James Reilly (Dublin North, Fine Gael)
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The Higgins report on the establishment of hospital groups, which I launched on 14 May, is the most radical and fundamental modernisation of our health system infrastructure since the State's foundation. To achieve the most effective high quality outcomes for patients in the most cost-efficient manner possible, reform of the structures and governance for the delivery of hospital services is now vital.

The report was informed by consultation with management and senior clinicians from hospitals, patient advocates, health agencies, and the clinical programmes, among others. Detailed data analysis also informed the report recommendations. It is important to make special note of the clinical programmes which have been instrumental in improving our health services, in conjunction with front-line staff and supported by the special delivery unit. The stroke programme and the congested heart failure programme were mentioned in the keynote address in Oregon last year by Don Berwick, who was Barack Obama's health spokesperson. Since the stroke programme came into being, we have moved from the bottom of the list in Europe for thrombolysis, the administration of clot-dissolving drugs, to the top and we now save an extra life a week and pre-empt the need for three people a week to go into long-term care.

We know the traditional practice of providing as many services as possible in every hospital is neither sustainable nor safe. The formation of Irish acute hospitals into a small number of groups, each with its own governance and management, will provide an optimum configuration for hospital services to deliver high quality and safe patient care in a cost-effective manner. By cost effectiveness I do not mean saving money for the sake of money but saving money to have resources to treat more patients more quickly.

The organisational structures and system of governance in the Irish hospital sector are unsatisfactory. Many Senators will say this is an understatement, because the governance of many of our hospitals in the past has not been at the level it should be. The investigations by the Health Information and Quality Authority, HIQA, into Tallaght hospital and the occurrences there exposed a huge weakness in governance which has helped us learn how better to govern our hospitals. We now have very clear direction on how this should be done.

The existing organisational structures have restricted the development of the management systems and leadership we require to run a world class national hospital network. In reforming the organisational structures for hospital services, I want to take the best elements of governance and autonomy found in our system to create a new governance framework which can yield the benefits of increased independence and greater control of local clinician and managerial leaders to every hospital in Ireland.

We look to ourselves to solve our problems but we also look outside our country. We are a small island nation and we can and do learn from others. In this respect, I thank Sir Keith Pearson for the work he did on governance while the chair of Tallaght hospital. I must also mention Professor Higgins and the huge amount of consultation he did on this issue. A total of 75 formal meetings and more than 70 informal meetings were held.

Since the Government approved the groups' establishment in May, there have been more than 50 additional meetings. I have visited each hospital group to address staff, including clinicians and community staff. We had good interactions. As I told them and as I am happy to confirm on the floor of the Seanad, this is the beginning of a conversation that will continue. People can feed into an e-mail address as they encounter problems on the ground and conceive solutions. The people who deal with our problems on a daily basis are the best placed to deal with them.

The success of the special delivery unit, SDU, was that it visited the front line and the clinical programmes, listened to what people had to say, assessed their suggestions and told them whether their suggestions would work, could work if they were less expensively priced or would not work.

In reforming the organisational structures for hospital services, I want to take the best elements of governance from around the world. As well as benefits in terms of safe, high-quality patient care and cost effectiveness, other key benefits that will arise as a result of the establishment of groups include stronger governance and management structures at the hospital level; an end to hospitals providing the same services unnecessarily within the same geographical area, that is to say, duplication; a concentration of complex services at appropriate hospitals in order to ensure quality; and efficiencies through the avoidance of duplication in terms of HR, finance, etc.

As I have often stated, the idea of model 2 hospital work such as hernia repairs, gall bladder surgery and so on being done in model 4 hospitals is grossly inefficient and is not cost effective. It is like bringing one's ten year old Volkswagen to the Ferrari testing centre. The centre will surely do a great job, but the same job could be done more conveniently and with a great deal less cost at one's local garage.

I am mindful of people's nervousness about the status of their smaller hospitals. Even though the small hospital framework document has been ready for some time, its publication was delayed to coincide with the major hospital groups. The two are inextricably interlinked. The framework demonstrates clearly that the future of smaller hospitals is secure. The establishment of the groups will see small and large hospitals working together as one. This is a key step on the way to the introduction of universal health insurance. There will be a live-in period, as it were, and trust formation lasting 18 months. The groups will be reviewed by the Department of Health to ensure that they are delivering better outcomes for patients as intended. For the CEO of each group, the other key performance indicator will be the amount of resources and worth that have been returned to the smaller hospitals.

When the groups are established, services can be exchanged between sites in line with overarching policy and the group's strategic plans. This will result in the maintenance of activity in smaller hospitals, allowing them to focus on provision of safe and appropriate care. A significant increase in the volume of activity in smaller hospitals is the expected result of these service improvements. One need only consider Louth County Hospital or Roscommon hospital to see the greater range of safe services that they offer to their local populations. At the same time, more complex operations and procedures are kept in those hospitals that are better positioned to deliver them.

The implementation of the recommendations of the group's report has commenced. In the past two weeks, I have visited all of the areas alongside the director general designate of the HSE and officials from my Department. We explained the policy objectives and listened to the staff's questions. This process has been useful and informative and the reaction has been overwhelmingly positive. Since the Government approved the groups' establishment, Professor John Higgins has also been carrying out briefings.

The implementation will be overseen by a national strategic advisory group, which will shortly be appointed, and be driven by the HSE. This group will provide guidance and ongoing direction in respect of the implementation of the hospital groups report and the smaller hospitals framework. It will also provide a forum to resolve issues and assist in the development of specific implementation guidelines on the steps required for full implementation.

I will appoint chairs to each group in the coming weeks. Advertisements to seek other board members will be placed in parallel with this process and the subsequent appointment of group CEOs and management teams. Each appointment will be made based on the competencies an individual brings to the board in line with the Health Information and Quality Authority, HIQA, report on Tallaght, but that will not prevent appropriate representation of the geographical areas in the group. The need to ensure primary and community care is also covered by board membership.

Within one year of the formation of hospital groups, each group will be required to submit a strategic plan that will outline its plans for future services within the group. These strategic plans will determine the way services are provided within each group. Critically, each group will develop its own plan. It must also decide on a new name. We have divided them geographically for indicative purposes. Having visited the Limerick mid-west area, I am aware that its group has determined its new name, that being, "University Limerick Hospitals". Its chair and board are in place and have met three times. The group is well advanced.

It is good that there will be seven groups, including the national paediatric hospital group. That they will operate differently in various fields will provide each an opportunity to learn from the others. Furthermore, instead of having 49 managers and management structures, we will only have seven, six of those in adult services. I intend to ensure that there will be regular meetings between these seven CEOs so that they might exchange ideas of mutual interest.

One of my main criticisms of the HSE previously related to the fact that, despite being a monolithic body that was supposed to deliver uniformity across our services, it did not. Excellence in one hospital was not transposed to other hospitals. A good way of handling scrubs in one hospital was not followed in other hospitals. One hospital's approach to staff was not taken elsewhere. Why are there nine nurses per health care assistant in some model 4 hospitals but only 2.8 per health care assistant in others?

The implementation of these plans by each group will be rigorously reviewed, including all necessary due diligence checks, to determine whether the groups are in a position to advance to hospital trust status after the necessary legislation is put in place, which is planned for 2015. As Mr. Tony O'Brien, the HSE's director general designate, has stated, trust status is not guaranteed. It must be earned and groups must reach the bar.

The Higgins report represents a major milestone in the health reform programme. I am confident that the new groups will help to deliver a more effective and efficient hospital service for patients with better outcomes. If all we do is predicated on better outcomes for patients, we will not stray too far from the right path. Although we have developed some measurements of hospital outcomes, we need more. Measurement is also light in primary and community care. I have invited those involved in these areas to join the Department and the HSE in developing outcome measurements so that we can focus more on those activities that we know improve outcomes for patients and less on those that do not.

By way of a rhetorical question, why is it that, when we have some of the best doctors, nurses and managers in the world, we do not have one of the best health services? The reason is that the health service was allowed to evolve in a chaotic fashion. We are trying to put order on it in a way that allows those who work therein to deliver of the excellence that they have been trained to deliver, are capable of delivering and want to deliver. It is frequently reported to me that people are frustrated by their inability to do their jobs because of the system in which they must work. We want to remove this frustration. For this reason, our meetings have been important and the e-mail address will be important. The reform is ongoing and will be informed by those who work in and use the service.

Marc MacSharry (Fianna Fail)
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I welcome the Minister to the House and thank him for making time to be with us today. As the Minister is here, I wish to raise a different issue to the one being debated today. While I appreciate that this is, strictly speaking, an issue for the Minister of State, Deputy Kathleen Lynch, I ask that the Minister's office would make inquiries into the delay of the transfer of the management of Cregg House and the services it provides to people with severe and profound disabilities. I gather there is a very serious delay in that regard. A price-comparison was done by the HSE and Wisdom Services which showed that the services provided by Wisdom Services at Cregg House were €40,000 cheaper, per user, than those provided at HSE-run facility at Cloonamahon. Wisdom Services has announced its intention to discontinue service provision because it cannot afford to carry on. The HSE tried to replace Wisdom Services with other operators but none were interested because of the lack of funding. The HSE agreed to take over the provision of services itself. A statement was released by Wisdom Services today to the effect that the HSE is playing games with this issue. While I appreciate that this is Deputy Lynch's area, I ask the Minister to have his officials investigate the delay because the uncertainty for the service users and their families is of grave concern. I apologise for taking advantage of the Minister's presence to raise that matter.

On the surface of it, most people welcome the idea of hospital groupings, with shared services, shared expertise, centres of excellence and so forth. However, a number of questions require answers. When is the licensing going to take place? When will the legislation for the licensing come before the Houses? It is not on the legislative programme for 2013 so will it be published in 2014 or later? Who will the hospital groups report to? Further down the line we will see the development of hospital trusts but will they be independent republics, capable of doing whatever they want, with no connection to the government of the day? Will we merely provide the money for the hospital trust and allow the trust to spend it as it sees fit or will there be some level of responsibility attaching to the Minister for Health for the trusts? What is envisaged in terms of the reporting structure? That is somewhat uncertain at present. In 2015, the HSE will no longer exist and I am interested in what will happen at that point.

The two reports published recently on hospital groupings refer to smaller hospitals, of which there are many in this country. The Minister claims that the future of such hospitals is now secure because they will be carrying out certain types of procedures and discontinuing others. The difficulty I have with this, as someone from the north west, is that a different sub-structure will be required for Letterkenny and Sligo because of the unique geographic challenges of that region, which the Minister, Professor Higgins and many others have readily acknowledged. I have concerns about the power shift to Galway. Having researched health in this country in recent years, it seems to me that medical politics would put these Houses in the ha'penny place in the context of the manoeuvring that goes on. Consultants try to build up the numbers attending their particular hospital to show that they are doing more cases, can achieve better outcomes and so on. Under the proposed hospital grouping for the north west, the power focus would shift to Galway. However, as one oncologist said to me recently, Galway is already beyond capacity. That is just in terms of cancer treatment. Inevitably, if Galway has the budget and the CEO, it stands to reason that it will come first. If two sitting rooms in two houses need to be wall-papered, obviously one will do one's own first before doing the one down the road.

The level of expertise that will be available to hospitals like those in Letterkenny and Sligo will be hampered down the line by the fact that the centre of power is elsewhere, namely, in Galway. Rather than extend the clinical programmes that are so celebrated throughout the country in the context of cancer care and cardiology, we still have no plans or indeed any indication that we will have any cardio-catheterisation laboratory facilities in the north west. There is no centre for radiotherapy. Professor John Crown will testify, I am sure, that in the United States they would not leave 250,000 people without access to radiotherapy or cardio-catheterisation laboratory facilities but we are doing that. I must say that the previous Government is just as guilty in this regard as the current one, if not more so. There has been a tendency to take refuge in the notion of co-operation with Northern Ireland on this issue but that is very sketchy.

At the briefing in Buswell's Hotel with Professor Higgins I was shocked when I questioned him about the situation pertaining to Galway, Sligo and Letterkenny. The Minister attended that briefing himself and would have heard Professor Higgins saying that he hopes that "existing synergies" between those hospitals will continue but that in the fullness of time, the road to Galway will improve. This is a Professor of medicine who, in fairness, did a very thorough job in going around and meeting everybody concerned. He attended approximately 150 meetings and I welcome his report. However, if this is the vision for the delivery of health care in the north west of the country then I have a real problem with that. The current Minister for Health was the best campaigner, when in Opposition, for a better health service, and would not have accepted medical professionals telling him not to worry, that the approach to improving health services in the north west would be to do up the roads. Surely the people of the north west are entitled to a little more than that.

Caít Keane (Fine Gael)
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Cuirim fáilte roimh an Aire chuig an Teach seo le haghaidh an díospóireacht an-tábhachtach atá ar bun againn inniu. I am speaking today on behalf of my party's health spokesperson, Senator Colm Burke, who cannot be here today and who sends his apologies. I commend the Minister for Health on the launch of the report on hospital groupings. The Minister has signalled the fundamental modernisation of the organisation of our health service, in line with best practice internationally. The traditional practice of providing as many services as possible in every hospital was neither sustainable nor safe. We must ensure that everybody who goes into hospital is safe, first and foremost and that the services being provided are sustainable. The formation of acute hospitals into groups, each with its own governance and management, will provide an optimum configuration for hospitals to deliver services to a very high standard in a way that is safe, efficient and cost-effective and I hope that when the Minister returns in a year's time, my words in this regard will be proven. The current organisational structures have restricted the development of hospital management systems and the leadership we require to run a world-class national hospital network. In reforming the structures the Minister has promoted new governance structures that will yield benefits from increased independence and greater control. Leadership is important in every hospital and the new structures will give autonomy, power and responsibility in terms of the duty of care to the leaders of the hospital groupings. I visited Tallaght hospital recently with the Minister and was very impressed with the grouping I was shown that day. The management system in place there now, under Dr. Eilish Hardiman, is most impressive and the figures in Tallaght speak for themselves.

In drawing up the hospital groups report, consultation was a priority. All of those on the ground in the hospital system, including consultants, management and so forth, were all consulted in the drawing up of the Higgins report. The aim of all hospital groups is the delivery of cost-effective hospital care in a sustainable and timely manner. At the aforementioned briefing in Tallaght, I discovered that the hospital in Naas, which is now part of the Tallaght hospital grouping, is doing marvellous work with stroke victims using the latest technology and in co-operation with other hospitals in its group.

The Minister made reference to the possibility of saving one extra life per week and preventing three people from entering long-term care every week. While I agree it is vitally important that lives are saved - that is what every doctor wants - it is equally important that we prevent people ending up in long-term care. Long-term care costs the State a lot of money so this is a cost-saving exercise as much as anything else. When one talks about health, one is reluctant to refer to costs but it is a fact that long-term care is costly.

I was pleased to hear about the appointments made, and the Minister mentioned that the chairs of the group would be appointed by mid-July. All of the appointments are based on competences that an individual brings to the board in line with the HIQA report. There will be no prevention of appropriate representation of geographical areas in the groups, as the Minister stated. Will he elaborate on how that will be achieved?

The panel of experts in drafting the report have done the State a service and the figures speak for themselves. Since the Minister took office, the number of patients has decreased, which means the system is being reformed. For example, the number of people on a waiting list for more than three months for a procedure has been reduced by 18% and at the end of 2011, 1,759 children were waiting over 20 weeks for inpatient or day care surgery but within a year, the waiting list has been reduced to 89.

There is a value for money aspect to this for taxpayers. Very often in the political sphere one would see a criticism in moving away from small hospitals and what that would mean for the local community. The Minister indicated in his speech that small hospitals will be doing more work in a safer way and the work will be appropriate to the job they were set up to do. As the Minister mentioned, Roscommon hospital has seen extra facilities and patients, which is testimony to what this process is bringing to the system. The Minister has seen politicians on the street and when he has tried to bring about centres treating a patient under one roof, political lobbyists ask why the Minister is taking away local hospitals, but this is proof that there will be more work in local hospitals that will be safe, fast, efficient and local to the community.

The idea of money following the patient is important as some hospitals are closing systems when the budget runs out. Will the Minister comment on the system of money following the patient and how it will work? It is an important element of managing budgets in the hospital.

John Crown (Independent)
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I will take a moment to compliment the Minister on the good work he is doing on the Protection of Life during Pregnancy Bill. It has not been an easy passage but the Minister has addressed it while others have neglected it. When the story of these times is told, people will recognise that he has taken a very wise and responsible course.

The hospital groups issue is being discussed today and there are two key elements. I am not an instinctive "save our local hospital" person and I have spoken for many years about the need to reform the Irish health system. The numbers may have changed slightly but as a general rule we had the highest number of hospitals and smallest number of hospital beds of any country in the OECD. That was a few years ago and the position may have changed slightly since. There was a clear and dramatic need for real and fundamental change in the number and configuration of our hospitals, with a particular need to concentrate resources.

We used to have absolute absurdities and even in our capital city, a hospital group had seven small hospitals - all allegedly university hospitals - with cardiology in one, endocrinology in another and some parts of surgery in one hospital and other parts elsewhere. As recently as a few years ago if a person had to have complicated treatment for primary bone cancer, care could be divided among four hospitals, which exemplifies the key need for a rationalisation of resources. I am 100% behind the Minister on the issue.

I am troubled by the bigger administrative picture emerging from this. The model of developing highly-centralised State-owned care in a trust system with a highly-developed cadre of managers is an extraordinarily accurate copy of exactly what happens in the UK National Health Service. The Minister should not take this as an unduly negative criticism but it should be thought through at this early stage of the reform process. It is not the right way to implement the process of money following the patient as money can only follow the patient where the patient goes. If, in a hospital trust system, all choice goes and a patient must go to one hospital, we may as well give the money to the hospital before the patient goes there on the basis of prospective budgeting. The purpose of money following the patient is so the patient can have a negotiable insurance instrument and can go to hospital A or B if he or she does not like the way hospital A is run or that fellow Crown. That is the way the process must be devised.

I am trying not to be pejorative but the copying of the British model to the extent of using the terminology of "trust" is not the way the go. It is easier to do it in places like Dublin where there can be a degree of choice between hospitals but we have seen the ultimate logic of the people being put in charge of this process. We have seen how they have acted in cancer care, and they have tried to take away that choice. Their model would be based on designing the system and deciding how many patients go through it, determining what they see as appropriate standards and auditing to see if those standards are met. Standards can be set high or low, which is the fundamental problem of the health quality movement, as it measures compliance rather than quality.

The Minister is aware that currently in the UK there is a major scandal brewing with regard to the spin-off in the Mid-Staffordshire hospital and health district, where systematic management issues have come to light in one NHS hospital, and as a result the Public Accounts Committee in the UK Parliament has called in the head of the NHS. There have also been calls for his resignation, as well as a focus on the notion of the gagging order culture. If there is a bureaucracy with a manager in charge, with the best will in the world, Acton's law will apply and power will corrupt. If there is no system of competition built in, there will inevitably be an emergence of a system of repression.

I agree with the Minister's comments on the extraordinarily high quality of our nurses and the general very high quality of our doctors. My concurrence with the diagnosis at that stage probably reaches a stone wall as I do not believe the next problem is that we need better managers. We should have the great doctors, nurses, physiotherapists and people who rise through the ranks of a profession put in positions of real leadership instead of being regarded as technicians. Currently, default leadership is provided by highly technically skilled managers who have no capacity for true leadership. We should follow such a model but I fear it will not happen here.

I may have to engage Mr. Bill O'Herlihy to get access to a high-powered ministerial team to make the following point. The Minister will come before the Seanad to deal with the health information Bill, which has within it the seeds of a real problem for clinical research in this country in the centralising, formalising and bureaucratising one of the few elements of the system that works relatively well in the hands of HIQA, the governance of ethical oversight for clinical trials.

Marie Moloney (Labour)
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I welcome the Minister to the House and the opportunity to say a few words about hospital services. At the outset I acknowledge the progress made in the terms of delivery of hospital services recently, particularly in my county. At long last, Kerry General Hospital in Tralee is home to one of the finest accident and emergency departments in the country and it is a wonderful facility for patients and staff alike. The old department is being converted into a cardiac care unit, and the new medical assessment unit is also working well, taking the strain from the accident and emergency department. We also saw the opening of the new west Kerry community hospital in Dingle and earlier this week we had the transfer of patients from the old Kenmare community hospital to a new facility in the town. It is important to acknowledge the progress that has been made. I understand that one of the two newly appointed accident and emergency consultants at Kerry General Hospital is to leave his post and I would like an assurance from the Minister that he will be replaced as soon as possible.

Although much progress and reform has been made, I sometimes wonder why it takes so long for some people to see a consultant in our public health services. An 83-year-old constituent recently received a letter from Cork University Hospital advising her of an appointment to see an ophthalmologist a year and a half from now. Nothing can justify keeping somebody waiting that long for a relatively routine appointment, and that women will be 85 by the time she gets to see the consultant. If she requires surgery or further medical intervention, how long more will she have to wait?

The average waiting time in Kerry for rheumatology is three years and two years for neurology, although an appointment can be made for a neurologist in nine months if the case is very urgent. These departments only have a visiting consultant but the waiting times are not acceptable, so there is more work to be done in this regard.

The major problem we now seem to have is the shortage of junior doctors or the inability to attract newly-qualified doctors into our hospital services. Sadly, too many of our new graduates are going overseas to better pay and conditions and our health services are suffering as a result. I would welcome the Minister's comments on an issue I heard about on the radio the other day. She may correct me if I am wrong, but I heard that of the 39 consultant posts advertised, only two or three have been filled. With the best will in the world, if we do not have the consultants we cannot deal with the problems of waiting lists, etc.

I would like to raise one other matter, namely, the long-stay facilities for the elderly and how it impacts on our acute hospital services. Last year alone nearly 250,000 hospital bed days were lost due to delayed discharges. I do not like to use the phrase "bed blockers" as it seems to imply that the patient is the problem, rather than the system. According to HSE data, of the 119 public long-stay facilities in this country, only ten will be fully compliant with Health Information and Quality Authority, HIQA, standards post-2015 if there is no further investment in those facilities. The ESRI projects an additional requirement for 888 places per annum up to 2021 to meet the needs of the growing elderly population. What steps are the Department and the HSE taking to plan for the long-term care of our older population in light of recent statements that indicate that up to €38 million is required to have public long-stay facilities fully compliant with HIQA standards by 2015? It is one thing to have all the standards laid down by HIQA - and I sincerely welcome those standards and provisions - but it is another thing to put the necessary resources in place to allow the facilities to meet those requirements. This would take major pressure off our acute hospital services.

I welcome the calls by the Irish Nurses and Midwives Organisation, INMO, and Nursing Homes Ireland for the establishment of a Department of Health-led forum on long-term residential care. For the vast majority of people, their interaction with our public hospital services and the staff who work there is usually a very positive one. The bottleneck seems to remain in accident and emergency departments and I look forward to hearing more from the Minister on what further progress we can make in that area. I commend Professor Higgins on his report and look forward to the progress of the new and reformed programme which will hopefully deal with some or all of the issues I have outlined. I recognise that the Minister has done much work in reforming the health services. I realise it is not an easy task. We will continue to work with him as best we can on that matter.

Mary Ann O'Brien (Independent)
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I thank the Minister for coming in to talk to us. The Minister made the point that we have the best doctors and nurses and I believe we do. However, I want to hear him comment on his move last October to reduce the salaries of consultants by 30% and the JobBridge-type programme he has produced for nurses. Speaking to a few consultants who are friends of mine, they are very worried about the level of quality of doctors we will continue to attract in this country. Like the previous speaker I would like the Minister to clarify exactly how many consultant posts the HSE has advertised, how many have been filled and how many have attracted any consultants to even apply for the job. In the business world when we want to fill posts with the best people we have got to pay for them. I know we are in times of great turmoil and nobody wants to see anybody paid too much money, but I would like the Minister to talk to us about administration and management. It is so important, but we also need the best front-line technicians, which we have managed to have in this small country of ours.

The Taoiseach wants us to be the best small country to do business in. I am sure the Taoiseach and the Minister want this to be the best small country in the world to be sick in, or to be cured by. Could the Minister please address this? The friends I am speaking to are getting older. Consultants in, for example, St. Vincent's University Hospital are leaving as we speak to take up posts abroad. New, younger consultants are not taking up the positions. My consultant friends say some of the consultants who are taking those positions are not of the calibre of the consultants we should be attracting to those positions.

John Crown (Independent)
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On a point of information, I am staying.

Thomas Byrne (Fianna Fail)
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Gabhaim buíochas leis an Aire as teacht isteach go dtí an seomra seo inniú. I have a few queries on hospital services. It is good that the Minister is here and it follows on from the briefing that took place in Buswells Hotel when he announced the situation regarding the grouping of hospitals. In the north east we have major concerns. They start from the individual hospitals, particularly regarding Our Lady's Hospital, Navan, which is one of the nine small hospitals earmarked in the report to lose their accident and emergency and intensive care services. Navan is part of a miscellaneous group that does not relate to the geographical area. The groups will decide within a year how to deal with the issues in the report. Could the Minister clarify what will happen to the full-time accident and emergency facility in Navan? The new facility that is being built in Navan was referred to by the Minister of State, Deputy McGinley, on behalf of the Government in the Seanad on the Adjournment debate a few weeks as an emergency department-minor injury unit. I want absolute clarity from the Minister on what is planned for Navan regarding that and the intensive care situation.

A number of hospitals were given guarantees in the hospital group report including Waterford, Tralee, Wexford and Letterkenny. No such guarantees were given regarding services in Drogheda and Navan. I want the Minister to explain those omissions and the inclusions of particular hospitals. Wexford always seems to do quite well when public expenditure is at stake in this country at the moment. Maybe that is just the way of politics. That seems to be how things are working. It got guarantees on the various services there.

There is major concern about the building of a regional hospital. Before the election, the Minister's party gave a commitment that it would build a regional hospital for the north east but the Minister's representatives, Deputies in the constituencies of Meath and a number of councillors and business associates said they were in negotiations with developers and investors about building a regional hospital in Navan. After Christmas, one of the Minister's party colleagues stated that the Department of Health and the HSE were involved in those negotiations and I would like the Minister to set out the exact position on those negotiations which his party colleagues in County Meath claim are taking place and involving his party colleagues and the HSE. Is there anything happening regarding that situation?

Perhaps the Minister might have good news for us about the regional hospital today. Two weeks ago Deputy Regina Doherty announced it was all still going full steam ahead and that is the position on the ground but I would like the Minister to set out the exact position from his point of view. Is it the way of the future that individual Deputies, politicians and business people will be negotiating Department of Health hospital plans or does the Minister have control over that? Perhaps he could give an answer to the people of County Meath. I look forward to hearing from the Minister about that.

Maurice Cummins (Fine Gael)
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I thank the Minister for coming in to let us have this debate. Health care reform is a difficult task, particularly in the current financial environment. The Irish people have heard promises before and have been disappointed. When elected to government we were given an mandate to radically reform our health service and put the patient at the centre of health reforms. Under the Minister's stewardship, progress is happening in hospital reform, including reducing trolley waiting times and improving outcomes, with consultants now seeing, treating and discharging patients on a 24/7 basis.

The establishment of the hospital groupings is the next major milestone on the path to universal health insurance. Hospital groups with large and small hospitals working together will provide more freedom to medical and nursing staff to deliver for their patients. We have some of the world's best health care professionals in this country. They know better than anybody else that the status quo cannot continue and we must change to meet the needs and expectations of patients and their families. Ours is a small country with increasing demands on our health system including demographic changes, increased public expectations and inequalities in access to care.

It is time to stop throwing money at the health service as was the will of previous Administrations and to work towards building a health care system that is worthy of the people who use it and the staff who work in it.

Reform of the health service will not be done overnight. We all know that. It is a complex and major undertaking that requires careful planning and sequencing. It will take time, patience, diligence and determination. This move signals a fundamental modernisation of our health system organisation in line with the best international practice. Each hospital group will have its own governance and management structure designed to deliver better outcomes for its patients. There has been no hospital framework to date. Our hospitals have been just evolving with the result that we have had a fragmented service that was riddled with duplication. That method of running the health service could not be allowed continue not only for cost reasons but for the safety and the health of patients using the services.

I would welcome clarification on the problems in regard to recruiting consultants. That matter has been mentioned by a number of speakers. How is it intended to address the issue? Is it as serious as mentioned here that we were not even getting people to apply for consultant positions? If that were the situation it would be very serious. This is a difficult task but one on which I am sure the Minister will work in the coming years. I ask the Minister to outline his plans briefly on the whole question of universal health insurance. We did not give a commitment to deliver it in this term but to deliver over two terms. The hospital groupings is a small step towards that. In his reply perhaps he will give a brief outline on the question of universal health insurance and where we go from here.

Denis O'Donovan (Fianna Fail)
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I call Senator Barrett. I remind the Senator to keep his comments brief in order that the Minister can respond. Other business is ordered for 3.30 p.m.

Sean Barrett (Independent)
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I would like to hear the Minister also. I welcome the Minister and reiterate our support for what he is doing on tobacco. I note that under a previous Leader of his party, he would be expelled for voting for his own Bill on the branding of tobacco. I believe he is against plain packaging. We will be on the Minister's side on that issue.

We are moving in the right direction in the health service but there are problems. Do we have an edifice complex? We have put in €5 billion worth of capital expenditure over ten years and yet the number of acute hospital beds decreased in that period by 1.9%. Are people staying in hospitals too long? That is certainly a theme in the Milliman report which shows as follows: medical inpatient admissions, in hospitals paid for by VHI, average 10.6 days, well managed 3.7 days, almost 2.9 times as long; and surgical implant admissions, paid by VHI, average 7.5 days, well managed 3.7 days, two and three times as long. Does that mean there are two and three times as many hospital beds?

Are we deskilling general practitioners? We have had forums on the issue previously, one of which was chaired by the ubiquitous Mr. Fintan O'Toole when neither of us was in the House at the time. Do general practitioners near hospitals become clerical people just referring people to consultants and writing references and medical certificates for people who are not really sick.

I am concerned, as is Senator John Crown, about the bureaucracy problem. The health service statistics record that we have 8,142 medical and dental staff but 16,000 administrators. The current Book of Estimates shows those administrators do not come cheaply at about €71,000 per year and the pay has increased by 10%, a combination of a pay increase in the pay bill for the Department Health and a reduction in the number of staff. I would be concerned about the layers of administration and would share Senator Crown's concerns in that regard.

We need a value for money culture. I am concerned that so few people who attend accident and emergency units are admitted. I wonder what kind of accident it was and what kind of an emergency it was and why general practitioners could not have administered to the victims. I am concerned there are so few new general practitioners when we deregulated access to general medical service. The Minister of State at the Department of Health, Deputy Alex White, told us recently that only about 100 new general practitioners have joined and we still have other general practitioners earning €700,000 per year on that scheme. I applaud the Minister's radicalism and will not intrude on his time to reply. There is much to be done. We need competing hospital trusts, as Senator John Crown said, so as to be able to get value for money. Too much bureaucracy would stop that. I deplore as he does the gagging culture in the UK where people are not allowed to speak in public when they want a service, which is a public service, to be improved.

James Reilly (Dublin North, Fine Gael)
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I thank all the Senators for their contributions while accepting that some are taking advantage of my presence to raise matters unrelated to the issue under discussion. In response to Senator MacSharry, I will certainly ask the Department to examine the situation. When will licensing be introduced? I have discussed the issue on a number of occasions with the chief medical officer. There is a huge amount of legislation going through the Department at present. Licensing is quite complex. I am very concerned that we do not have a licensing system for private hospitals in particular and our citizens need to be protected. There are other means of intervening and that has happened in the past when there has been trouble and problems but I would much prefer a much more straightforward licensing system and certainly I hope that will be done in the next 18 months.

To whom will the hospital groups report? Each hospital group will have its board. Each hospital will have to report to its board and those boards will have to report to the Department and the health care agency that replaces the HSE. The Senator was particularly concerned about Sligo and Letterkenny hospitals within the context of the Galway group. I can understand that given where he comes from and his constituency but one of the reasons these groups have found so much acceptance and have landed so well with the people is that they have seen them in operation and they have seen Galway deliver. When Mr. Bill Maher took up position? There were 9,901 people waiting nine months or longer for an inpatient service. By last September everyone of them was treated. At the time there were regularly 40 to 50 people on trolleys with an average of 27 on trolleys; the average is now seven people on trolleys. That is still too many and we will do more to address the issue.

In relation to Roscommon hospital, there is grave concern over the change from an emergency department to an urgent care centre and what that would mean for the future security of that hospital. That issue has been more than addressed. I said in my address that it is a key performance indicator for the new management and a bar they have to cross in terms of proving their fitness to go to trust status that they have devolved resources out to the smaller hospitals. Specifically for Roscommon hospital, that means a rheumatology service, a phlebotomy clinic and plastic surgery which it never had previously. Louth hospital has a coloscopy clinic and a range of other services it did not have previously. There is a menu of about 40 procedures that can be carried out with absolute safety in smaller hospitals. It is up to each group with parity of esteem to come to a decision on what services each hospital should provide.

I want to make a general point which cuts across what many people spoke about, namely, the principle of the money follows the patient. Money follows the patient is coming in on a shadow basis this year and on a full basis next year. It will drive the group and its CEO to ensure the service is provided at the most cost-effective place and that will be the smaller hospitals because they have less overheads. Perhaps I can give examples. There are people from Connemara who are happy to go to Roscommon hospital for their procedures because they can get them done quicker in a nice pleasant environment where there is not the same sense of chaotic activity that sometimes can be the case in a larger model 3 or model 4 hospital.

When I visited Ennis hospital where I opened the 50 bed unit, I met a young lady from Limerick who was there for a procedure and was delighted to be there.

As people start to experience the new services they will be very happy to travel.

I want to get through the issues quickly, if I can. Delivery of service is a key performance indicator and drives the CEO of the group to make sure that services are delivered in the most cost-effective place. Obviously the lower the overheads then the more cost-effective a place is. The transfer of resources is an issue.

Senator MacSharry mentioned the health service relationship between the north-west region and the North of Ireland. Real and tangible things are happening in the region. The Government has invested €19 million in radiotherapy services at Altnagelvin Hospital. Advanced progress has been made regarding the discussion on a helicopter service. There is no helicopter service in the North but there is one in the South. If we expanded the service to Donegal, parts of Sligo, etc., then the North could justify having a helicopter service and we could move our service down as far as the most southerly tip of the country. We are exploring the initiative and a range of other issues with our northern counterparts.

We will sign up to a paediatric all-island cardiac surgery service. A single team of surgeons, comprising people from Belfast and Dublin, will operate at both sites. The more complex work will be carried out at Our Lady's Hospital, Crumlin, and the less complex work will be carried out in Belfast. The service will be available to people in Donegal, Sligo and along the Border. It will be much more convenient for people in the region to bring their children to Belfast rather than Dublin. We have real co-operation and synergy with our northern counterparts that benefits the health of people living on both sides of the Border. However, we all know that health and illness do not respect borders and politics. Once we have the helicopter service in place it will allow access to cardiac stenting 24-7 for people in the north west. The region does not have the service at present.

It would be wrong of me to allow Senators to leave here with the impression that Professor Higgins, or any other medic, suggested that the future of the health service was contingent on us building better roads. That is clearly not the case. The clinical programmes and the different way that we conduct business is proof of that.

Several Senators raised the issue of recruitment. The hospital groups have gone a long way to address the matter and other issues. Let me explain. Doctors and other staff like it shown on their curriculum vitae that they have worked at a teaching hospital. We do not have many teaching hospitals. The hospitals have grave difficulty attracting and retaining the best clinical staff due to their location and not being a teaching hospital. Now that each hospital group has a strong academic partner and an academic officer will be on the executive management of a board, a strong association can be made with research and innovation.

I will take this opportunity to send a message. As I travelled around the country I implored all of my people who work in the health service to do the same. Too often, government and others, have considered health to be a drain on resources. Health is a resource and a healthy workforce means a healthy economy. The scale and size of hospital groups along with their strong academic partner means that they will become very attractive to international and national partners for research in terms of medicine, new medical devices and new methods for delivering care. Dr. Susan O'Reilly, director of the national cancer control programme, HSE, has stated that an improved management and organisation can also improve outcomes for patients by up to 10%. We have a wonderful opportunity here on a host of levels. Health is a resource that can deliver in terms of the economy and that is how it must be viewed. I shall return to the matter at the end of the debate.

Maurice Cummins (Fine Gael)
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I wish to amend the Order of Business. I propose allocating five more minutes to the Minister and to conclude at 2.40 p.m.

Denis O'Donovan (Fianna Fail)
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Is that agreed? Agreed.

James Reilly (Dublin North, Fine Gael)
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I thank the Leader for the extra time. I have addressed Senator Keane's concern about a shift of power, money and resources to the centre. As I have said, the initiative is a key performance indicator but I accept that everybody here shares her concern. Professor Higgins has made it very clear that the resources is one of the major parameters to judge whether a hospital group is suitable to change to trust status. The money follows the patient is a further measure that drives the initiative.

Senator Crown is troubled by the new administrative management arrangements and I shall discuss them in a moment. However, there will be competition for national and regional management services. Cost comparisons will be made between trusts. For example, how much will it cost to treat a patient with a hernia at a trust hospital. There is no reason for procedures to be more expensive for the Dublin east group than the south-south west group.

Quality of service is critically important and the new patient safety authority will be very important in this regard. The authority will provide patients with somewhere where their complaint will be listened to and it will act as a patient advocate. As I have said often, it has been my experience as a doctor that nine times out of ten people want an acknowledgement that something went wrong, an apology for it going wrong and an assurance that it will not happen again because things will be changed. With the current system everyone pulls down the shutters leaving patients utterly frustrated and having to resort to litigation. The issue then takes on a life of its own. That is very wrong. A third of compensation for medical legal claims goes to the legal profession. I have nothing against the legal profession but the money should go to the people who have been harmed.

Senator Crown raised an issue about using the term "trust". Let us examine what happens with trusts based in the UK, even though that may make the Senator a bit nervous. We have looked to the North of Ireland for information on special delivery units, to Denmark and Canada for patient safety and to Holland and Germany for how to deliver health care using a multiple insurer model. I heard what the Senator said about the Mid-Staffordshire hospital and health district. That is why it is so important that key performance and quality indicators are not just box ticking exercises. They must be real measurable markers for better outcomes for patients.

I agree with the point the Senator made about leadership. We need leadership in medicine and we are getting it through the new clinical programmes. We need leadership in nursing and we are getting that as well. A new chief nursing officer has been appointed an assistant general secretary, the highest level in the Department. The appointment is long overdue. There have been chief nursing officers before but not at the new level. Over 37,000 nurses work in the health service and they must be represented at the top table as the health service evolves and reforms.

I must talk about managers here because Ireland has not had the required skillset. Administrators, many of whom are excellent people, have been promoted into management positions without being given the training or skillset to do the job. Let us compare that with doctors and consultants. It costs about €1 million to progress from pre-med to consultant level. A person is supported during the time in terms of studying and continuing professional development. Even when a person becomes a consultant development is still catered for and encouraged by the tax system. What is given to managers? They are just left there. They do not receive that type of support but we need it. Equally, six hospital groups will provide us with the level of management expertise that we need and it will grow a new management beneath. Last year the SDU provided funding to support and train managers. Thirty people have availed of the initiative and 30 more people will be aided this year. However, we need to do more. We will continue to examine the programme. As I have pointed out, the management and organisation of the health service is critically important in terms of outcomes for patients.

Senator Crown expressed his concern about the health information Bill. The legislation is critically important in terms of developing the health service, public health initiatives and screening, etc. I am quite prepared to listen to his concern about the legislation.

Senator Moloney talked about improvements at Kerry General Hospital. That reminds me of something. I cannot address the health issue here without mentioning the real and measurable improvements that have taken place despite the loss of 10,000 staff and the €16 billion budget for the health service being reduced by €3 billion. We have also managed to reduce the number of people who must endure long waiting times on trolleys by 24%. There are still too many people on trolleys but we are working on the problem. We met the one-year target in the first year. In other words, nobody will wait longer than a year for inpatient treatment. We met the nine month target last year and we will meet the eight month target this year. The waiting times are still too long but we are working on the problem.

We have reduced by 95% the number of people who are waiting longer than 13 weeks for an endoscopy and the number of children who must wait for 20 weeks or longer for an inpatient procedure has also been reduced by 95%. These are real, measurable and provable. I am not afraid and nor is my Department of the truth or of putting it out there. This is the reason that for the first time, the current Administration has measured the number of people who are waiting for an outpatient procedure. As Senator Moloney mentioned, it is not that 386,000 people are waiting for an outpatient appointment that is the true scandal here. The true scandal is that more than 16,000 people have been waiting for longer than four years. That is utterly unacceptable and I have given an undertaking that this problem will be tackled in the same way as were the other problems, which is that when the urgent cases and cancer cases have been dealt with first, the longest waiters will be dealt with thereafter and no one should be waiting for longer than one year by the end of 2013. I accept this is still too long but we must start and continue from a starting point that is realistic and we will continue to do that.

Senator Moloney was also concerned about the recruitment of non-consultant hospital doctors, NCHDs, and the number of consultants being appointed - I believe Senator Mary Ann O'Brien also raised that issue - and the issue of long-stay care. The nursing home supports scheme is visible and because it is a pot of money, people head for resources. We have discussed this issue in the Department and elsewhere and we must have more choice available to people before they enter long-term care. It should not be a case of hospital, home help and long-term care. While we need home help and home care packages, we also need supported sheltered housing and tiered support. I know of particular facilities in the south east, where some people come, stay the day and then go home at night, while others arrive and stay the night and then go home during the day. We must address people's needs and not dictate the service on the basis of what is available. Moreover, we must inform ourselves of what are people's needs and we are doing that. We will have a much greater and broader range of services - with funding. However, as we only have a limited amount of funding, that funding must come back from long-stay care to pay for these other, more cost-effective and, I believe, better facilities. I know of no one who wishes to be in long-term care a day before it is necessary to be there.

Senator Mary Ann O'Brien was concerned about the reduction of salary for consultants about which I wish to make the following point. The new consultant starting salary level is €116,000 to €121,000. While it is all very well to compare this with the salaries that obtain in the United States of America or somewhere like that, why not simply look up the road to the North of Ireland or across the pond to the United Kingdom, where the starting salary for a consultant is £80,000, which is less than €100,000? As a doctor, an Irishman, an Irish citizen and a republican, I believe it is not simply money that binds our people to our country and I believe we pay well. I also believe we have a huge problem regarding the cost of insurance in Ireland. For example, we are paying the same sort of money for procedures that used to take two hours but which now take 20 minutes. I will give Members a classic example without mentioning any names. It concerns a particular individual, who complained that he could do only nine procedures all week in the public system but could get ten done on a Saturday. However, he neglected to mention that he gets €800 a pop, which comes to €400,000 per year for a one-day week. Consequently, there are serious issues to be addressed in respect of the problems around this matter. I am not in the game of haranguing consultants because they do phenomenal work. They are extremely well trained, work extraordinarily hard to get to where they are and must be remunerated properly. However, this must be done in a transparent way that is fair because if one spends a lot of money on one thing, it means one has less money for something else. In the past, some doctors would prescribe drugs the cost of which was not their concern. However, that cannot be the way any more because there is only a single pot of money. If one prescribes something that is hugely expensive on one side, one will deprive several people on the other side of some other service, perhaps a life saving one.

As for the issues pertaining to recruitment and career paths, much of this has to do with the nonsense of giving people six-month contracts. In the main, these are young married men and women with families but who have no certainty. They spend six months in one place but do not know where they will be six months later. They should be given three or four-year contracts and I wish to discuss that with the organisations concerned that represent them and with those who are involved. Equally, however, it also relates to the lack of respect that has been shown to NCHDs. Moreover, some of that lack of respect has come from senior doctors. I refer to scenarios in which people are advised that while their contracts provide they work on a nine-to-five basis, which is what they get paid for, they had better be in attendance by 7 a.m. and had better be prepared to stay until 7 p.m. if needed, because otherwise they will not get a reference. I know this has happened. Doctors are people and will not wear that. While they will take the hit for the six months for which they are caught, thereafter they will be gone. Many of these factors are influencing this problem, as does the issue of the clear career path. One should be able to come into a hospital and if one does one's work and if one qualifies through the exams, one should then come out as a specialist - end of story. While one may not get a consultant job, one is a specialist and is recognised as such. At present, however, that does not happen. One does not tend to be a specialist until one is given a consultant post. I want all these issues to be addressed and I want the people to be treated with respect. Moreover, one of course should encourage people to go abroad to finish their training. My point is not that I expect a consultant who has worked for ten years abroad as a professor of cardiology to return here and start on a salary of €121,000. While that is not the case, it is not a bad starting point for a doctor who has just finished his or her training and is now a specialist. I think it compares favourably with many countries in Europe.

I agree with Senator Cummins's comments and have covered the issues regarding the recruitment problem, salary and career path. As for the universal health insurance building blocks, the Senator is absolutely correct but I do not think time will allow me to go into the subject in the manner he would wish. I undertake to revert to him on it.

Paddy Burke (Fine Gael)
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I remind the Minister that the Minister for Social Protection is waiting outside.

James Reilly (Dublin North, Fine Gael)
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Very well, I will conclude.

Thomas Byrne (Fianna Fail)
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I have asked questions to which I seek answers.

James Reilly (Dublin North, Fine Gael)
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As Members raised questions, I will do my best to answer them as quickly as I can. I am glad Senator Barrett is on the side of plain packaging for tobacco, an industry that kills one in two of those who use their products. I agree the number of acute beds has fallen and that is because more day surgery is being carried out. Moreover, as medical technology advances, one is capable of doing more things more safely within a shorter period as day cases. The Senator is absolutely correct about deskilling general practitioners, GPs. When one builds a new hospital, the GPs who live in its shadow can be deskilled. For example, they might not bother suturing wounds as people can go to the hospital where it is quicker and easier. We must try to guard against this. I have spoken about management, training and support. I imagine the GP on €700,000 has several other GPs working with him or her. That normally is the case but obviously I cannot state that for every case. I believe I have covered virtually everyone's questions, with the exception of the issue of the consultant posts. This is of 1 January 2013 and I note 136 were advertised this year, 34 are at commencement or clearance stage, 52 are at the stage of recruitment and 50 have been filled thus far. This is from the Department and from the gentleman behind me, Mr. Hardy, who very kindly has gone out to get that information.

Although I am Minister for Health, I often feel as though I am the Minister for ill-health because all we appear to talk about is disease and illness. What we really should be about is prevention and about keeping people well. The Government has bought into this and has launched a framework document, Healthy Ireland, into which all the Ministers bought because they all understand that the Department of Health cannot do this on its own. It requires input from education and justice to keep the streets safe and from the environment side to provide good footpaths, well-lit areas, etc. The Government wants to move away from hospital-centric medicine back to the community and indeed back to the patient's house, which technology will permit as time goes by. I will conclude by noting that the National Health Service was formed in 1948. It probably is one of the best things Britain did in the last century. While people there think they did many good things, this is one that has stood the test of time and they did it out of the rubble of the Second World War. In 1845, the blackest year this country ever endured - we lost 2 million people - there still were people in this country with the vision and conviction to open a new university in Galway in that year. That is our gene pool and I believe we can take this huge challenge and turn it into a wonderful opportunity to give our people what they want, which is a health service in which everyone feel safe and of which all the people who work therein always feel proud.

Paddy Burke (Fine Gael)
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That concludes the statements.

Thomas Byrne (Fianna Fail)
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A Chathoirligh, I was nice to the Minister and complimented him on his briefing of Members. Even though I asked him nicely, he has not answered the question in respect of Navan hospital.

Paddy Burke (Fine Gael)
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Unfortunately, the time is up.

James Reilly (Dublin North, Fine Gael)
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I do not mind answering the question. In respect of the emergency department in Navan hospital, I have always made it clear that there would be changes down the line but that such changes would not happen unless there was capacity in the system to deal with those patients who currently attend that hospital.

The capacity is not there yet and I do not pretend it is there. In terms of the discussion on a regional hospital, no one is negotiating on my behalf on the matter and I never gave a commitment on it.