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Dáil Éireann debate -
Tuesday, 25 Apr 1995

Vol. 451 No. 8

Private Members' Business. - Hospital Services.

I move:

That Dáil Éireann, mindful of the unacceptable hardship being caused to hospital patients and their families due to appointment and admission cancellations, long waiting lists and continuing overcrowding in hospitals and also erosion of morale among hospital staff, condemns the Government for its failure to recognise the crisis and to adequately address the problems.

I wish to share my time.

I am sure that is satisfactory and agreed.

The Minister for Health is well aware that since I took on this portfolio I have been at pains not to provide what I perceive to be a dated and ineffectual version of Opposition — to be stridently opposed to anything and everything a Government does. I have not failed to acknowledge when the Minister has taken appropriate action.

However, when it comes to the issue of overcrowding and bad management of patient numbers in our big, publicly-funded hospitals, it is imperative, not only that the Opposition oppose, but that the Minister changes what he is doing in response to that opposition.

Since the start of this year there has been a failure by the Government and the Department of Health to recognise the crisis in hospitals. That crisis has led to industrial action by nurses, a group of workers that normally do not take to our streets unless there is a serious problem, there is no doubting how real and substantial the problem is. Accident and emergency care has reached breaking point, particularly in Dublin but also in hospitals all over the State.

In the past, Casualty as it used to be called, was precisely what it sounded. It was the place to which a mother brought the toddler who had fallen off his or her bicyle and who needed more treatment than the mother felt competent to provide. Similarly, the person who had been involved in an industrial mishap, or the student in school who was injured on the sportsfield were brought to casualty. Casualty was the place where broken bones were set and bleeding wounds staunched. There were some times of the day or, more specifically, of the night, that caused particular pressure, and there were some nights of the week when, for obvious reasons, casualty was more crowded than others.

However, we do not talk about casualty any more; we talk about Accident and Emergency Departments. What now happens in what we used to call "Casualty" is so different and so complex that the sign "Accident and Emergency" does not really fit the bill.

It might be simpler to put an entrance sign over the Accident and Emergency Department sign because, increasingly, that is what it is serving as; an assessment and induction point for the seriously ill who need admission to acute care wards. In other words, the role of Accident and Emergency Departments has changed beyond recognition and it will not change back.

If hospitals were just businesses, merely in the profit and loss area, the implications would be obvious; our marketplace has changed, therefore, our facilities and management expertise need to change quickly. However, hospitals are not just businesses, they do not simply deal with money, they deal with people and that is all the more reason to change the way the operation is managed. Why should the imperative be less simply because the focus of a hospital is on patients, rather than profits?

That change has not happened. The Department of Health has not examined this recurring issue which has been happening again and again at the beginning of each year. The Department has not accepted that the position has changed and that the change must be managed. On the contrary, the Department seems to be hoping that the position will somehow change back, to let it off the hook of doing what it is supposed to be doing — providing health care for the nation.

What the Department of Health has done over the past three months is a sorry saga. The loudest sound has been the washing of hands as the Department has shrugged, portraying the disgraceful conditions patients are enduring as an haphazard outcome of old, unpredictable pressures rather than the inevitable outcome of a change in the way hospitals are used by the patients who need treatment.

There has been an implication — never quite spoken, but there, nonetheless — that bad, manipulative patients are trying to subvert good hospital systems by getting themselves improperly admitted through Accident and Emergency Departments.

Let us consider that in real terms, as opposed to Department of Health terms. An Accident and Emergency Department, in any hospital, is not the place to go to have a Teddy Bear's Picnic. It is not a place to go for a chat because you were a little bored with "Coronation Street" or "Glenroe". Accident and Emergency Departments are Dickens crossed with Kafka. There is constant activity and anxiety, but no apparent end result. There are sights, smells and sounds that would put you off your food for a week. There are machines being wheeled into curtained cubicles. There are trolleys, clanging prisonsides, which are imitations of beds designed for someone to lie on for an hour or maybe two.

When you cross Dickens with Kafka you get something that is grim and scary, something that makes no sense to the patients or to the professionals who are doing their best to cope with it. A doctor in charge of a major Accident and Emergency Department in one of our largest hospitals described it to The Irish Times just before Easter by saying “it is like Puck Fair”. He was putting it positively. That is what we are subjecting patients to. It is no wonder that nurses are striking to draw attention to their desperation in the face of this madness. There is patent mismanagement.

Nursing staff say that Accident and Emergency Departments have become makeshift wards. There is no throughput of patients because of the shortage of acute beds throughout the remainder of hospitals. This results in patients spending several days on trolleys.

For instance, in Beaumont Hospital recently, a pregnant woman with a history of miscarriage had to spend two days on a trolley in the Accident and Emergency Department. She was waiting for a bed to become available on a ward. She was one of the lucky ones. On some days, some patients do not even get a trolley. Often there are three or four ambulances held up at the door of the Accident and Emergency Department while patients are treated on stretchers until trolleys become available. Sometimes patients are laid on mattresses on the floor, others can spend hours sitting in armchairs. The constant fear for nursing staff is that someone will die on a trolley or in a corridor. It is also practically impossible to nurse somebody if you are down on your knees on the floor.

There have been cases of elderly patients dying a couple of hours after moving from a trolley to a bed. These people and their families deserved to be treated with greater dignity.

Accident and Emergency Departments are clogged because beds on wards are not being made available quickly enough. There is a chronic shortage of step-down facilities where non-critical patients are taken out of acute hospital beds and cared for in nursing homes or in their local communities. If these facilities were available, up to 20 per cent of beds in hospitals around the State would be freed up.

Problems have arisen in Dublin because of the lack of co-ordination of the city's two ambulance services. The Mater and Beaumont Hospitals currently take 50 per cent of ambulance calls. These hospitals are located in areas where there are large populations, especially of elderly people, who require medical services. It means that these two hospitals are under incredible pressure all the time just from their local areas. Therefore, there has to be co-ordination of hospitals and ambulances within the Dublin area.

However, this is not happening. For instance, when the Mater is full, it sometimes takes up to three hours for that to be communicated to the Dublin ambulance services, resulting in patients arriving at the Mater and then having to travel to another hospital.

The crisis in hospitals and casualty departments led to the recent industrial action by nurses. They are not looking for extra pay but will not tolerate constant overwork and overcrowding. They want to provide a quality service to patients. They also want to be able to do their work without being abused about the overcrowding which is not their fault.

Nursing staff do marvellous work and it is unfair that they should be the victims of inefficiencies and inadequacies of the health boards and the Department of Health. The problems in accident and emergency departments have not arisen overnight. But there appears to have been a persistent failure by the Department of Health to address them and this Government and Minister for Health have failed to recognise the crisis or get to grips with it.

If the Department had any sense of responsibility, it would, within the past three months, have taken two kinds of action. It would first have put emergency funding into the hospitals under pressure to allow for the opening of more beds and the taking on of extra staff to cover what might be called the ‘first quarter curve' in admissions. Second, it would have moved in quickly to examine what was going on and developed new systems to cope with it. Instead, it played "blame the patient": sending out the message, subtly and not so subtly, that this was happening because patients wanted to get around waiting lists.

Let us examine for a moment the possibility that the patient wants to get around a waiting list. Is that a dreadful thing? Is that patient an awful person? Should they just bide their soul in patience and not be trying to jump the queue? Should they learn to be a good obedient, patient patient? I am sorry to have to tell the Minister that the re-education of patients has to take second place to the re-education of the Department of Health.

I was a teacher, as was the Minister. I was a good teacher. I suspect the Minister was a good teacher, too. And so I feel safe in suggesting that the Minister would agree with me when I say he cannot teach a student much when a student is frightened, or in pain, or nauseated, or in discomfort that falls short of pain but goes way beyond malaise. The people the Department of Health would like to re-educate are people who are sick, a small but important point. They are not looking for admission to hospital to have their appearance improved. They are sick. They have symptoms. They need action taken. Sometimes, their life is disrupted by whatever ails them. So they are not going to be really good students; they are not going to willingly learn to stand in line, accept queues or postpone solutions.

If someone is sick and anxious enough to submit themselves to the ‘Puck Fair' conditions of our accident and emergency departments in the major hospitals, knowing that they are likely to be left lying on a trolley for a night, or longer, then they must be pretty desperate. It is crazy for the Department, or anybody else, to send out the message that these bad patients are just trying to sneak around a perfectly good system.

It is not a perfectly good system and the Department, and the Minister, should be fixing it and doing so quickly. There are examples of the Department's failure in this matter. For instance, several Ministers for Health have made funds available to address bed shortages and reduce waiting lists. Both problems are interlinked and incapable of being resolved separately. However, the Department of Health appears to have failed to grasp this.

Now money is being provided to deal with one set of waiting lists. However, because of the crisis in accident and emergency departments, appointments and admissions are being cancelled, creating a new set of waiting lists or emergencies. One list is just being substituted for another.

More than 550 elective admissions to the Mater Hospital were cancelled during the first three months of this year because of pressures on the hospital's accident and emergency department. In January elective admissions for 266 patients were cancelled. In February 143 were cancelled and last month 146 were cancelled. Escalating admissions to accident and emergency departments at various hospitals throughout the country are disrupting normal services at the hospitals as the pressure on beds increases.

As pressures on the service began to mount, the Cork city hospitals, for example, used a service disruption score to measure the effects of the crisis. When it was introduced the score was 30 but it recently climbed to 70. The scoring system was introduced to measure the level of disruption caused by the numbers being admitted through accident and emergency departments against the numbers awaiting admission from the community and from GPs, the numbers of extra emergency cases in five-day beds and the number of extra beds being introduced to cope with the situation. Every option possible to reduce bed-stay and to improve co-ordination of tests was being tried.

A major increase in casualty admissions in the first quarter of this year and the lack of step-down bed facilities have contributed to many of the hospitals much publicised casualty crisis. There is pressure on the system to continually provide additional step-down arrangements for patients in acute beds to ensure rapid discharge. There is an increased demand in all hospitals for non-acute accommodation which needs to be met and which will require joint planning between the hospital managements, the Department of Health and the various health boards. Hospitals are being continually hampered by their inability to discharge acute patients to appropriate facilities at any given time, thus causing blockage of beds. There is clearly a need for additional non-acute beds and there is also a need for more short stay beds within hospitals to deal properly with the elective workload.

Any cancelling of elective admissions as a result of the large increase in accident and emergency admissions will clearly have long term effects on waiting lists if it continues. The Department of Health appears to be refusing to accept any responsibility for this. The Department is not participating in this week's summit on the crisis in accident and emergency departments. All the other parties will be there and the Department should be there too as it has an important role to play in solving this crisis and integrating health services.

This integration role for the Department has been set by the health strategy document which was produced by the Fianna Fáil - Labour Government. It proposed that the Department, the health boards and the hospitals should come together to tackle problems. Since the Minister for Health has not insisted on the Department's participation, does this mean he does not agree with the health strategy document? Does he also not agree with its proposals on action for acute hospitals which included an objective to ensure quality facilities for patient care? What happened to this objective as it has certainly not been to the fore in this current crisis?

I am very tempted to say the Department needs its head examined, because it does not seem to be able to learn from experience. If you go around the country and talk to the people in the health boards — I am delighted the Minister is in the process of doing that — they will say that what is happening this year has been happening for the past few years. It is a well established trend, this big curve of extra demand at the beginning of the year, but the Department seems determined to pretend that it is not real and it does not need to plan for it. That is roughly the equivalent of a leaving certificate student saying at this time of the year that there is no real need for him to revise his work in the next few weeks. Any mother would say to such a student: "you need your head examined." Any patient or relative of a patient who has got a free sample of accident and emergency departments in a major hospital in the past few months would say that the Department needs its head examined. I am not sure that is true. I think it needs its heart examined — if it has one, and I hope, with Deputy Noonan in charge, that it might have one. If the Department of Health had a heart, it would be observing the truth about the current situation which is that the people who go to accident and emergency departments are often the most vulnerable, are the people who do not have the money to go the private route for care and treatment. They are the people who do not know how to work the system. The patients who suffer most are those vulnerable people, the very young, the very old, particularly the very old. The people who have gone on strike this year are the last people you expect to go on strike. Nurses can and do take a great deal of punishment and an awfully big workload. Even when they went on strike this spring they did it in ways calculated to inconvenience patients as little as possible; they were obviously trying to draw the attention of the Department to the fact that here was a problem that was simply not being acknowledged or managed.

I am asking the Minister for Health to take action on this. The motion demands an increase in the level of funding to adequately address the problems. I would go further. I ask the Minister to stop his Department behaving as if this yearly crisis was a minor problem caused by patients. Plans must be developed to prevent this unacceptable hardship to patients and their families.

This Government has been in office for less than five months and it is unbelievable that in such a short period it has lost touch with reality. It is obsessed with looking after the privileged. Despite the presence of Labour and a Democratic Left Minister for Social Welfare it gave a 2.5 per cent increase to social welfare recipients and pensioners which will probably not even match inflation this year. Worse again, the rise only applies to a social welfare recipient's primary payment, not to dependant and supplementary allowances. At the same time a Labour Party Minister for Finance gave major tax breaks in the budget to the financial institutions which already make massive profits. The Government abolished the bank levy which resulted in a windfall of £12 million in 1995 for the financial institutions. Next year this windfall will be £24 million. The financial institutions will also make a killing from the 2 per cent cut in corporation tax.

The Government seems to know how to look after its banking friends but has no interest in the health services. When we came to Government seven years ago we immediately set about rebuilding the hospital and health care infrastructure. It took time and effort. It was done painstakingly and with attention to detail. While we were trying to solve the problems the then Opposition's only reaction was to criticise us. As is now clear the Opposition's words were hollow. In a debate on 3 November 1992 on the general medical services proposed by Deputy Owen, now Minister for Justice, she stated, as reported at column 1876 of the Official Report, that in all arguments about the health service and GMS "the most important individual is the patient". She appears to have forgotten this now that she is a Cabinet Member. If she has not, why does she not push for resources for the State's hospitals?

She is not the only one in the Fine Gael Party with amnesia. As reported at columns 1319-1323 of the Official Report, 30 March 1993, Deputy Flanagan complained bitterly about waiting lists. He wanted action and stressed that hundreds of beds had been taken out of use in all the Dublin hospitals. He wanted the Minister for Health to commit himself to action. That Government took effective action but it has been let slip by this Government. Where is Deputy Flanagan now that his party is in power and can take action? He is keeping his head down because instead of taking action this Government is adding to the problems by not recognising the crisis in the health services and providing adequate resources.

Deputy McManus, now Minister of State, was also a vocal contributor to the debate on the health charges in March 1993. As reported at column 1654 of the Official Report she considered there was a massive decline in spending on health care. She said she wanted our health services to be "better and more equitable and at the same time to provide jobs for more of our highly trained young people". She is now a member of Government but she and Democratic Left appear to have fallen under the spell of the financial institutions and have forgotten the crisis in hospitals and accident and emergency departments.

The breaks given to the banks in the budget are in sharp contrast to the provisions made for the health services. No allocation was made for the provision of extra step-down facilities which would free up acute beds in hospitals. The extra resources required could be found if the Government made health care a priority over tax breaks for banks. It is to be condemned for its failure to recognise the crisis and must immediately assess the level of funding required by the Department of Health and the health services and consider an increase so that the crisis in the health care service can be adequately assessed.

There is no doubt that the general medical and psychiatric services are going through a turbulent period. One might say this is nothing new. However, we have now reached a crisis point. As yet no definitive corrective action has been taken by the Minister, the Department of Health or the various health boards. Previously we had problems regarding orthopaedic. ENT and vascular patient waiting lists and outpatient appointments which were remedied somewhat when extra funding was provided. Now we hear more of the same — £8 million for a quick fix solution; a stop gap programme; more band-aid to stop the bleeding and prevent the problem worsening. This is not the way forward. We must carry out a proper analysis of health care. We must look at community care, the GP setting, in-patient and outpatient services in hospitals, psychiatric services and services for the mentally handicapped.

Recently I came across a hemiplegia patient who suffered a stroke and required two or three incontinence pads a day. The health board was only willing to supply one pad per day. Despite much effort I have not had any success to date. This shows the intransigence and inflexibility of health boards. This hemiplegia, stroke patient, now confined to a wheelchair, was looked after by the family for 12 years yet the health board was unwilling to give the family two or three incontinence pads a day. How much had that family saved the health board during those years? This shows the health board does not know where money is well spent.

We talk about preventative care yet we do not have a proper immunisation programme. I know the Minister together with the IMO and others is trying to have such a programme. When we look at admission procedures in hospitals we find many people are admitted to hospital through casualty. This is not how it should be. We should have medical and surgical assessment units in hospitals where patients who do not need to be admitted to hospital can be referred back to their doctor and looked after in the community. The casualty department is often cluttered with the wrong patients. It should be a place for seriously ill patients to attend and they should be seen to in a reasonable time. However, this does not happen.

There are too many patient recalls to outpatient departments. Consultants see patients and bring them back ad nauseam. That should not happen. Patients should be dealt with and then sent back to their general practitioner.

The Minister was in Galway recently and I hoped he might say something about phase II of the Castlebar Hospital. The position regarding orthopaedics there is terrible. Patients must travel more than 110 miles if they sustain a simple fracture such as a Colles's fracture of the wrist or need minor procedures carried out. This shows we are not serious about providing a proper cost effective service. Two orthopaedic surgeons in Castlebar would provide an excellent cost effective service.

The problem of geriatric patients taking up acute beds has not been resolved in any of the health board areas. This problem will worsen as time goes on. We have not used our imagination in regard to this problem. We are not using properly our district hospitals or our nursing homes, whether private or public. We are not using our day hospitals, carers, home helps or respite care, etc. in a manner which would alleviate the demands on acute hospital beds.

Recently I became aware of a 45 bed unit in the Western Health Board area which was getting a subvention of £70,000, which was insufficient to keep this unit in operation. In the Eastern Health Board area a similar institution would receive three or four times that amount of subvention. I fail to see the difference between the Eastern Health Board region and the Western Health Board region. An annual subvention of £70,000 for 45 patients is very little. We fail to see what can be done in the private and public sectors in regard to giving good value for money in nursing homes.

In the mental health area, recent publications by psychiatrists complain that there are insufficient acute beds, especially in the Eastern Health Board and Southern Health Board areas. This leads to too early discharge of patients, some of whom may have to be re-admitted, resulting in further demands on acute beds.

Psychiatric units were closed and large numbers of patients were discharged into the community. This does not mean we no longer require acute beds. We will always need acute psychiatric beds in good modern units. Those discharged into the community will need proper psychiatric follow up, either in a high support or medium support hostel settings or small units properly placed in the community. Even if placed in their own family they will still need community care and proper psychiatric follow up. We do not want the problems here which have arisen in England in regard to psychiatric patients. We do not want to see psychiatric patients wandering around and becoming the new homeless. We need proper follow up and occupational therapy, where feasible.

Mental illness and handicap do not generate the same concern as coronary bypass surgery, heart, lung and bone marrow transplants. Nevertheless for those who suffer mental illness it is very real and they should be treated and acknowledged in the same way by the Department of Health as people with other illnesses. The mental health area should receive adequate funding. Most psychiatric nurses say there is a real need for this funding which is not forthcoming.

During the last few years very few psychiatric nurses have been trained. In the not too distant future we will not have an adequate number of trained psychiatric nurses. If psychiatric hospitals are to be attached to general hospitals in the future I hope they will not be in the basement or at the back of hospitals next to the mortuary. The available funds should be directed in a proper manner to give us the best possible service.

I am pleased to support my colleagues on this motion. I am not being political but I appreciate when one assumes the responsibility of ministerial office, because of its nature and the burden of work to a certain extent one loses contact with constituents. It is appropriate to remind the Minister of what is happening in the real world. It is nice for him to go around Limerick and announce £12 million projects. It is an opportunity we would all like to have.

Few would dispute the many shortcomings of the Irish health service which cause added pain, anxiety and stress to many thousands of people. Most reprehensible of all is the cheque book aspect of the service which dictates that your place in the medical waiting queue can be dramatically improved if you have the ability to pay for the treatment you require. One can hardly blame the well-to-do for using their wealth for health. A system which permits this to happen can lay no claim to cherishing all the children of the nation equally, as the poor, the aged and the unemployed know only too well.

Hundreds of people in the Western Health Board region are on a long waiting list for orthopaedic treatment. Others await corrective heart surgery and still others need specialist services to restore their quality of life. Their crime is that they do not have the money to pay for the treatment. Day in, day out, their pain continues and many GPs will confirm that several have died while still on a waiting list. I suggest that those queuing for treatment as public health patients forget about their hips and hearts and apply instead for gender reassignment surgery. They might well get to the hospital theatre faster as the Irish health service paid — from the taxes paid in by the people we represent — £24,000 for three men to have gender reassignment surgery at Charing Cross Hospital in London. It is comforting to know that this Government has our health priorities right and hip and heart patients should realise that sex change operations are more urgent than their trivial ailments.

At the end of December 1994, 1,500 patients from Mayo were awaiting outpatient appointments going back five years. Even when seen, they waited an average of two years for treatment. This is not acceptable. While I recognise it is a problem that has built up over the years and is not something that has happened since the Minister assumed office, positive action can be taken if the political will is there.

From January to mid-April each year there has been substantial overcrowding in our public hospitals due to a large number of dependent elderly people in remote isolated areas requiring hospitalisation. Levels of overcrowding in the region of 180 per cent are unacceptable. This requires extra staff on a temporary basis; extra beds and space are required urgently. While hospital staff cope as best they can, a clawback of resources takes place in each individual hospital for the balance of the year to meet the critical need during the winter months. Sixty-five beds for 107 patients is not an acceptable norm for an average of four weeks in a three month winter period. General practitioners will continue to refer isolated dependent elderly people to public hospitals, in times described in the last few days as a litigious age, because the much heralded community resources are stretched thinly on the ground. Many of the elderly hospitalised on a cautionary basis could be retained in their communities if the Minister recognised the huge untapped resource of the home help and the meals on wheels scheme. Because of the geographical distances involved the GP may admit a borderline case, particularly where a home help service is not freely available and is under resourced.

Payments of £1 per hour to home helps in the Western Health region — as discussed here several weeks ago — are scandalous. While the Minister may say ad nauseam, while he retains his brief, that the allocation of resources in the first instance is a matter for the chief executive officer of each health board area, he must be concerned with improving the delivery of health services to those most in need. The optimum use of resources amounting to about 7 per cent of GNP should be assured. Money should be properly allocated and policy implemented that will see an improvement in the availability of health services to the people we serve.

Limerick East): I wish to share my time with Deputy Ring.

Is that agreed? Agreed.

(Limerick East): I move amendment No. 1:

To delete all words after "That" and substitute the following:

"Dáil Éireann

— endorses and supports the action of the Minister for Health in increasing the allocation for acute hospitals by £17 million in 1995;

— welcomes the Government's agreement as set out in the Programme A Government of Renewal to continue funding for an initiative on waiting lists in the coming years of this programme;

— agrees fully with the steps which the Minister for Health has taken to relieve pressure on the acute hospitals by the provision of appropriate alternative facilities".

I thank Deputies for their contributions. Where they have brought new material to my attention I will take that into account and have it examined.

Deputy Geoghegan-Quinn spoke of the hospital services as a mixture of Dickens and Kafka. Whatever about the hospital service, the Deputy's speech was a mixture of Dickens and Kafka, more Kafka than Dickens. There were shades of "Bleak House" and "Hard Times", but the idea of a senior politician in Fianna Fáil, having been in office for seven years, making the speech she made on the failures of the health service to a Minister who has been in office for three months in Kafkaesque in the extreme.

When will the Minister drop that line?

(Limerick East): I think it is a good line and it will run for a long time yet. Let us be reasonable. We have been in power for a couple of months and we have listened to an analysis of the fundamental flaws of the health service by a Deputy whose party was in power when the last three Health Ministers held office. In 1989, in the middle of an election campaign — Deputy O'Hanlon had been Minister for Health for two years — the Taoiseach at the time went on radio to apologise to the people saying he did not know how bad the services were as nobody had told him. Next we had Dr. John O'Connell as Minister for Health when the Progressive Democrats and Fianna Fáil were in Government and, then we had Labour and Fianna Fáil the last two years. Am I to take seriously a lecture on the improvement of the health services from the people who presided over them? There are two choices. The Opposition can say they presided over a catastrophe during the last seven years, or they can face the facts and admit that the health services have been substantially improved and are not as bad as they are painted. There are difficulties, which we would all admit, but the latter is the honest account of the position.

It was also Kafkaesque to listen to the Opposition spokesperson on Health lambaste a Department of State, paragraph after paragraph, and hardly referring to the Minister. That is highly unusual. It was a kind of Punch and Judy show where, instead of Punch being whacked on the head by Judy, the fellow who runs the carnival is whacked on the head. What is the agenda when people who have run the Department for seven years lambaste the Department of Health? I cannot understand it.

I do not intend personalising the argument but Deputy Geoghegan-Quinn made one major suggestion. She said there is a lack of sub-acute beds in the country, and that is true. She said that if sufficient step-down facilities could be provided it would do much to solve the problem — 20 per cent of the people who occupy acute beds could be put into step-down facilities. There are 12,500 acute beds in the country, 20 per cent of which is 2,500. Is the Deputy seriously suggesting that I should have provided 2,500 beds in three months when her own party was in office for seven years and failed to provide these step-down facilities? There was a huge reduction in bed numbers from 1987 onwards, not an increase. I do not follow the Opposition argument, or perhaps I do but it would be better not to go into it.

I would like to be constructive and say what has been happening since I took over as Minister to alleviate the problems which exist and which have been pointed out by the three Deputies who have contributed so far. I will do this under the headings of improvements in acute hospital services, improvements in the accident and emergency services and waiting lists and waiting times initiatives.

I am sure the House will be happy to know that I have made a very large allocation for a programme of improvements in hospitals services. In 1995 I allocated an additional £17 million revenue in this area. This is a significant sum which is providing a wide range of improved services throughout the country. This figure includes improvements in all eight health boards and covers a wide range of specialties in hospitals. These will be referred to in greater detail by my colleagues. As part of these improvements I have also moved to improve the pre-hospital ambulance service.

In addition to the £17 million revenue I will also be providing capital funding of approximately £70 million in 1995 to improve the infrastructure of the hospital system. In particular it will see the continuation of the building programme at the new hospital at Tallaght and other schemes of improvement in hospitals throughout the country.

One of the first things I noticed when looking at the Estimate for the Department of Health was the great disparity between the current side and the capital side. Out of a budget of about £2.3 billion last year, only £65 million was spent on capital. Is it any wonder that the infrastructure is poor when the whole balance of funding is going on the current side and very little investment has been made over the years on the capital side?

The accident and emergency departments of the major hospitals operate a 24 hour service, seven days a week. Because of the nature of the service provided, it is not possible to predict the workload that will present at an accident and emergency department at any given time. However generally speaking, there is sufficient capacity within the accident and emergency services to deal with the needs of patients.

Much of the recent focus concerning accident and emergency services has centred on the major providers of this service in large centres of population, particularly Dublin, Cork and Galway. With regard to the upsurge in activity this winter, the Irish experience is by no means unique. Hospitals all over northern Europe have experienced an upsurge in accident and emergency activity this winter very similar to that in this country. The prolonged spell of cold and wet weather has, in particular, affected elderly people and put exceptional pressure on medical beds, mainly for the treatment of serious respiratory conditions.

The Minister has to check against delivery.

(Limerick East): The Deputy did not give me an opportunity to reannounce the good news for Galway, so I will have to skip that and take it as read.

The Minister misunderstood me.

(Limerick East): Perhaps I should have read it out — good news should be repeated and I could give the people of Galway an opportunity to applaud my efforts once more.

Accident and emergency services in Dublin are provided by six major acute hospitals — the Mater, Beaumont and James Connolly Memorial on the north side of the city and St. Vincent's, St. James's and the Meath on the south side. The accident and emergency departments of the six major hospitals in Dublin provide 24 hour cover all year round. The figures are striking, and it is in the context of the overall figures that we should look at the problem. I am not saying everything is perfect or that everything was perfect over the winter. There were real problems in these hospitals over the winter and the nursing staff had real problems in the hospitals. Looking at the figures one can see why. Last year there were 226,933 new attendances in the six accident and emergency departments and 45,149 patients were admitted to the six Dublin hospitals through the accident and emergency departments.

While the Eastern Health Board has the co-ordinating responsibility for the accident and emergency services in Dublin, the six individual hospitals have direct responsibility for the overall management and provision of the service. The operation of the service is, accordingly, co-ordinated by a steering committee chaired by the programme manager, general hospital care, Eastern Health Board and includes the accident and emergency consultants of the six hospitals together with their hospital managers/chief executive officers. It has recently been agreed to broaden the membership of the steering committee to include representatives of the accident and emergency nursing staff from each of the six hospitals.

As is the case with the rest of the country, it is not possible to predict when the accident and emergency services of the Dublin hospitals will be required or the volume of cases which will need these services at any particular time. Accordingly, from time to time, delays do occur, particularly during the winter when there has tended to be an upsurge in the number of patients presenting at accident and emergency departments for treatment. That is predictable but the level of the increase this year was not predictable because it was more than is normal seasonally.

A number of aspects need to be examined. There is a downturn in activity in all hospitals from about 15 December for a variety of reasons — Christmas, leave and so on; but there is an upsurge in January when the cases deferred in December are dealt with. If this is magnified by a particular problem, as happened this year when the elderly suffered respiratory problems during the spell of bad weather, the problem becomes more serious. It is not possible to gear the service to cater for peak demand and treat this as the norm; if we did so we would be accused of wasting public money during the rest of the year but there is a difficulty and it will have to be examined and dealt with.

When admissions to hospitals from accident and emergency departments are high some non-emergency elective admissions are cancelled. This is not new; it has been the practice for many years that if hospital beds are full because of emergency admissions non-emergency admissions suffer. It is regrettable when this happens and it would be better if that was not the case but the cancellation of non-emergency elective admissions is not a recent phenomenon. It occurred under previous Administrations. I hope the position will be improved but I do not think the problem can be eliminated completely because in certain years there will always be a peak of demand which has not been allowed for in the normal provision of services. When this happens some elective admissions will be cancelled or deferred, which is the more proper description. Where non-emergency elective admissions are cancelled hospitals try to reschedule the appointments as soon as possible. Experience suggests that, despite the exceptional difficulties of recent months, the number of elective patients treated over the whole year will be similar to the number in 1994.

The approach necessary for an effective response to the problem of delays in accident and emergency departments is threefold. It is important that general practitioner services are appropriately utilised. Very often patients come to accident and emergency departments in the first instance instead of going to their general practitioner. I understand that St. James's Hospital recently completed a pilot project involving general practitioners in the accident and emergency service with a view to encouraging more appropriate utilisation of the services available by patients. My Department is examining the possibility of extending this project. We will also be entering into intensive discussions with general practitioner interests to agree on what further steps can be taken to improve the availability of services outside normal hours, particularly in Dublin.

It is also important that the operation of the accident and emergency department is properly integrated with the operation of the hospital as a whole. My Department has urged hospitals to look at how they manage their workload having regard to the level of admissions through the accident and emergency department. Hospitals will have to accept that, as night follows day, they will be under exceptional pressure at particular times of the year and they must organise themselves to deal with the problem. This is as much part of their role as providing specialist services on an elective basis.

It is necessary that there are sufficient appropriate care facilities available for those patients no longer in need of acute care. This point was made forcibly by Deputy Geoghegan-Quinn. One of the principal causes of delay in placing patients in the most appropriate type of accommodation has been the shortage of suitable facilities. That shortage results in elderly and young chronically sick patients having to remain in acute hospitals longer than necessary, thus reducing the number of beds available for new admissions. This has been a particular problem in Dublin in recent years and one that has faced different Governments. The resolution of this problem is now a priority and will be the subject of intensive and sustained attention until we have achieved a satisfactory balance between acute and continuing care provisions.

It is unfair to criticise the Department of Health when there are difficulties in a particular service. The health services are organised on the basis that the Department provides the money and states the policy but responsibility for the day to day running of the services lies either with the health boards or the voluntary hospitals. Deputy Geoghegan-Quinn made the point that on one occasion when the Mater Hospital was under pressure the ambulance service, which is integrated in Dublin, was not notified for three hours; according to protocol it should be notified immediately. If the protocol is not followed it is not for me to make the telephone call from the Mater Hospital to the ambulance service, neither is it appropriate for the secretary of the Department to do so. Who runs the Mater Hospital? These questions will have to be asked. When something goes wrong and there is a minor administrative problem where someone does not put through a call in a hospital which has full authority, strong funding, talks about its ethos and has full control, this is not the fault of the Minister for Health or the Department but of the person who was responsible.

I am as committed as Deputy Geoghegan-Quinn to the health stategy produced by the previous Government, part of which deals with the integration of services and devolution of responsibility to the health boards and voluntary hospitals, but with devolution goes responsibility. There is no point devolving responsibility if people are not prepared to take responsibility when things go wrong. One cannot go out from Hawkins House in the middle of the night and run the hospital. Management in the health boards and hospitals will have to take responsibility and put their own procedures in place to improve the position. They will receive every help from me but we can carry this too far. In this House we accept the blame for many things when in fact responsibility lies elsewhere.

The Government has taken action this year, for example, through the provision of funding for additional facilities — sub-acute accommodation — for the care of the elderly in the Dublin area. I provided £850,000 to the Eastern Health Board in January, the biggest allocation ever made for this purpose, to provide as a matter of urgency additional alternative accommodation for patients in acute hospitals who no longer require acute care. Placing such patients in accommodation more appropriate to their needs eases the pressure on the acute hospitals and reduces the delays in admitting patients to hospital. In addition, and in view of the difficulties identified in the provision of accident and emergency services at the Mater Hospital, I have provided £200,000 in 1995 to enable that hospital provide more staffing for extra treatment cubicles in the casualty department with a new 12 bed observation ward in its accident and emergency department.

It is not true that no attention was paid to what was happening in accident and emergency departments this winter, that the Department was unaware or reluctant to take action or, to quote Deputy Geoghegan-Quinn, was washing its hands of a particular problem. There was no washing of hands and if we check the records we will find that the allocation of £850,000 was made to the Eastern Health Board before there was any publicity in the newspapers about accident and emergency services in Dublin in January.

I now turn to the question of waiting lists for in-patient treatment. Over the past two years, when the Fianna Fáil-Labour Government was in office, £30 million was provided to tackle the problem of long waiting lists. The action programme for which this funding was allocated has led to the most dramatic reductions in waiting times for treatment and has reduced considerably the excessive waiting lists which were allowed to build up during the late eighties.

The waiting list initiative was driven by the need to improve equity of access to the hospital system as set out in the health strategy. There is no need to remind the House that the most important factor from the viewpoint of the patient is to ensure that the time spent waiting for treatment is as short as possible. Funding was therefore provided to ensure a reduction in waiting lists where waiting times for adults were in excess of 12 months and for children in excess of six months. The specialities of ENT, ophthalmology, orthopaedics, plastic surgery, vascular surgery, general surgery gynaecology and urology were targeted as needing particular attention. In addition, a special programme of investment was undertaken in association with the waiting list initiative to address the urgent need for an improvement in cardiac surgery services.

The Department has recently concluded an analysis of the waiting list position. The figures are interesting. The 1994 initiative provided that a total of 12,468 additional procedures would be undertaken to address the problem of long waiting times in the problem specialities. These procedures were in addition to the normal levels of hospital activity. Targets were formally agreed with individual agencies and value for money was guaranteed by ensuring that hospitals would only benefit from the additional funding where the targets for additional activity were fulfilled and normal activity levels maintained. Where hospitals did not meet their targets funding was clawed back and reallocated to hospitals which were more than meeting their targets. It is now clear that hospitals have once more responded to the challenge presented by the waiting list initiative and the targets set for each specialty have not only been fulfilled, but in certain areas have been exceeded. By the end of the year, the total level of additional activity carried out under the initiative amounted to 16,669 procedures, 4,201 procedures more than originally agreed. This represents an excellent return and excellent value for money.

While the waiting list initiative has resulted in a major increase in the number of operations being performed in hospitals, it goes without saying that the real measure of the success of the initiative is the effect it has on the number of people waiting for treatment and length of time which the individual patient must wait. The House will, therefore, be pleased to know that the total number of people waiting for treatment in all specialties has shown a reduction.

In June 1993 when the first initiative commenced the total waiting list for all specialists was 40,130. At the end of 1993, the total numbers waiting for treatment stood at 25,373. This number had increased to just under 28,000 at the end of March 1994. By 31 December 1994, this figure had been reduced to 23,835. A reduction of 13 per cent has therefore been achieved on the March 1994 peak and since June 1993, when the initiative commenced, the overall waiting list figure has reduced from 40,130 to 23,835 at the end of December 1994. Over the 18 months to the end of last December the total waiting list has, therefore, fallen by 16,295 or 41 per cent. I would like to put the figure for the waiting list into context. While 23,825 people are still waiting the number of people hospitalised in 1994 was 911,713. The waiting lists, therefore, represent less than 3 per cent of the annual throughput of acute hospitals. When put in context, what looks like a huge waiting list becomes a very small percentage of the throughput. We should congratulate everybody involved, particularly the medical and nursing staff in hospitals, for giving great value for money and taking up the challenge of the waiting list initiative.

Even more impressive progress has been made in those specialties which were targeted for special attention. At the end of March 1994, 44 per cent of all adults waiting in the problem specialties had been waiting over 12 months. By the end of 1994 the proportion waiting in excess of 12 months had been reduced to 35 per cent.

Similar progress has been made in children's waiting lists. The proportion of children waiting over six months for treatment has fallen from almost 57 per cent at the end of March 1994 to 40 per cent at the end of last December, a reduction of 17 percentage points in the numbers waiting over six months. In addition, within the overall figures there has been a number of significant advances. For instance, during 1994 the plastic surgery waiting list for children which includes those waiting for treatment for conditions such as cleft palate, fell from 462 to 190, a reduction of 58 per cent; the number of children waiting over six months for ear, nose and throat procedures such as tonsil and adenoid operations and for grommets fell by 60 per cent from 691 to 277; the number of adults waiting over 12 months for general surgical procedures fell from 1,520 to 691, a reduction of 55 per cent during the year; the waiting list for varicose vein surgery fell by 35 per cent from 2,311 to 1,509. I know it is difficult to grasp statistics when they are read out very rapidly, but they will be on the record of the House. It is important that the House, which authorises expenditure of much money on the waiting list initiative, should know that the initiative introduced by the previous Fianna Fáil-Labour Government has been very successful and we will continue it this year.

It is clear, therefore, that the waiting list initiative has resulted in higher levels of activity, shorter waiting lists overall and, most importantly, less time spent waiting by the individual patient. The results of the 1994 initiative have shown that even with a reduced level of funding for the initiative compared to 1993, the health service can continue to deliver steady progress towards the eventual target of eliminating waiting times in excess of 12 months for adults and six months for children. The performance of the health service during 1994 demonstrates the value of special programmes of targeted investment such as the waiting list initiative and justifies the Government's commitment to continue the initiative in the coming years.

By targeting resources at those areas where waiting times are longest, the waiting list initiatives of the past two years have gone a long way towards improving equity of access to acute hospital services. Notwithstanding the excellent results so far, there is still more work to be done if the target waiting times are to be reached for all patients. As announced in the budget by my colleague, the Minister for Finance, a further £8 million is being provided this year to maintain the progress of the last two years. My Department will shortly enter into discussions with health agencies to explore how the funding available can be employed to best effect. I am most concerned that allocation of funding in 1995 continues to reflect the principle that those agencies which have shown themselves to be effective in reducing in-patient waiting lists and waiting times continue to be rewarded for their performance. I will, therefore examine the possibility of allocating some of the funding which will be available this year towards addressing waiting lists for out-patient services. The funding provided this year will build on the progress already made and I look forward to the further improvements in waiting times and equity of access which will result from this year's allocation.

The various initiatives I have outlined this evening provide clear evidence that this Government has provided sufficient resources both to maintain hospital services and to enhance the range of services available. Waiting lists for hospital treatment are lower and waiting times shorter than they have been for many years. Additional facilities and funding have been provided to address the problem of delays in accident and emergency departments.

However, while considerable funding has been provided for the hospital services this year, I would remind the House that the hospital service is but one element of the health service and cannot be viewed in isolation. There are many other areas of need within the health services and the provision of additional resources for the hospital system must be carefully weighted and balanced against the equally deserving needs of, for example, the mentally handicapped, the physically disabled and children at risk. We should, therefore, beware of the temptation to focus our attention entirely upon one service when the needs of other areas must also be considered.

From the outset, the Government rejected the narrow and short-sighted focus on individual sectors which underlies this motion and has concentrated on building a comprehensive and high quality health service. With the significant provision which has been made for the health service this year, the Government has demonstrated its commitment to the approach of providing a balanced and equitable service for all those who depend upon the health services. Accordingly, I commend this amendment to the House.

As a Deputy from County Mayo I wish to outline the legacy of the last three Governments in that county. I will press the Minister to ensure that phase two of the hospital project is implemented very soon. Orthopaedic services in the county are a disgrace. People from Belmullet, Ballina and Westport who suffer a simple sprain, a broken finger or whatever, may have to travel 200 miles to see an orthopaedic surgeon. I have had a number of meetings with the Minister and spelled out the requirements in the Mayo General Hospital in Castlebar. I hope when phase two is completed there will be two orthopaedic surgeons in that hospital. Proper maternity services are also required and I hope the best facilities will be provided in this regard.

The present Minister is a caring Minister who has been little more than 100 days in office. I have no doubt he realises the challenge facing him. He has seen the way the health services have been neglected in recent years and I compliment him on providing an extra £17 million this year for that purpose. In reply to a parliamentary question I put down today on the number of people awaiting hip replacement operations in Mayo I was told that 1,491 persons are on the waiting list. That is a disgrace. I ask the Minister to ensure these queues are shortened. I also ask him to ensure that two orthopaedic surgeons are appointed to Mayo General Hospital to cater for people from Ballina, Belmullet and Westport. Those people should not have to travel to Galway to see specialists. The Minister has started well and he should keep up the good work. I am glad he is looking after the underprivileged in our society. He has a good grasp of his brief and I have no doubt he will do a good job.

I look forward in the next few months to the Minister telling me that two or three orthopaedic surgeons will be appointed to the Mayo General Hospital in Castlebar. I will keep the pressure on the Minister, not like my friends on the far side who forgot about the health services. I remember when the Taoiseach of a recent Government did not realise there was a crisis in the health services. We have come into office when there is a crisis and we will resolve it. I look forward to hearing good news for the people of County Mayo very soon.

I wish to share my time with Deputy Callely.

I am sure that is satisfactory and agreed.

I speak on this motion as Fianna Fáil spokesman on labour affairs. I listened carefully to what the Minister had to say and I have heard the same type of comment from a number of Ministers since the formation of the Government. They do not seem to realise that they are in a position to make decisions to deal with issues. Other Ministers, like Deputy Bruton, blamed Fianna Fáil regarding the community employment initiative. Such Ministers do not seem to appreciate there were two parties in the previous Government. I ask the Government to face up to the fact that it has been in power for four months and that it is up to it to deal with this issue.

I am conscious that nursing staff, in particular, have been protesting on this issue and they do not do so without good reason. The Minister should listen carefully to what they and their representatives have to say. I note the Minister in his opening address acknowledged the role of the two parties in the previous Government and has given them credit for some achievements.

I want to refer specifically to the crisis which has been allowed develop in Dublin, north and south of the Liffey, in the six acute hospitals. Morale among hospital staff is at an all time low and patients and their families are enduring unacceptable hardship. As the main Opposition party we have not just a right but a duty to speak out on these issues. It is disingenuous of the Minister or anybody else to accuse us of being opportunistic. We have been criticised at times for being too quiet on issues, but we have heard what those representing patients, nurses and hospital staff have said to us. We have a duty and a right to speak out and we will not be silenced by any Minister.

Problems have been highlighted, particularly in the Mater Hospital and Beaumont Hospital, and they are replicated in other major Dublin hospitals. The crisis centres around the fact that there are too few beds and too few staff within the system. Sadly, the response has been to lurch along from one crisis to another. There is no fundamental forward planning either at hospital management level or ar ministerial level. Government policy depends on the latest press release from the Minister promising more money to reduce the waiting list. That is all very fine and sounds good, but when we look behind those promises of extra funding, we see that in this year's budget £8 million has been set aside for reducing the waiting list. That headline may read well, but the sum compares most unfavourably with allocations made in the past two years, £10 million last year and £20 million the previous year. The reality behind those announcements — we have heard some tonight which I welcome — is that patients and their families are suffering and hospital staff have to endure impossible working conditions.

I wish to put on record my admiration for the dedication and commitment of the thousands of nurses and hospital staff. No doubt at some stage in our lives we have all, either as hospital patients or as visitors, seen at first hand the high quality of care provided. The current dispute is not about pay, but about deplorable conditions and the lack of a cohesive plan to deal with the current crisis and chart an adequate and realistic way forward for all concerned.

It is evident that the accident and emergency services need to be more adequately co-ordinated and optimum use made of every bed space. There are glaring contradictions in the actions of the Minister and hospital management in addressing the issue of the number of bed spaces. The Minister announces the provision of more funds to deal with bed shortages while at the same time there are seasonal bed closures in hospitals for two months of the year. While the Minister is making additional moneys available to provide more beds, he is also extending the waiting list by closing hospital beds. This practice of summer bed closures, which has become the norm, should be ended. It does not make sense.

What we are witnessing is an accident and emergency service in Dublin that is in disarray and in critical need of an honest analysis. I propose such analysis should take place. The Minister referred to various consultations and analyses being undertaken. There should be a clear analysis followed by a five-year action plan. It is time the Government faced up to its responsibilities and decided on a long term strategy rather than simply making announcements.

Can the Minister say with any conviction that he and his Department have planned in a coherent way for the next three to five years to provide adequate staff for accident and emergency services? Are there adequate numbers coming through the nursing education system for casualty, theatre and intensive care services? Unfortunately, the answer is in the negative. What needs to be appreciated is that an experienced casualty nurse is a valuable investment. The shortage of experienced staff has led to a greater dependence on temporary personnel. That shift from permanent to temporary staff is a worrying trend and reflects a fundamental lack of a long term strategic plan.

There is considerable scope for improvement in the management of our hospitals. For example, I question why it takes a minimum of four doctors to see a patient before he or she is admitted. The patient has to be seen by a junior doctor, a registrar, a consultant and so on. Why is it not possible for a registrar or consultant to be on duty at all times so that either one could make a decision on admittance? There is also room for substantial change in consultants' practices in hospitals. It is only right and proper that a ward round be done every morning and evening. This would surely be in the interest of an efficient service and, most importantly, it would be in the patients' interest.

The proposals put forward by the Irish Nurses' Organisation for the provision of community nursing units is relevant to this debate. I am pleased the Minister referred to that item. It would involve taking elderly patients who are recovering from illness away from an acute hospital setting to a community-based environment where they would be helped in a nursing unit to regain their independence and return home. The Minister should seriously consider establishing a nursing unit pilot scheme. I am convinced it would be very much in the patients' interest, providing a personalised health care and support system that would prove to be cost effective. Elderly patients recovering from an illness are not always appropriately placed. Instead of being in an acute ward they would be cared for in a homelike atmosphere where they would undergo intensive nursing and rehabilitation treatment.

This debate is not about pay, it is about the organisation and administration of our hospitals, it is about providing a caring service for hospital patients and their families and the treatment of our hospitals staff who are at the core of the service and who are the backbone of our health care system. Much has been said, and quite rightly, about the tremendous reputation, professionalism and high standards of care historically provided by Irish nurses but when one reads recent reports and observes recent happenings, one can readily appreciate what they had to endure. They have protested as a result of genuine frustration and anger at the lack of commitment to find real, lasting solutions.

Shortage of beds has meant that the casualty unit in the Mater Hospital was used as a holding area for patients, they were unable to sleep and they were left in chairs or on trolleys for the night. That is not an exaggeration or engaging in dramatics. How can we claim we are a caring nation when we allow this to happen? The answer is not for the Minister to say that our Government did not resolve it because it is clear, even from the Minister's remarks, that the former Government made some effort to resolve it. I remind the Minister that he is now in possession and it is up to him to deal with the issue. He should stop this nonsense of blaming the preceding Administration. In the same hospital an elderly man had to lie on a coat on the floor and an elderly woman was put lying on a bench; in some cases, patients did not have proper washing or toilet facilities and proper meals were not served.

The underlying problem is a shortage of beds and lack of co-ordination between the various hospitals. I am aware that particular problems have arisen occasioned by the number of elderly people in need of care over recent months — I acknowledge that — but surely there should have been some contingency plans drawn up for such circumstances bearing in mind that there are such a high number of elderly people. When things did go wrong, that problem should have been addressed. It is not good enough to suggest, as did the Minister this evening, that this has been happening right across Europe, that this problem is not peculiar to this country.

It is time for the Minister to acknowledge that the system within which he and his Department work is in need of his urgent attention, that the overall hospital care system badly needs his urgent attention. What is not required is more rhetoric or announcements but rather concrete action. It is simply not good enough to come in here and, in the first quarter of his speech, deride our spokesperson on health, Deputy Geoghegan-Quinn, and the very valuable work done in the past. The Minister must face up to his responsibilities. Crises arise from time to time and warrant action rather than the type of Ministerial response given this evening.

The Minister has taken a duster and wiped the motion tabled by our spokesperson, Deputy Geoghegan-Quinn and others off the agenda by changing every word. It is regrettable that he does not recognise or accept some of the sentiment expressed in that motion.

In tabling his amendment the Minister took the opportunity of clapping his Government on the back, claiming that patients and their families have not suffered any hardship by being unable to obtain appointments, having appointments cancelled or having to wait considerable periods before being seen by medical staff. The Minister does not recognise there is overcrowding in hospitals or that there is any erosion of morale among their staff. That is regrettable.

While I have a certain admiration for the Minister for Health, in as much as he has a record of addressing issues and getting things done, he appears to be shying away from this issue. All he need do is recognise that a problem obtains rather than shy away from it or wipe it off the board. He should then adopt a stepped care approach — we do not expect him to resolve the problem over night — in addressing the issues before him.

The Minister referred to improvements in the acute hospitals services and to the accident and emergency services, referring to the co-ordinating role of the Eastern Health Board. Would he please come clean on this issue? What does he mean when he talks about a co-ordinating role? Does he hear the knocks on his door or the cries for help on the part of the co-ordination body when they say there are insufficient beds? If he does, what is his response? He comes into this House — this is not the first time this issue has been raised in the House in recent weeks and refers to co-ordination and to the voluntary sector, but we must remember that the buck stops somewhere. Can somebody inform me where the buck stops on this issue?

The Minister referred to the largest ever allocation to the Eastern Health Board to free up some beds that may be blocked through occupancy by elderly patients and mentioned the figure of £850,000. What will that amount of money do for the population of Dublin, for the six hospitals involved? For example, will it free up all the blocked beds and if so, for how long — weeks, days, months? I hope the Minister recognises that it will free up approximately 42 beds only which, when divided between the six acute hospitals and their catchment areas, will mean very little, if anything, and will do nothing to address the overall problem. Indeed, this is not the first time this type of fire brigade response has been given to the freeing-up of beds; last year and the preceding one there was a similar allocation. There are insufficient long-stay accommodation beds within the Eastern Health Board area accompanied by insufficient step-down facilities.

I wish to revert to the matter of the Eastern Health Board to which the Minister likes to refer whenever it suits him. Ten years ago the Eastern Health Board identified the need for such step-down facilities, yet ten years of dust has settled on the board's submissions to the Department. Would the Minister respond to that charge alone — that for ten years the statutory authorities sought funds, capital and running expenses, to develop appropriate step-down facilities? The Minister talks about the first unit coming on-stream very shortly, a 50 bed unit. Let him come clean on that issue. That was a land swop under which a private developer is building a 50-bed unit for the Eastern Health Board without one penny being donated by the Department of Health.

Most people would acknowledge that, with regard to the Eastern Health Board, I have a knowledge of the matters about which I speak, and that what I am saying is factual and truthful. The Minister is not recognising any of these very serious issues. We are talking about people who cannot avail of the hospital services they need. That is a very serious issue. Is there somebody sufficiently honest to stand up in this House and acknowledge that what I say is correct and warrants addressing? I do not expect a magic wand to be waved, I do not expect answers tomorrow or the appropriate plan to be implemented within a matter of weeks or months but, when I hear the Minister read nonsense by way of standard, bureaucratic replies, in cutely worded sentences, choosing areas very easy to identify, one must ask how many people seek plastic surgery, for example, the first issue referred to this evening?

Debate adjourned.
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