. The situation is critical. Portiuncula Hospital is between 30 and 50 miles away from most people in Roscommon. It is a fine hospital but it is located close to four hospitals, two of which are private, in Galway thanks to the new national primary route. However, there is an area between Galway and Mullingar which does not have acute services.

The report to which I referred was presented by Mr. Alan Moran to the management of the HSE but it would take more time than I have to go through every aspect of it. At the end of the day, arising from the transfer of all acute surgeons and anaesthetists to Portiuncula Hospital, Roscommon County Hospital will not retain its accident and emergency department 24-7. It would put patients and people in the region at risk. The hospital was used recently following road accidents and young people were saved. According to best practice, a patient should be in a hospital within an hour of an accident occurring, which is referred as the golden hour. Relying on ambulances on inadequate roads is not helpful. Of more than 10,000 patients examined in a study by the University of Sheffield, the risk of death for patients who were unconscious, not breathing or who had chest pains increased by 1% for every six miles travelled. Portiuncula Hospital is 30 miles from Roscommon County Hospital. Is this a justifiable risk of death due to this proposal?

The Minister attended meetings on 12 September 2006 at which she gave commitments on the continuation of acute services at Roscommon County Hospital. In May 2007 the Taoiseach stated services at the hospital would not be downgraded. The statement was confirmed by Professor Drumm at a meeting of the Joint Committee on Health and Children last November. Consultants at Roscommon County Hospital have written to the HSE.

The Minister is well aware of the circumstances of the county hospital, the demand for continuation for services, the upgrading of services that has taken place with the provision of a new accident and emergency department, theatres and a CAT scanner, and the investment that has taken place over recent years. I believed the issue had been resolved and the hospital was working efficiently and effectively. It provides an excellent service to the people of County Roscommon. When I served as Minister of State at the Department, the issue was the closure of the hospital. I averted its closure at a cost politically to myself, but nevertheless it was retained as an acute general hospital with surgical, medial and psychiatric services and an accident and emergency department. The decision was made by the Government at the time and I have that decision in writing.

The downgrading of Roscommon County Hospital will have to be a Cabinet decision because I have no confidence in the HSE to make it. The decision may be based on the Hanly report but senior politicians stated decisions would be based on location and getting safely to hospital. It is a vital issue everywhere and in my region in particular. I appeal to the Minister to examine the issue. She was elected Minister but I did not elect Professor Drumm. The House did not elect him or the HSE board. The Minister must intervene in these issues and take political decisions in the best interests of the people.

Nicky McFadden (Fine Gael)
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I thank the Minister for attending the House again. The last time she was present I referred to the closure of breast cancer services in Mullingar hospital. While we all accept specialised services and centres are needed, I do not accept we should be discriminated against because we come from the midlands. No transport services have been put in place to make it easy for people from the midlands to access services in Dublin hospitals. For example, the people of Longford and Westmeath have to leave home at 6 a.m. to get to Dublin for chemotherapy. This is inhuman.

I spoke previously about a situation where a lady told me she had to get off the train to be sick and then get back on. This is unacceptable. The service that is provided goes halfway around the world picking up patients. The Minister said there would be a revision of transport services. We should have a state-of-the-art, comfortable service that brings patients to Dublin. Will the Minister give me the up-to-date position on that service?

I am also concerned about the primary care unit in Athlone. When I asked the Minister about this the last time she was in the House, she said she did not know anything about it. Does she know anything about it now? There have been further developments. This is an ongoing project on the Clonbrusk site in Athlone. I take my hat off to the local manager who is fantastic and is doing his best with the resources he has. The project has been ongoing since 1999. We were told that it would go to planning and construction stage in April 2007.

Last month we were told the situation had changed and that general practitioners were not interested in being involved in the primary care unit. I worked as a medical secretary for ten years and have experience of making health representations for people but I cannot understand how we can have a primary care unit without general practitioners. The project has fallen further behind. The size of the unit will now be reduced and the project must return to the design and planning stage. This seems like delaying tactics. I ask the Minister to use her offices to engage with the general practitioners. The reason they do not want to be involved in the project is because there has been no compromise and the delaying tactics since 1999 have not inspired confidence.

I am also concerned about an anorexic adolescent from the midlands whose treatment and care in the UK costs the regional health service €500 per day. We have only six adolescent psychiatric beds in Ireland. Will the Minister comment on this? Can we improve the situation? I can only imagine what it must be like for that young person's family with regard to visiting her and keeping in contact.

The departmental website advertises free dental services for all children under 16 years of age. In the midlands area children up to sixth class are treated free. However, we have had a reduction in the number of dentists in the area this year and are now short of one dentist. When I asked about dental services the manager could only say that is the situation. This is unfair. If we want to encourage good dental care, we should be able to offer those under 16 free care.

On the issue of the pharmacists, what will happen in the event the strike goes ahead. I know issues can be resolved at the last minute and I hope this happens. The Minister is very capable——-

Geraldine Feeney (Fianna Fail)
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On a point of order, I thought we would have our question and answer session at 6.50 p.m. and that this debate was on patient safety.

Nicky McFadden (Fine Gael)
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The issues I am raising are all relevant.

Paddy Burke (Fine Gael)
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That is not a point of order, Senator Feeney.

Liam Twomey (Fine Gael)
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If someone is given the wrong drug on 1 May, we will know all about patient safety very quickly.

Nicky McFadden (Fine Gael)
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What provisions have been put in place for patients if the strike goes ahead? When I asked the Health Service Executive this question, I was told that Boots would be able to look after 23,000 people in the midlands area. The issue is a matter of grave concern to the people, especially with regard to their safety. One pharmacist to whom I spoke today told me about an epileptic child whose drugs were being brought in from England at a cost of €1,200. She said she was at the loss of €100 in dispensing that one product. What will happen in this situation and how will that child access those drugs next month?

There are many other issues. As Senator Quinn said, the Minister has a difficult portfolio. She is doing the best job she can but the area is a quagmire. I hope she will respond as best as she can. I am not, as Senator Feeney suggested, trying to personalise the situation. It is important we get answers for the people we represent.

Pearse Doherty (Sinn Fein)
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The theme of these statements is patient safety. I believe the biggest threat to patient safety is the grossly inequitable nature of the health service presided over by the Government for the past 11 years. Patient safety is the biggest issue of concern for everyone and the biggest failure of the Administrations in which Deputy Harney has served as Tánaiste and Minister for Health and Children.

There is a tendency to personalise the issue and target the Minister, as if she were solely responsible. That is very convenient for other Members of the Government, especially the Fianna Fáil Members. They, too, bear full responsibility for the disgraceful state of our public health services and for the disastrous policies that have led us to this situation. The members of Fianna Fáil and the Green Party now hide behind the Minister for Health and Children, Deputy Harney, trying to dodge their responsibility for health services. The Minister in turn hides behind the Health Service Executive which is the most unaccountable quango and most monstrous bureaucracy ever established in the State.

We all owe a significant debt of gratitude to the late Susie Long and her family because she exposed the reality of the two-tier public private system. As a public patient she was denied timely access to a diagnosis that could have saved her life. She found this out when she talked to a private patient sitting beside her in a hospital waiting room. The Taoiseach and the Minister said the system failed Susie Long. This was not just an unusual error. This is the way the system is built. It is a public-private system of apartheid and the Minister, the Government and their colleagues are reinforcing it. They are pouring public money into privatised health and co-locating for-profit private hospitals on public hospital sites. We will never know how many Susie Longs there have been but there must have been thousands. These are the people who were denied timely diagnosis and hospital care and timely access to a range of services because they were public patients.

MRSA and other virulent hospital-based infections are major issues for patient safety. This was thrown into stark relief by the release of the first national hygiene services quality review by the Health Information and Quality Authority last November. It states that the majority of public hospitals need to improve their hygiene standards dramatically. The report states that just seven out of 51 hospitals have good hygiene standards while none was found to have very good standards. Nine hospitals were rated as poor and the remaining 35 rated as fair.

The HIQA states the findings show that most hospitals need to take measures to improve standards. The need for more single rooms and isolation units to combat MRSA was identified as far back as 2001, but no action was taken. Accident and emergency units and wards are under constant pressure and the highest standards of hygiene cannot be maintained. As a result of the privatisation of hospital cleaning services, the standards of cleanliness have not been maintained. Cleanliness and hygiene should be an integral part of every hospital's work, with cleaning staff employed by the hospital and part of the hospital team.

Sinn Féin calls for an effective national strategy against MRSA to be delivered locally in every hospital and nursing home and every other care setting. Patients must be fully informed when they have MRSA and deaths attributable to MRSA should be recorded by coroners. The prevalence of MRSA is one of the reasons the promised 3,000 additional hospital beds must be delivered. Single rooms and isolation units should be included in that figure.

On the pharmacy dispute, thousands of patients are concerned that from next Thursday they may not be able to get their medication. I ask the Minister, Deputy Harney, to outline plan B. I understand the Minister's plan B was to take these pharmacies to the High Court. However, many pharmacies have not responded and the deadline passed yesterday. Therefore the Minister's only option is to take these pharmacies to the High Court. If the Minster fails in the High Court, what will happen next Thursday? The option of Boots providing the service is unlikely as I understand it has informed the Minister that it will not be able to cater for the demand. In Donegal alone there are 55,000 prescriptions every week under the medical card scheme. I ask the Minister in terms of patient safety, what is the plan B that will assure patients they will get their medication after 1 May.

Mary White (Fianna Fail)
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I wish to speak on two issues. Five years ago I used to visit an elderly man in St. James's Hospital. I have spoken previously on this issue in the Seanad but I did not name the hospital. This evening I will name St. James's Hospital and praise the Minister, Deputy Harney, for the transformation I have seen over these five years. When I first visited the hospital, I could sense it was not clean. When a building is thoroughly clean and washed properly with soap and water and whatever is required, it is clear to see. There is no odour in the air, which is what I found there. When the Minister, Deputy Harney, started the programme on the improved cleansing of hospitals, I did not notice a difference in St. James's Hospital after the first audit. However, by the time of the second audit there was a transformation in the hospital. I compliment the Minister, Deputy Harney, on progress. In my experience of visiting St. James's Hospital over five years I have seen a transformation in the cleanliness. The Acting Chairman, Senator Feargal Quinn, knows as a businessman and food producer how important cleanliness is. It was said earlier how important hygiene is in the area of health. However, as a food producer I know the standard of cleanliness must be 100%.

Although it is not related to patients, the Leader advised me that I could raise the matter of suicide prevention in Ireland. The agreed programme for Government has adopted a target of reducing the rate of suicide by 20% in 2012. The programme says we will implement as a matter of urgency the recommendations of the Oireachtas Joint Committee on Health and Children to deal with the high levels of suicide in Ireland. I presume our mission is to implement the programme for Government. The programme also says we will implement urgently the recommendations of Reach Out, the Government's national strategy for suicide prevention. I am afraid we will not reach the target of a 20% reduction by 2012 unless we have action locally.

The bottom line is there are 11 positions for the post of suicide officer in the country. The job is to integrate with the local communities and do everything possible to prevent suicides happening in communities. At present there are three vacancies for the position of suicide prevention officers throughout the country, one each in Naas, Bray and Ardee. I will meet with Dr. Doorley next week. The Minister, Deputy Harney, knows the man in question. I spoke to him on the telephone and I want to know when the positions will be filled. I do not care whether there is an embargo on filling positions. I want to know, as a business person, the reason he cannot get three people out of the 100,000 people employed in the Health Service Executive and move them into those positions. I will meet him next week and I told him to have his answer ready. I want to see this happen.

Jerry Buttimer (Fine Gael)
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Hear, hear.

Mary White (Fianna Fail)
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This is common sense and a no-brainer. Surely there are three people in this country working for the HSE who would love to help people locally in the area of suicide prevention. I again compliment the Minister of Health and Children on the progress in St. James's Hospital. In my experience it is now impeccably clean.

Jerry Buttimer (Fine Gael)
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In the Acting Chairman's eloquent remarks he said we should accentuate the positive. Let us do this. The Minister, Deputy Harney, has had great success. She has billions of euro at her disposal, a committed staff and frontline services run by excellent people who work around the clock on our behalf. However, these people feel let down. They are worried and frustrated but, more importantly, the biggest threat to patient safety is the Health Service Executive. I wonder if the Minister, Deputy Harney, is not on a "mission impossible". I do not know if she is a James Bond fan, but I do not think the people around her resemble 007, whatever about the Minister. Senator Pearse Doherty is correct to say that the people alongside the Minister are using her. They hide, blame and love to hate her. I hope the future Taoiseach will move the Minister, Deputy Harney, from the Department of Health and Children and put one of his cronies in there, because they deserve——

Mary White (Fianna Fail)
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He will not.

Jerry Buttimer (Fine Gael)
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——to be held to account as they are equally as guilty as the Minister, Deputy Harney. The Fitzgerald report on the HSE paints a poor picture. In 2004 the Minister, Deputy Harney, said that it was "a-once-in-a-generation event ... our generation's chance to put patients first in the design of the management of health services". Who will accept responsibility? The former Minister for Health and Children, Deputy Micheál Martin, sure as heck did not. He ran from everything, commissioned report after report and denied everything when he appeared before the Oireachtas Joint Committee on Health and Children and was asked a straight question about responsibility. This is what the former Minister, Deputy Micheál Martin has done. Fianna Fáil members do not want to know anything about health. They are pleased with Deputy Harney as Minister for Health and Children because she is honest and sincere.

The Minister should not allow herself to be painted as the bad girl of politics, so to speak. Consider what is happening with the Mercy University Hospital, Cork. A sum of €5 million has been spent on a new accident and emergency department, yet it will only open from 8 a.m. to 8 p.m.

There has been a systematic failure by the HSE to address the ongoing concerns of patients, staff and ordinary citizens. This is not make-believe; it is real. When canvassing every day on the streets of Cork, I hear horror stories about MRSA, people getting sick in hospital, lack of patient care and neglect of duty in hospitals. Senator Frances Fitzgerald spoke eloquently of different people. This is all about people. They are not statistics or stories but real people. The HSE is letting people down. Human beings deserving of dignity, treatment of care and respect are not being given these. Errors, systems failures and lack of communication should not happen but they do time and again.

Can the Minister explain the reason that after 12 years of this Government and billions of euro spent on health, the common currency used by ordinary people is the quality of our service? Will the Minister say why this is the case? She is far more intelligent than I am. Billions of euro have been spent and surely we should have a health service of which we can be proud rather than having people ringing up Joe Duffy or Neil Prendeville in Cork or going to the newspapers and having to raise funds for equipment. Why is this the case? I ask the Minister to answer my question because I certainly cannot figure it out.

I ask the Minister to accept the Health Service Executive has been a monumental failure and she should pack it away and start again. She would have cross-party support for this action.

Paddy Burke (Fine Gael)
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The Leader gave the impression on the Order of Business today and last week that the Minister for Health and Children would answer any questions from Members about health issues. I have no doubt the Minister is well qualified and well able to answer any question that is put to her.

The Minister has come to this House many times and I compliment her because she always speaks off the cuff. She knows the system inside out and she is familiar with every aspect of the health system. What is wrong with the system? The Minister is much better informed than us to answer that.

There is something seriously wrong within the Health Service Executive because it is not working. It has been brought to my attention recently that under the former health board system, when people were going for promotion, the human resources officer or the senior staff nurse would make the recommendation and the chief executive officer for the district would sign off on it, but I understand that now in some cases it can involve up to ten different stages for a person to be granted promotion or for human resource decisions to be made. This is unbelievable and unrealistic.

I was informed recently that the Minister for Foreign Affairs and Mark Durkan, MLA, the leader of the SDLP, stated that the centre of excellence in the north east should be situated on the Border. It is outrageous that the Minister for Foreign Affairs should even be associated with this statement. If there were to be any centre of excellence along the Border, it should be placed in the Sligo-Leitrim-Fermanagh area in that blackspot which has no hospital cover. The golden hour is not covered in many cases in the north west.

When will the centres of excellence be established and funding put in place? It is quite clear that adequate funding is not being put in place. Everyone agrees Galway should be the centre of excellence in the west. I refer to the problems in Galway, not least of which is parking in the city centre. It is a nightmare for people visiting patients and it is sometimes necessary to park on the Headford Road which is miles away. Even at this late stage the Minister should revisit the issue of Castlebar and Sligo as satellites of Galway and the case has been well made by the people of the west.

The pharmacy dispute is heading for disaster on 1 May. Nobody seems to know what will happen. What are the contingency plans in place for County Mayo, the third largest county in the country? Will these be administered from Castlebar General Hospital? How will people get their medicines? I hope the Minister will allay the fears of the people with respect to the pharmacy dispute. The HSE is wrong not to engage in discussions with the pharmacists who have a lot to offer in this dispute. There are many ways in which the HSE and the Department of Health and Children can save money. If the pharmacists were given the opportunity to put their case in a proper fashion to the HSE and if the executive were to listen to them, the dispute could be resolved and there would be substantial savings for the health budget and the Department.

Paul Bradford (Fine Gael)
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I welcome the Minister to the House. We hear from her regularly and we are thankful for her attendance. Unfortunately the problems which she has come to address seem as if they are almost beyond repair and this is not politically acceptable. It is quite extraordinary that notwithstanding the huge economic boom and the significant investment across the length and breadth of the health service, we must report that two decades after the political sloganeering from Fianna Fáil about health cuts hurting the old, the sick and the poor, the cuts seem greater than ever, the service seems less and we have serious questions to ask.

When the Minister set in train the proposals to create the Health Service Executive as a new entity, I would have been a supporter. I saw the significant difficulties associated with the old system of the health boards. I had presumed the new system would be much more effective, cost-effective and efficient. I regret to say my judgment appears to have been misplaced. We now have a monster which appears out of control. The service to the public is certainly diminished and staffing levels have not altered in any sense. I note that a senior grade which formerly had six or eight persons now has hundreds of people at that level.

The taxpayer is investing enormous sums in the health service and he or she appears to be getting very bad value for money. Patients and the public are not receiving the service they deserve. The funding of the health service could be a subject for a broader debate. From a European and international perspective we are not spending the proportion of national income on the health service which is needed to put in place an improved system. I concede that the current level of expenditure is substantial but the taxpayer is right to ask where the money is going and the patients are right to ask where the service has gone.

I concur with my colleagues' fears about the outcome of the pharmacists' dispute. If I may be excused the use of a pun, I cannot prescribe a response. All we can ask for is dialogue. Whether it relates to the politics of Northern Ireland, Europe or any issue facing us, dialogue is necessary and important. We need to re-engage in dialogue with the pharmacists.

I wish to make some parochial points. I concur with Senator Buttimer's remarks about the Mercy University Hospital in Cork city. It makes very little sense that the public has spent so much money and the service is not available. The Minister will be aware of the excellent hospital in Mallow which last year was given the award for the cleanest hospital in the country. There are grave fears in Mallow about the future of the hospital. No one seems to be in charge of the budget or of making decisions fundamental to keeping Mallow as a positive general hospital for the town and the north Cork region. I extended an invitation to the Minister to visit the hospital to see at first hand what a small hospital can do effectively and efficiently. I again ask her to consider a visit to a hospital such as Mallow in the near future.

I apologise for straying beyond the issue of patient safety but this debate will need to continue because it is the biggest issue facing the public in this post-Celtic tiger era. Where has the money gone and how do we plan for the future to give the public a service to which it is entitled?

Paddy Burke (Fine Gael)
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As agreed on the Order of Business, I will call each of the leaders of the groups to put a further brief question to the Minister.

Geraldine Feeney (Fianna Fail)
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Like other Senators, I welcome this type of debate where the discussion is followed by a question and answer session with the Minister. I am sick and tired of asking on the Order of Business about services for eating disorder sufferers and I am sure Members are fed up listening to me calling for a debate. It is not the Minister's fault that this urgently required debate has not taken place. I am sure I speak for all Senators in saying we would be pleased to have the Minister return to the Chamber for a debate on eating disorder services that would take the same format as today's discussion. I have often said in this House that an eating disorder is a matter of life and death for the sufferers and their families. I and other Members have met such people and it is heart-rending to hear their stories. They are effectively going around blindfolded and with their hands tied behind their backs because there are only six adolescent public beds and 12 private beds between St. John of God Hospital and St. Patrick's.

It is not a large lobby group but the work being done behind the scenes by Bodywhys is incredible. It is the most dignified lobbying organisation I have met. Its members do not have much money and do not have loud voices but their hearts certainly are in the right place. They have been very patient as their hopes of receiving support have been disappointed time and again. Will the Minister agree to take part in a debate on this issue?

In regard to the pharmacy dispute, I have been contacted by only one member of the public but by several pharmacists. There is undoubtedly misinformation abroad and people feel vulnerable and fearful. I ask the Minister to clarify the pharmacists' claim that in dispensing a box of insulin, they are now down €8 on the price charged them by the wholesaler. I disputed that figure but one pharmacist offered to send me the invoice from the wholesaler and the documentation showing the corresponding amount he has received from the Health Service Executive.

Frances Fitzgerald (Fine Gael)
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The Minister has had so many questions that it is clear we need more time for a debate on all the major pillars of the health service.

Senators:

Hear, hear.

Frances Fitzgerald (Fine Gael)
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Members on both sides of the House have raised issues of serious concern but the Minister will not be able to address them in the time available. It is clear that the policy pursued by Fianna Fáil and the Progressive Democrats in the past ten years has failed to deliver adequate health services. I would like to say more about this but there is no time to do so.

What action has the Minister taken within her Department to lead reform of the Health Service Executive in light of the Fitzgerald report? What will be the scale of future cutbacks and how will the Minister prioritise the areas in which those cutbacks will occur? Will cutbacks be confined to administration or will they continue to affect frontline services? I urge the Minister to clarify the situation. Members are hearing daily how cutbacks are affecting constituents.

Phil Prendergast (Labour)
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My questions relate to specific issues. In response to a question last year on the ambulance service in Carrick-on-Suir, I was told a review of the service would be completed last September or October. What is the status of this review? I also await a satisfactory response to my question about the future of maternity and gynaecological services at South Tipperary General Hospital. In addition, a review of maternity services in the Dublin hospitals was to be completed in December but I understand that report has not yet come to light.

I join Senator Feeney in expressing my concern at the lack of adolescent psychiatric beds for persons suffering from any psychiatric disorder, whether an eating disorder, depression or another illness. I receive representations on this every week. The high rate of suicide among young people is a matter of great concern. I apologise for being parochial but my colleagues have addressed the main national issues, namely, the pharmacists' dispute and the Health Service Executive cutbacks which are affecting people in all areas.

Mary Harney (Dublin Mid West, Progressive Democrats)
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It would take me an hour to answer all the questions posed. Instead, I will make several observations with particular focus on the point made by Senator Quinn and others. Life expectancy is one of the international measures used to compare health systems. Between 1999 and 2003, life expectancy in Ireland increased by three years. A child born in Ireland today will live longer than one born in the United Kingdom, Belgium, the Netherlands, Germany or Denmark. That is a measure of achievement. The numbers dying from heart disease in the State have dropped by 54% in the past eight years. The survival rates for pancreatic cancer have improved by 31%, by 24% for prostrate cancer, 14% for lung cancer, and 9% for breast cancer. The OECD recently described this improvement as one of the fastest in the world. We are top of the class in regard to children's cancer, ahead of the United States and the rest of Europe.

I make these points because one might have an entirely different impression of the health service based on the debates in these Houses. One aspect of the problem in this regard is that some of those working in the public health system like to criticise it. That is quite unusual. One never hears a member of staff in a private hospital criticising that institution in public. However, such criticism is frequently heard in the public health system. It is a great pity.

Criticism was directed at me yesterday in view of the announcement that a private company's contract to supply hospital in the home services was not being renewed. I am normally criticised because such contracts are being given to private companies. That was mentioned during this debate. The reason the contract is not being renewed is that we have capacity within the public system to provide the service.

In regard to the dispute between the Health Service Executive and pharmacists, we all would agree that health care professionals, above all else, take their ethical responsibility seriously and generally put patients first. If there is an industrial relations dispute or, as in this case, a dispute over money between the HSE and pharmacists, the priority must be that patients should not suffer. We are all entitled to expect that. Pharmacists receive €100,000 more per year in dispensing fees than their counterparts across the Border. Furthermore, it costs us €600 million, a margin of 17% to 18%, to take €1.1 billion of drugs from the producers to the patients. I am not an expert on Senator Quinn's business but I doubt he would pay €600 million to take €1 billion of product to customers. It is a huge margin and double the EU average.

We are not reducing the money going to pharmacists. Our objective is to stop the huge rise in the cost of drugs. The cost is rising so rapidly that it has the capacity to consume all the additional money we can make available to the health services. The agreement between the 1,600 pharmacists and the HSE is to get a dispensing fee for the general medical service, GMS, scheme of €3.27, a dispensing fee for the drug payment scheme and a 50% mark-up. There is no agreement between the pharmacists and the HSE to pay a distribution fee for anything. Nor is there any agreement between the wholesalers and the HSE in regard to distribution. When the HSE recently put to tender the contract for the distribution of certain products, the successful company won it on the basis of a 4% margin.

I established a three-person group because the Irish Pharmaceutical Union, IPU, representatives made the case to me that the HSE is the procurer of 70% of the service they provide and that an independent process was required. I put in place a group of three led by Mr. Sean Dorgan, former chief executive officer of the IDA and Secretary General in two Departments. The group also includes Mr. Mark Moran, who previously worked in the pharmaceutical sector and was formerly chief executive officer of a Dublin hospital, and Ms Mary O'Dea, consumer director of the Irish Financial Services Regulatory Authority. These are all highly regarded individuals. They have been given until the end of May to report on this issue. IPU representatives met the group last week, as have other interested parties. I appeal to pharmacists to give that group a chance. We are talking about a matter of four weeks from 1 May. I really hope that can happen.

Fidelma Healy Eames (Fine Gael)
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What about the dispensing after 1 May?

Mary Harney (Dublin Mid West, Progressive Democrats)
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I hope the Senator will agree with me that patients should not suffer.

Fidelma Healy Eames (Fine Gael)
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Absolutely.

Mary Harney (Dublin Mid West, Progressive Democrats)
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We pay dispensing fees of €100,000 more per pharmacist than they do in Northern Ireland. That cannot be sustained.

Fidelma Healy Eames (Fine Gael)
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Who will dispense?

Mary Harney (Dublin Mid West, Progressive Democrats)
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I do not envisage that we will have those issues. I certainly hope we will not.

Fidelma Healy Eames (Fine Gael)
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They are already waiting.

Mary Harney (Dublin Mid West, Progressive Democrats)
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The contract of employment requires three months' notice. The HSE wrote to pharmacists last week. I understand a number of them indicated they are considering whether to dispense. They have not said they are withdrawing their services.

Fidelma Healy Eames (Fine Gael)
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I have the letters.

Mary Harney (Dublin Mid West, Progressive Democrats)
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Yes, I know that. I understand the five pharmacists who said they intended to withdraw their services have now said they will not do so. A great deal of dialogue is needed. It is an industrial relations issue. I do not want to add to the difficulties being experienced by both sides. My view is that it would not be professionally or ethically acceptable for patients to suffer. Patient safety is at the heart of what pharmacists do when they dispense medication. I believe that pharmacists take that responsibility very seriously. I have a very high regard for pharmacists. As Senators are aware, I resolved the conflict between pharmacists and general practitioners in the legislation that was passed and welcomed by many pharmacists. We want pharmacists to have an enhanced role.

Fidelma Healy Eames (Fine Gael)
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Does the Minister have any contingency plans?

Paddy Burke (Fine Gael)
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I ask the Senator to allow the Minister to continue. She has many questions to answer.

Mary Harney (Dublin Mid West, Progressive Democrats)
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I was also asked about ambulance and maternity services, etc. I understand that Senators are naturally concerned about their individual localities. We are too often obsessed with where things happen rather than what happens. Patient safety has to be paramount. It is a fact that it is not safe for a person who goes to an accident and emergency department at 10 p.m. or 11 p.m. to be seen by a junior doctor. When people talk about the "golden hour", they are not talking about the time within which one should be brought to a place called hospital but about the need to access expertise as quickly as possible. If one has a stroke, one needs to be given certain medication within three hours.

Paddy Burke (Fine Gael)
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I ask the Minister to conclude.

Mary Harney (Dublin Mid West, Progressive Democrats)
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As I have said, I could answer more questions. I will be more than happy to come back to deal with some of the other issues on another occasion.

Terry Leyden (Fianna Fail)
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We need more time for this debate.

Mary White (Fianna Fail)
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More time is needed.

Jerry Buttimer (Fine Gael)
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The Senators on the Government side stayed quiet on the Order of Business.