Dáil Éireann debate -
Tuesday, 13 Oct 1998

Vol. 495 No. 1

Private Members' Business. - Hospital Waiting Lists.

Mr. Shatter

I move:

That Dáil Éireann deplores the scandalous increase in the hospital waiting lists, which on 30 June 1998 stood at 34,331 an increase of over 13 per cent since this Government took office, and the failure of the Minister for Health and Children to implement the broad range of reforms necessary to end the waiting lists crisis.

I propose to share time with Deputies McGinley, Perry, Stanton, Deenihan, Naughten and Crawford.

Our health services must be patient centred and must put patients first. Inadequacies in the public hospital service are depriving those who need it of access within a reasonable timeframe to the medical services to which they are entitled. Those in the front line of healthcare provision, namely, doctors and nurses, are also required to work under unacceptable and intolerable pressures. During the lifetime of the current Government and the term in office of the Minister for Health and Children, hospital waiting lists have escalated dramatically and the length of time patients are forced to wait before gaining access to essential treatment or surgery has lengthened unacceptably.

Fianna Fáil and the Progressive Democrats entered Government promising waiting list reductions. Fianna Fáil promised dramatic waiting list reductions in its election manifesto in June 1997. Instead, the two Government parties have shown contempt for GMS patients and failed to harness the benefits of the Celtic tiger economy to provide, for everyone who requires it, speedy access to medical treatment and surgery.

A democratic state that guarantees people the right of access to a lawyer if they commit a crime should also guarantee their right of access to a physician and essential in-patient hospital treatment or surgery if they take ill. It is an indictment of the Minister that the number of patients awaiting admission to hospital for treatment and elective surgery is steadily increasing.

As of today we have access to only the published information concerning in-patient waiting lists as it stood at the end of June 1998. At the end of June 1997 there were 30,453 people on the in-patient hospital waiting list. By the end of June 1998 the number had risen to 34,331 patients. These figures included 7,638 people awaiting ear, nose and throat surgery or procedures, 6,648 people awaiting orthopaedic surgery, 3,608 people awaiting ophthalmology services, 2,545 women awaiting gynaecological procedures, 2,762 people awaiting vascular treatment, 1,430 patients awaiting urological procedures, 1,211 awaiting cardiac surgery and 1,243 awaiting cardiological procedures. During the summer 1,477 hospital beds were closed for varying periods.

In the context of these closures and further autumn cutbacks being implemented by hospitals throughout the country which are attempting to remain within their financial budgets, it is reasonable to estimate that the number of people currently on hospital in-patient waiting lists is in the region of 36,500. However, the real figure will not be known for at least another two months. Waiting lists increased by 13 per cent in the first 12 months of the Minister's term of office. As of today, it is reasonable to estimate that they have increased by 18 per cent. It is not merely the number of people on in-patient hospital waiting lists which is of particular concern, it is the length of time adults and children must wait for essential treatment.

The Minister for Health and Children publicly stated that he has an objective to ensure that where an adult requires surgery it will be undertaken within 12 months and that where a child requires surgery it will be undertaken within six months. The Minister has failed to achieve this objective. At the end of June 1998, 827 adults had been awaiting cardiac surgery for in excess of 12 months. Some of these people have been awaiting surgery for almost two years or longer. At the end of June 1998, 47 children had been awaiting cardiac surgery for in excess of six months. It was recently reported — the Minister may or may not confirm the accuracy of the report — that there are now 56 children who have been on cardiac surgery waiting lists for in excess of 18 months.

While I accept the waiting list initiative targeted cardiac surgery this year and as a consequence, in fairness to the Minister, it must be acknowledged the overall cardiac surgery waiting list has been reduced, the initiative nevertheless fell abysmally short of what was required to meet the essential objective articulated by the Minister. In other areas, the Minister's waiting list initiative had virtually no impact. For example, on 30 June 1998, for in excess of 12 months 650 adult patients had been awaiting cataract surgery, 435 adult patients had been awaiting hip replacement operations and 2,216 had been awaiting ear, nose and throat procedures. As of 30 June 1998, for over six months 1,456 children had been awaiting tonsil and adenoid surgery, 194 had been awaiting grommet surgery and 136 awaiting various ophthalmology procedures.

At a time of unprecedented economic prosperity it is unacceptable that so many public patients must wait so long to be admitted to hospital. It is indefensible that life-enhancing, pain-relieving operations such as hip replacements should be out of reach for months — in some cases even years — for elderly and infirm people. It is unacceptable and unjust that children's school attendance is disrupted by ongoing bouts of debilitating infection while the ear, nose and throat surgery waiting lists grow longer by the month. It is also unacceptable that school-going children with hearing difficulties have their education seriously impaired. It is shocking that in this day and age cardiac patients die while on the cardiac surgery waiting list. It is scandalous that in a reply to a recent Dáil question the Minister for Health and Children admitted that neither he nor his Department had readily available information regarding the number of patients who have died while awaiting cardiac surgery. This is something I would expect to be of central concern to a Minister for Health and Children.

Is this information "not readily available to the Minister"— to use the phrase which appeared in the reply to which I referred — because he does not want to know the reality of the tragedies which confront families reliant on access to public hospital healthcare or is it not readily available because he does not wish to be held responsible for such deaths and is more concerned with his Department's possible legal liability than with the plight of patients. Astonishingly, this is not the only information stated by the Minister in reply to a succession of Dáil questions to be "not routinely collected" or "not readily available to his Department". For 12 months the Minister has been unable to supply me with full details of all requests from hospitals throughout the State for additional financial allocations to either modernise their facilities or provide additional services. I am now seeking this information under the terms of the Freedom of Information Act.

Last week, in reply to a Dáil question, the Minister informed me that information is not "readily available" to detail existing requests from hospitals throughout the State for the appointment of additional consultants and the nature of the specialities concerned. Nor was information readily available regarding the number of current vacant hospital consultant posts throughout the country or the relevant hospital and health board areas to which these vacancies relate. In addition, the Minister could not inform me of the posts currently vacant due to delays in his Department providing the required financial sanction.

Obviously there is considerable concern on the Fianna Fáil back benches about the scandalous state of the public hospital in-patient waiting lists. As recently as last Thursday, Deputy Callely asked the Minister "if his attention has been drawn to the cancellation of appointments and ward closure in hospitals, reported to be due to inadequate budget allocation to meet the demand, with particular reference to the Mater and Beaumont hospitals". The number of temporary bed closures in Beaumont Hospital to date this year is 191, while the number for the Mater Hospital is 60 for a period of 12 weeks. I understand a similar number of beds in the Mater Hospital will remain closed for the last quarter of this year.

It is obvious that Deputy Callely was stirred by the plight of his constituents who are regularly being informed that surgery fixed for particular dates, many months in advance, is being cancelled. It is not unreasonable to assume that Deputy Callely, prior to tabling his parliamentary question, had discussed his worries with the Minister for Health and Children and this question was the last throw of a desperate man concerned about his electoral prospects at the next election. What did the Minister say to him to set his mind at ease? Did he get the assurances he was seeking? Did the Minister respond to his clarion call of concern? The reply he received from his Fianna Fáil ministerial colleague was that his Department does not collect information on numbers of postponed elective procedures or appointments. The Deputy was told that temporary bed closures form a part of the normal bed management function performed by local hospital management with an overall budgetary management strategy. All he got essentially was a piece of political gobbledegook which, when translated, was basically an acknowledgement by the Minister that he had failed to provide to either hospital the funding each required for 1998 and that as a consequence they each had to close down beds and elective surgery had to be cancelled. Implicitly, the Minister was telling his colleague that while he remained Minister for Health and Children the same would happen in 1999. I wonder did Deputy Callely circulate the Minister's reply to his parliamentary question around his constituency with his usual enthusiasm.

Hospital bed closures are a false economy. Waiting list reductions effected by waiting list initiatives are ultimately off-set by bed closures which result in the cancellation of elective surgery. So far I have been addressing the problem of in-patient hospital waiting lists, the only waiting list published. There are two waiting lists, one visible and one hidden. The visible waiting list is that of the 36,500 public patients who are today waiting to be admitted to hospital for surgery or treatment. The second hidden list is made up of those thousands of people who have been referred by their GP to a consultant, who are awaiting for many months — some for more than a year — to see the consultant to whom they have been referred. They are essentially a queue to potentially join another queue, the in-patient hospital waiting list queue. Again astonishingly, the Minister for Health and Children collates no information and is unable to estimate the numbers of patients on this hidden queue to join a queue, nor the length of time within any area of speciality during which people must wait to see a consultant.

The delays experienced by public patients create unnecessary anxiety not only for people whose medical condition may already be a cause of concern, but place extra strain on close family members. These delays are also directly impacting on the quality of life of patients and their families, and in the context of particular illnesses place patients' lives at risk.

I acknowledge that the individual waiting list initiatives of the Minister and his predecessors have solved the individual health problems of many thousands of people. However, waiting list initiatives have not and cannot structurally solve the waiting list problem. Nevertheless it is clear that a further substantial sum must be allocated as a waiting list initiative by the Government in its forthcoming budget to tackle today's chronic waiting list crisis.

I am dismayed to read of the recent speech to the Irish Hospital Consultants' Association by the Minister for Health and Children in dealing with this aspect of the waiting list issue. It seems that when speaking in public about this problem the Minister is incapable of accepting that it is his responsibility and the responsibility of the

Government of which he is a member to address and resolve it. He is reported in one of the medical journals over the past two weeks as stating that he will seek £20 million for a waiting list initiative for 1999 from the Minister for Finance. His presentation of this resembled that of a supplicant collecting crumbs at the table of an uncooperative and unsympathetic finance Minister. His comments suggested that he was not optimistic he would get the sum he was seeking so that in the event of this amount being allocated to him he can present himself in heroic guise. The Minister should know the audience he is addressing in this manner is not impressed. The Minister is part of the Government and not apart from it. Instead of this public playacting, he should ensure in discussions with his Fianna Fáil colleague in the Department of Finance that the funds required to tackle the waiting list crisis are allocated and he should in the last quarter of this financial year now urgently seek an additional allocation of funds to prevent the inevitable bed closures in October, November and December.

Apart from funding an allocation for waiting list initiatives, a great deal more is necessary. To tackle the waiting list crisis, a broad range of reforms are required which impact on departmental, health board and Comhairle na n-Ospidéal procedures, on hospital structures, the management of waiting lists and the manner in which GPs and consultants work, as well as medical staffing. The co-ordinated nationwide use of the latest interactive communications as a diagnostic tool and for the administration and monitoring of the health service is also crucial to ensuring a caring health service responsive to the community's needs and equipped to meet the challenges of a new millennium. At a time of unprecedented economic growth and Exchequer income, funds should be targeted to put in place a comprehensive programme of measures which once and for all addresses the waiting list problem.

Experience has taught that ad hoc piecemeal initiatives merely act as a palliative. What we need is a cure. Fine Gael proposes a number of specific actions designed to tackle the in-patient and out-patient waiting list crisis in a systematic and practical way, and to make the acute hospital services more patient centred. First, we propose that national guidelines be put in place detailing specific timeframes within which a patient should attend with a consultant for an opinion and within which treatments would be provided or surgery undertaken. Financial allocations to the health service and the appointment of medical personnel should be designed to facilitate compliance with these guidelines nationally and to set a standard for the provision of medical services.

There is also a need for a radical overhaul of the approach taken by the Department of Health and Children to monitor the provision of medical services. New information systems and technology are required by the Department to link into existing hospital and health board computer systems to enable the Department to have available to it up to date statistics and information so that it can fully monitor and analyse the manner in which the medical service is functioning within each health board area and within each hospital within each health board area. At present only quarterly figures are published for in-patient hospital waiting lists. There can be anything between four and six months delay for information contained in such figures to become available. The Department, as we have already seen, does not maintain up to date statistical information in a variety of other areas. These issues must be addressed by a proper monitoring system which gives on-line up to date daily information on the workings of the health system.

Where consultation posts are vacant or new consultant posts have been approved appointments should be made without delay. In the event of retirement, death or incapacity of a consultant in an approved post, hospitals and health boards must be given the authority to immediately set in train the necessary recruitment procedures and to make the required permanent appointment without recourse to the Department of Health and Children. There is also a need to ensure that health boards and hospitals fill temporary posts which are required without delay. At present unnecessary delays frequently occur in filling positions. These delays are exacerbating the waiting list problem.

There is a need to appoint additional consultants and this need is apparent throughout the health service. The growth in the waiting lists is a direct consequence of the failure of the Minister to sanction the appointment of the additional consultants required. Provision also should be made for a new grade structure in the health service to allow for the appointment of specialists, a grade above that of senior registrar but below that of consultant. Doctors recruited as specialists would have to have qualifications approved as appropriate for identified specialities by the postgraduate medical colleges. Specialist posts would be for a fixed term of three, four or five years and an educational and career structure should be put in place to provide for the possibility of specialists ultimately becoming consultants. The creation of such a new grade would have to be tailored to meet the needs of the health service. Clearly the most pressing need is for additional medical and surgical capacity to assist consultants to reduce and maintain a reduction in the public patient waiting lists. Specialists would have the skill to take consultations or perform specified procedures or routine surgery with the agreement of the consultant. The appointment of specialists would reduce pressures on consultants and the unnecessary delays experienced by patients.

Procedures should also be agreed to facilitate consultants who specialise in a particular branch of medicine in a particular hospital or health board area to join their colleagues and collaborate in operating joint waiting lists. Those who have long waiting lists should share some of their work with colleagues who have shorter lists. To maintain patient choice and in recognition of patients' wishes, those who wish to wait for a surgeon or specialist would be free to do so.

Where appropriate in hospitals to which there is attached two or more consultants who have the same speciality, consultant teams should be formed whose workload can be regulated by a clinical director within the speciality to ensure efficiency in dealing with waiting lists, in-patient admissions and discharges. The clinical director within such a team would fill this position for a period of two or three years and it would pass by rotation to other members.

Throughout the country, hospitals are suffering nursing shortages. Without further delay the Minister should urgently implement the recommendation of the Commission on Nursing and he should in doing so recognise that nurses, who have specialist qualifications, are entitled to additional income to reflect the nature of their qualifications.

We also call for a national assessment of unused capacity within each of our hospitals. Hospitals which operate efficiently and have no significant waiting list in a particular specialty or which have unused capacity should have the option to buy in work from outside their area. This does not happen at present.

The necessary legal provisions and financial and administrative mechanisms should also be put in place to facilitate cross-Border co-operation between health boards and hospitals. There is no reason cross-Border consultancy posts could not be created to ensure that the broadest range of specialist care is available to those who live adjacent to the Border in this State or in Northern Ireland.

There are a variety of additional proposals by the Fine Gael Party which are now published in the document entitled "Patient First" and which we believe, if implemented, would dramatically impact on waiting lists, not on a temporary basis, but would provide the structural basis for tackling our waiting list problem and once and for all addressing it in a comprehensive way.

I call on the Minister to take the necessary action to tackle the problem, not just by waiting list initiatives but by implementing the necessary structural reforms in our health service. I anticipate from leaks that have occurred that some of the reforms the Fine Gael Party is proposing may be included in the report of the review group on waiting lists submitted to the Minister's desk. Strangely this report has sat on his desk since last August, yet he is extraordinarily reluctant to publish it in full. I call on him to do so because we will then know what is recommended by the group appointed by him.

I challenge the Minister to implement the various recommendations contained in the Fine Gael document published last week entitled "Patient First". He has sought to deflect attention from the real extent of the waiting list problem. It is our hope that as a result of this debate he will be finally forced to take action that should have been taken a long time ago.

Mr. McGinley

A good indication of a Government's level of concern for its people is the manner in which it treats the sick and infirm and the level of care it provides for them. Applying these guidelines the Government is well down the league and the slippage continues. We now know from the Minister's figures that the waiting lists for hospitals have increased by 13 per cent nationally between June 1997 and June 1998. This deterioration occurred at a time of unprecedented economic development and when Exchequer returns are better than forecast by even the most optimistic economic commentators. Exchequer surpluses are no longer estimated in millions but in billions of pounds. This is a good country for the healthy, but is hell on earth for the sick and infirm.

While the situation nationally is serious it is disastrous in the north west and County Donegal. During the period from June 1997 to June 1998 the hospital waiting lists in Letterkenny General Hospital and Sligo Regional Hospital, the two main hospitals in the north west, have grown not by 13 per cent but by 30 per cent, an astronomical increase in a one year period. In Letterkenny General Hospital the waiting list for serious surgical procedures now stands at 632 while in Sligo Regional Hospital it is 1,544 making a total of 2,176. Over a year ago, when the Minister took office, it stood at 1,644. This represents an increase of 532 or 30 per cent. What a record. This is an intolerable situation and cannot be allowed to continue.

These figures do not include the many hundreds who have been referred to consultants by GPs, to what my colleague, Deputy Shatter, has referred to as the queue to join a queue. In addition, there are many more hundreds from County Donegal and the north west on waiting lists for Dublin hospitals where more complicated procedures are carried out, such as cardiac surgery, chemotherapy and radium treatment. Many have been on the list for a year or more. There are 153 on the Letterkenny General Hospital waiting list for over a year and in Sligo Regional Hospital the situation is more critical, where there are 269, excluding approximately 200 children.

If one is fortunate enough to be in a position to pay for private treatment one can be admitted almost immediately. This is a most unjust system. I know of people in County Donegal who have sacrificed their life savings to go private to relieve their pain and suffering. Everybody agrees that the present situation cannot be allowed to continue. The Minister has failed dismally to deliver an adequate service. His performance as Minister does not match the eloquence of his promise when he was in Opposition.

More resources are urgently required. The practice of ward closures during the summer and holiday periods must be discontinued. There should be more co-operation between the North-Western Health Board authorities and the Northern Ireland health authorities where under utilised facilities exist. I appeal to the Minister to seriously address the scandal of waiting lists for admissions to hospitals.

Mr. Deenihan

A headline in today's Irish Medical Times states that more than one in three patients are on hospital waiting lists for one year. It goes on to report that, according to new figures, more than one in three patients have been on a hospital waiting list for in-patient treatment for over a year and that of the 30,777 patients on the targeted specialty waiting list nationwide at the end of June, 14,329 adults had been awaiting treatment for between three and 12 months while 12,319 have been on the list for over one year.

The figures released by the Minister's Department showed an increase of 42 per cent in the waiting list for public in-patient treatment for Tralee General Hospital. I subsequently checked with the Southern Health Board and it has revised those figures to 50 per cent. This is unacceptable. I wish to quote the following from a letter I received during the week from a concerned parent:

I am writing to you in the hope that you might be able to do something for my son. He has been on the waiting list for about one and a half years to get his tonsils out. I am at the doctors every week or every two weeks with him. He has not even been called to see [the consultant] yet.

Every time I go to the doctors they say they have written or telephoned them, but no call has come for him. I know there is a long waiting list but he is very sick with the tonsils and is also losing weight.

It is unacceptable and unjust that children should have had their school attendance disrupted by ongoing bouts of debilitating infection while the waiting list for ENT surgery grows longer by the month. I appeal to the Minister to do something about the matter.

The figures for Tralee General Hospital also indicate that the gynaecology waiting list had increased since June 1997 from 146 to 273, an increase of 127. While there may be a reason for that, it is unacceptable that it should be allowed happen. In addition, the waiting list for orthopaedics has increased from 82 last year to 106. The overall figures for Tralee General Hospital provided by the Minster's Department show an increase of 366, which is unacceptable.

I appeal to the Minister to look at the problem in Tralee General Hospital, especially the ENT waiting lists. There is a problem with all waiting lists there. The lists for the other hospitals in the Southern Health Board region do not appear to be as bad.

Mr. Crawford

I congratulate Deputy Shatter on raising this important issue. The Government is very popular and is riding high on the Celtic tiger. However, unfortunately, for the elderly and those of whatever age on hospital waiting lists there appears to be no relief or no possibility that the problem will be resolved. In my six years as a Member of Dáil Éireann I have never received so many complaints from people who cannot get an indication of when they will be called for their hip replacements operation, general orthopaedic surgery or whatever. A total of 477 people, many of whom are from my constituency, are on a waiting list at Our Lady's Hospital, Navan. It is unacceptable that they do not know when they will get relief from pain. A total of 29 beds were closed in that hospital, a recipe for disaster. Those people should be able to have the operations they need and the Minister should provide the necessary finance. More than 500 people are on waiting lists at the Cavan-Monaghan surgical hospitals, which is not a record of which to be proud.

I wish to follow up on Deputy McGinley's request that the Minister give serious consideration to the opportunities available through the Northern Ireland structures to deal with some of these problems. In the past many people, even from as far away as Cork, travelled North for surgery and that improved the position. We all hope the peace will last. As a result of it, accommodation is available in many extremely high quality hospitals in Northern Ireland. If the Minister cannot open beds in hospitals south of the Border, he should consider the opportunities that are available to relieve the dreadful pain many people are suffering.

This is not the only area of the health services that is in crisis. Many of the elderly who were in nursing homes in Northern Ireland have had to be taken out of them because of the scarcity of resources and others, who are incapable of looking after themselves, have had to return to their homes. The indications are that the health services are in crisis and the buck stops with the Minister.

Mr. Perry

I thank Deputy Shatter for sharing time with me. The most critical issues affecting Sligo General Hospital are in the area of medical admissions, day surgery facilities, the appointment of a second ophthalmic surgeon and a third general surgeon. Medical admissions increased dramatically this year, but there has been a continuing increase in admissions dating back to the 1970s. That has increased the demand for medical beds. The provision of a dedicated day surgery unit would improve matters significantly. Many hospitals in the South, including Letterkenny General Hospital, has such a unit. It is generally accepted that such a unit is much more efficient, productive and involves significantly less cost per patient treated.

Regarding childcare services and family support, the Minister will be familiar with the recent McColgan report. While those services have improved since the 1980s and early l990s, we have a responsibility to ensure the resources that are available are used to make the greatest impact possible on child protection and family support. Many more resources need to be devoted to this area. Other areas which require further development include family support services, parenting and education programmes and the development of a youth strategy. There is also a need for additional direct intervention by social workers, after hours social work services, a strengthening of support services for social work teams, the approval of additional premises in the Sligo-Leitrim region, ongoing training of foster parents, inter-agency co-ordination and purpose built residential homes.

It is anticipated that in the next 25 years there will be a 60 per cent increase in the number of people over the age of 85 in the Sligo-Leitrim area. Demands for services for the elderly will continue to increase. It is national policy that at least 90 per cent of the elderly, should be retained in their homes in so far as possible. That demands significant resources by way of home help support. The hours worked by home helps could be doubled to maintain the standard required. There must be a substantial additional allocation for the home help service which is inadequate in certain areas. A good deal more could be done to keep the elderly at home. A large number of elderly people live alone in very remote areas of Sligo-Leitrim. That area has the highest population of elderly in the country. The North Western Health Board pays home helps less per hour than any other health board and I would like the Minister to examine that. Primary health care is at the core of a comprehensive health care system. There is a development programme for primary health care, but additional provision is required for the home help service. Additional health centres are required and much more funding is necessary to develop centres which provide respite care.

Sligo General Hospital requires the appointment of a third general surgeon. The area requires three surgeons, one with a special interest in urology, one with a specific interest in the colon-rectal area and another with a special interest in cancer care. The appointment of a third surgeon would assist greatly in dealing with that devastating condition that affects so many families.

There is a long list of people waiting for an appointment for hip replacement operations. Given the additional revenue in the country, I appeal to the Minister to make more funds available to reduce the number on that waiting list. It is unreal that people have to wait up to three years to get a hip replacement. That is only one of the operations for which people are on waiting lists. I appeal to the Minister to allocate additional resources to the North Western Health Board, which is doing outstanding work in the care of the young and the elderly and in all other areas of health care.

Mr. Stanton

I thank Deputy Shatter for tabling this timely motion. Almost every Sunday evening one of my constituents, an elderly man who is a gentle soul, telephones me to know if there is any news. He wants to know when he will have his hip replacement operation. He has told me that he can hardly stand the pain he is suffering. I go through the motions of telephoning the hospital, the consultant's secretary and I write letters, but I am told nothing can be done. Initially I was told he was not on the waiting list. That was before I understood there was a waiting list for waiting lists. I then discovered he was put on the waiting list four or five months after he had been seen initially. I could not understand why that was the case, but it might have been done to show the figures in a slightly better light. Perhaps we could find out how many are on the waiting list for waiting lists. That constituent telephoned me last Sunday night and asked if he would have his operation sooner if he were able to scrape together a few pounds.

I tabled five questions to the Minister for Health and Children last week and his reply consisted of five or six lines. I asked him the average time people have to wait for hip replacement operations in the orthopaedic hospital in Cork, but he declined to put that information on the record. I asked him how many operations were carried out each month over the past year, which should have been easy to find out, but he declined to put that information on the record. I asked how many of those people hold medical cards, which should also have been easy to find out, but he also declined to put that information on the record. My biggest fear is that matters are a good deal worse than they appear.

Another constituent, who is housebound and has been waiting for a hip replacement operation for months telephoned to say she is in terrible pain. She has great difficulty and requires assistance to get in and out of her car. We can quote statistics and facts, but we are dealing with people who are in real pain and who have real problems. I appeal to the Minister to do his utmost to alleviate suffering, especially among the elderly who are defenseless. I take it the Minister is a compassionate man. I urge him and his colleagues in Government to do more because much more needs to be done. It is not good enough that the number of people on waiting lists has risen dramatically since this Minister took office. I urge him to make an effort.

It is not fair on the staff of Cork University Hospital that they must ask people to wait all day for minor operations and x-rays. It is not the fault of the staff but is due to a lack of resources. Some people have had to stay on trolleys in corridors and that is happening throughout the country. I urge the Minister, in the name of humanity, to act on this.

Minister for Health and Children (Mr. Cowen)

I move amendment No. 1:

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

"Dáil Éireann

(1) commends the Minister for Health and Children for allocating £12 million in 1998 to deal with waiting lists, which represents a 50 per cent increase in the sum allocated by the previous Government in 1997 as an important initial step towards implementing a comprehensive programme to address the issue, commencing immediately,

(2) notes that the Minister for Health and Children has undertaken the first ever formal analysis of the underlying causes of waiting lists and waiting times which enables a comprehensive overview of the needs of the health care system towards addressing the issue, and

(3) endorses his on-going strategy of dealing with waiting lists and waiting times in a structured, co-ordinated and multi-disciplinary manner, involving all components of the health care system."

I am pleased to have an opportunity tonight to deal with the issue of waiting lists and to outline what the Government is doing to tackle the matter. I am conscious that the issue of waiting lists is one which gives rise to genuine concern among members of the public.

While the actual numbers on public waiting lists have been on the increase recently, little, if any, attention has been paid to the length of time that patients must wait. The length of time spent by public patients on waiting lists in a number of important specialties has actually been reduced in recent months and in other specialties it has remained static.

For example, waiting times for adults requiring treatment in cardiac surgery, general surgery and urology fell between March and June of this year. Similarly there were improvements in waiting times for children in cardiac surgery and ear, nose and throat procedures. It is vital from the very beginning of my contribution to stress that looking solely at numbers will distract us from the real issue of how long patients are waiting for treatment. That is the issue for every individual referred to by each Deputy as regards their own regions — how long must they wait?

In addressing the question of waiting lists and waiting times, we must remember that they are an international issue. No country has wiped them out, nor can any country claim that it is easy to reduce them very quickly. A number of practical difficulties arise, irrespective of how much funding is available to deal with waiting lists.

When it becomes apparent that inroads are being made in a lengthy waiting list, new cases tend to be added quickly to the list to replace those who have received a service. This is entirely understandable, but it again underlines how inadvisable it is to look at waiting lists in isolation from waiting times. Waiting lists can be replenished by additional patients. The important point, however, is that these patients are receiving a service without undue delay.

The increase in the population, especially the older population, has resulted in an increased need for health care generally and hospital care in particular. The demand for health care has been increasing continually. As we make advances in technology, it is medically possible for patients to receive services for conditions that were previously treatable or treated as successfully.

Even a sustained and successful effort to reduce existing lists may not address the underlying cause of waiting lists developing in the first instance. Waiting lists can arise due to inadequate staffing or equipment, problems with management of the hospital's facilities, shortages of non-acute facilities or a combination of these factors. It is vital therefore, to address the underlying causes of waiting lists and waiting times so that the available funding is targeted very clearly at addressing them.

In this regard, it is not possible to deal effectively with waiting lists and waiting times within the acute hospital system alone. Each component of the health care system has a role to play. Addressing their interdependence is a critical factor in dealing with the issue in the long-term. Before dealing further with the underlying causes of waiting lists, I propose to review briefly the approach taken towards reducing waiting lists by successive Governments over the past few years.

In 1993, the then Fianna Fáil-Labour Government introduced a new waiting list initiative. It was based on allocating separate, dedicated funding to participating health board hospitals and voluntary hospitals so that they could carry out a specified number of elective procedures for patients who had been waiting for significant periods of time on a public waiting list. It was agreed with agencies that the work must relate to patients awaiting treatment and must be over and above the activity that would have been performed in the hospital from normal funding.

A total of £20 million was allocated to that in 1993 and by the end of that year, the total numbers awaiting treatment had fallen from 40,000 to 25,000. A further £10 million was allocated under the waiting list initiative in 1994 and waiting lists fell further by the end of the year to just under 24,000, a decrease of just 1,000. The progress made in those years was partly because of the level of funding that we allocated and partly because there was some spare capacity in the hospital system to take on additional activity. It is clear that in the case of some hospitals spare capacity has now been fully utilised and it will be necessary now to assess the capacity of individual hospitals to take on additional work.

During the lifetime of the Government that took office at the end of 1994, comprising Fine Gael, Labour and Democratic Left, the impetus for serious attention to waiting lists declined. A degree of complacency set in in tackling waiting lists and waiting times after the initial successes and that Government's reaction to rising waiting lists was, as a result, unplanned, unstructured and did not heed the danger signs in failing to maintain the momentum which could be seen in the 1994 figures.

It did not build on the initial success of the previous Government, reducing investment on the assumption that spare capacity was utilised fully and undertaking little analysis of the impact of the reduced investment. The previous Government allowed funding for waiting list activity to fall to £8 million and the negative effect this had on the numbers waiting will not be easy to undo. However, I am committed to addressing the problems that have arisen as a result of that.

The numbers on waiting lists and the length of waiting times for many specialties inexorably rose during the period 1995-7. When the Fine Gael-Labour-Democratic Left Government took office in December 1994, waiting lists stood at 24,000. When they left office in June 1997 waiting lists had increased to over 30,000. They rose to 32,000 by December 1997 due in part to the allocation by that Government of just £8 million for waiting list work again in 1997. This represents an increase of 33.3 per cent during the lifetime of the previous Government. With the reduced funding provided by the Rainbow Government, waiting lists rose by one third.

We can argue the facts here all night and the Opposition can refer to increases since I took office and I can refer to increases during the last Administration. However, the facts stand as they are. It is important to emphasise that in the years in which funding for waiting lists fell to £8 million — such as in 1995 and 1997, when the parties opposite were in office — waiting lists increased substantially. They rose by 4,000 in 1995 and by 6,200 in 1997. This suggests that, for the foreseeable future, we need more significant funding to address the problem of waiting lists.

It was with this in mind that I allocated £12 million for waiting list work this year, which represents an increase of 50 per cent over the funding made available by the previous Government in 1997. The additional funding will result in an extra 15,000 procedures being carried out during the current year. Again, I caution against the simplistic approach of counting numbers only, with no regard to waiting times, but it is quite clear that adequate funding is required to support a sufficient level of dedicated hospital work to reduce both waiting lists and waiting times.

When we came into office, we gave a clear commitment to tackling the problem of waiting lists and waiting times in a planned and structured way, starting with an analysis of the underlying causes of waiting lists. Since taking office, I have taken a number of initiatives in relation to the operation of the waiting lists as they then were. I ensured that hospitals received earlier notification of the level of funding that was to be made available to them under this initiative. They received details of their waiting list funding in December whereas in previous years the funding for waiting lists tended not to be allocated until July. This earlier notice has enabled hospitals to plan their activities more easily with money for the waiting list initiative now being made available during the course of the full year. This provides for better planning on the part of health agencies.

I placed an increased focus on waiting times as well as waiting lists so that we would not lose sight of our major concern, that is, to reduce the length of time patients must await treatment on a public waiting list. The target is that children should have to wait no longer than six months and adults no longer than 12 months in the specialties targeted for attention. I instructed hospitals to designate an individual to act as a co-ordinator of waiting list work and as a contact point with my Department on waiting list issues.

The changes will take some time to have effect but they are an important starting point and should be acknowledged as such. The Government has implemented a more planned and structured approach to the issue of waiting lists. I took one further vital step in April this year, that was to establish the first ever formal analysis of waiting lists and waiting times. I appointed an expert review group on the waiting list initiative drawn from the clinicians who provide treatment under the initiative, the managers who oversee it and officials of the Department. Its terms of reference were to examine the underlying factors giving rise to waiting lists and waiting times and to make recommendations on the most appropriate means of addressing the underlying causes of substantial waiting lists and waiting times. The review was to have particular regard to the net effect of the waiting list initiative on waiting lists and waiting times; any incentive effects of the waiting list initiative on participating hospitals in relation to their activity and treatment schedules; the extent to which hospitals can consistently and accurately validate waiting lists, and the adequacy of existing information systems, which have been criticised, to permit routine evaluation of the waiting list initiative.

The review group comprised consultants in the specialties of accident and emergency, cardiology, orthopaedic surgery and geriatrics. It also included a general practitioner, a specialist in public health medicine, a former chief executive of a major Dublin teaching hospital, a deputy chief medical officer and other senior officials of the Department.

The urgency I attach to this issue is underlined by the fact that the review group reported rapidly within a few months of its establishment. I received its report in mid-August. I thank the members for their work. I consider it to be a useful contribution, as an analysis of the causes of waiting lists and as the basis for the work which is under way as a priority in the Department on the development of a comprehensive plan to address the underlying causes of waiting lists and waiting times.

I propose to present the plan to Government as soon as the logistics of what is a complex exercise have been worked out carefully. I cannot emphasise strongly enough the commitment of the Government to deal with the issue but it will not attempt to do so in a short-term, knee-jerk manner. Waiting lists and waiting times can only be dealt with in a structured, co-ordinated way, involving all components of the health care system working together. This involves developing a long-term plan, not merely attempts at quick fix solutions.

The report of the review group sets out a logical and structured means of addressing waiting lists and waiting times. These include, as immediate-term objectives, a further study of hospital capacity to be carried out as a matter of urgency——

Ms Shortall

More reports and studies.

Mr. Cowen

——a review of information systems by agencies to ensure they can maintain accurate and up-to-date waiting list initiative data — agencies should be assisted if specific shortfalls are identified; a bulk postal review of patients on waiting lists where hospitals have not done so in the previous 12 months; the encouragement of an improved flow of information between primary and hospital care regarding the status of patients on waiting lists; a continued move towards day case work, the appointment of bed managers and bed utilisation committees; agreement under each agency's service plan regarding the mix of public and private patients treated, and a written policy on planning the discharge of older patients and liaising with community based services.

The review group recommended, as medium-term objectives in 1999, that WLI funding should focus on a limited number of specialties and take the greatest possible account of health and social gain; that the Department of Health and Children should consider introducing possible financial incentives for hospitals to reduce their waiting times; that protocols be developed in all major waiting list specialties for the validation and prioritisation of cases, and that a number of measures be pursued to reduce the pressure from accident and emergency services on acute beds.

The review group recommended, as long-term objectives from 1999 to 2001 — these are focused primarily on freeing up acute hospital beds — the development of geriatric day hospitals and rehabilitation facilities on the site of acute hospitals; the development of a planned programme of investment in appropriate facilities for those in need of long-term care; that the case for providing stand-alone day surgery units on the site of acute hospitals for acute patients should be examined closely, and that the question of providing additional hospital or other short-term accommodation for patients who do not otherwise need to stay overnight in an acute bed should be pursued as a means of reducing unnecessary hospital stays.

The report of the review group highlights the main pressures on the health system, particularly the features that give rise to problems in meeting the genuine needs of public patients. Some of the most important of these features relate to an increase in the total population; an increasing number of older people in the population with consequent need for additional short-term and longer-term facilities, and increasing demands for health care generally and acute hospital care in particular.

Before turning to the specific needs of older persons, it should be remembered that the population as a whole has grown by 150,000 since 1990. As the in-patient capacity of acute hospitals has remained virtually static in recent years, its ability to cope with the increased demand arising from the growth in the population has been greatly challenged. At the same time there has been a growing demand on acute hospital facilities with the number of persons treated as in-patients and as day cases rising significantly in recent years.

The National Council on Ageing and Older People projects an increase of nearly 30 per cent in the population aged over 65 from 1991 to 2011 and, more significantly, an absolute increase from 74,000 to 130,000 in the number of persons aged over 80 years in the same period. On average, those over the age of 65 consume four times more hospital and community resources than the rest of the population. The higher usage of hospital services by the older age groups will place increasing pressure on acute beds and waiting list activity.

Of particular concern is the recent survey of acute hospitals by my Department which indicates that at least 3.5 per cent of acute hospital in-patient beds are occupied by patients who through no fault of their own are inappropriately placed. These include older patients who do not require or who no longer require acute care. An example would be persons who have made a good recovery after surgery and who no longer need acute care but who are not ready to go home. Another example would be older people who require longer-term care rather than the intensive treatment offered in an acute hospital setting but who cannot gain access to appropriate non-acute facilities.

The figure of 3.5 per cent of patients who are inappropriately placed in acute care is equivalent to approximately 150,000 bed days per year. The Government is committed to tackling this figure and ensuring all acute hospital beds are freed up for the purpose for which they are intended. Success in utilising these 150,000 bed days for acute care as opposed to other forms of longer-term non-acute care would have a major impact on the ability of hospitals to carry out their waiting list work.

The report of the review group elaborates on the factors which lead to an increased demand for acute hospital facilities by older people and others needing long-term care. These include the shortage of appropriate community services and day assessment services which contribute to inappropriate admissions of older patients to acute hospitals; insufficient provision of rehabilitation facilities which results in an increase in the average length of stay for patients, even when the initial referral was appropriate; insufficient liaison between acute and community services which can lead to unsatisfactory discharge planning and an unnecessary prolongation of hospital stays; a shortage of long-term care facilities which can result in excessive utilisation of acute in-patient facilities by older patients, and a poorly developed service for older patients suffering from dementia associated with behavioural disturbance which often results in inappropriate referral to acute hospital services or an inability to discharge them after an appropriate admission to an acute hospital.

The review group's findings in this area serve to underline the fact that inappropriate placements in acute hospitals, whether of older people or of others such as stroke victims and those involved in serious road traffic accidents, cannot be addressed by hospitals alone. The review group rightly argues for a co-ordinated approach right across the board from primary care to acute hospital services and on to sub-acute and longer-term forms of care. It is only when we address the issue of waiting lists in that manner that we will make real progress on this issue.

To this end the review group has highlighted the need for facilities which will first benefit older persons and others needing long-term care and, second, which will free up acute hospital facilities for their core business, including treatments for those on a waiting list. These facilities include geriatric day hospitals for the assessment and planning of treatment of older persons, rehabilitation facilities for older persons and others with chronic conditions, community nursing units to meet the long-term residential care needs of older persons, commuity-based support services such as home help, physiotherapy and speech therapy services and hostel and other short-term accommodation for patients who do not otherwise need to stay overnight in an acute hospital bed.

Our policy in Government seeks to recognise these facts and we must build on them. My colleague, the Minister of State at the Department of Health and Children, Deputy Moffatt, was appointed with special responsibility for older people. In 1997, its last year in office, the Fine Gael, Labour and Democratic Left Government made available £3 million for a capital programme for older people. That was the figure and that was the commitment. This year alone my colleague, Deputy Moffatt, and I are making available almost £14 million capital moneys for the development of facilities for older people and we must do more. The review group highlights the importance of this and we will continue with this significant investment programme.

The report argues that the case for providing stand-alone day surgery units for acute patients should be examined closely. It also points to the need to develop closer relationships between primary care and hospital services and to take further measures to reduce pressure on accident and emergency departments.

As regards the review group's report, the Government is committed to implementing its recommendations as quickly as possible. As I mentioned earlier, my Department is currently working on the implementation of the report. As a first step, it has commenced the assessment of the current capacity of the acute hospital system and I have asked that this work be completed shortly. I assure the House that the Government is not lacking in its will to tackle the problem of waiting lists, but in a planned and co-ordinated fashion. It is clear that implementation of the report will involve a well developed working relationship between all sectors of the health service. We will need a partnership approach in which primary care, acute hospitals and continuing care services work closely together to achieve the maximum benefit. We will need the continuing enthusiastic co-operation of consultant medical staff in implementing a successful waiting list initiative but we will need to go further. The entire health system must be harnessed to address a key priority problem which we all recognise as unacceptable.

I would like to place the numbers on waiting lists and the performance of the waiting list initiative in context. First, the number of people on waiting lists on 30 June 1998 was 34,331. Within this figure there is a wide spectrum of ill-health among the patients waiting for different procedures. In this context the length of time waiting is not the sole determinant of access to treatment. The severity of the person's condition is also important and, irrespective of which criterion is used to determine access to treatment, it is clear that a large number of patients are waiting too long for surgery.

While the current numbers on waiting lists are clearly not satisfactory, this figure must be set against the total number of patients who have been treated over the past year. In 1997, for example, there were over 535,000 in-patient discharges from acute hospitals and a further 250,000 day cases. The waiting list figure of 34,331 represents 6.4 per cent of all in-patients and 13.7 per cent of day cases seen in acute hospitals last year. When the total activity of 535,000 in-patient discharges and 250,000 day cases are combined the numbers on public waiting lists represents 4.4 per cent of all such activity.

I also emphasise that, contrary to some claims, the level of activity in acute hospitals has been rising noticeably since the beginning of the year. For example, overall acute in-patient acitivity between January and June 1998 increased by over 1 per cent and the increase for day case activity in the same period was almost 10 per cent. This underlines the fact that our acute hospitals are working extremely hard to meet the demands placed on them and that they are to be commended for their work.

We have now spent a total of £70 million under the waiting list initiative since its inception in 1993. There have been some claims in the media that this £70 million has been wasted or that it has failed to reduce waiting lists in the way that was intended. This claim does not stand up to close examination. While waiting lists remain a significant problem, we must remember that the £70 million was used to treat thousands of patients over the past five years who would otherwise have been waiting for a much longer period of time. These include vital treatments such as hip replacements, cataract procedures, cardiac surgery and vascular surgery — all treated as a direct result of the funding provided.

Put simply, this money helped to treat public patients much faster than if a separate stream of funding had not been made available for those on waiting lists. In the years 1993 to 1997, a total of 85,000 patients benefited from the waiting list initiative. I anticipate that at least a further 15,000 patients approximately will benefit in 1998 as a result of the £12 million allocated this year. This will bring the total number of patients benefiting from the waiting list initiative to 100,000 since it began in 1993. We should bear these facts in mind before claiming that the money allocated to waiting lsts has had little effect.

It should also be noted that the money has been used in a highly efficient manner. For example, last year the hospitals participating in the waiting list initiative set out to carry out some 7,500 procedures for those in the target specialities. In fact, the hospitals managed to carry out over 11,000 procedures under the waiting list initiative. This year we estimate the figure will be 15,000. The fact that waiting lists have not decreased despite that efficient performance underlines the speed at which patients can be added to the list.

I would like to draw the attention of the House to one particular area in which the waiting list initiative has been noticeably successful. This is the area of cardiac surgery which has been adverted to by Deputy Shatter. Without going through the matter in detail I must highlight the fact that the approach we have adopted is bringing about results and is reducing the time spent on waiting lists. My Department is attempting to apply this type of approach to a wider number of specialities as a result of the findings of the review group. That approach provides us with the best prospect of success.

I have set out the progress of the waiting list initiative to date and I have pointed to the challenges involved in reducing both waiting lists and waiting times. I believe that if we are to have a debate about waiting lists it must be an informed one. We must quickly depart from the simplistic notions put forward in some quarters about waiting lists alone. So too must we accept that solving this issue will require a co-ordinated approach, using the partnership idea across the entire health service.

The factors that give rise to waiting lists and the success with which they are addressed are complex. I believe the review group's report represents a very valuable starting point from here and I am committed to adopting its recommended approach in dealing with the issue.

I am willing to discuss strategies on how best to address the waiting list issue with all interested parties throughout the health system and central to this is an acceptance that the rate of change in medical and surgical has moved on substantially. The model of the acute hospital system as a single multi-purpose facility for treatment, recuperation and rehabilitation is simply no longer valid. Patients need a continuum of care involving all components of the system. We must work on the basis that co-operation between all sections of the health system is critical and that waiting lists are not just an acute hospital issue. The interdependencies between sectors is vital and must be recognised by all concerned. The long-term strategy proposed by the review group will have an impact on all levels of our health and personal social services and it is essential that the relevant developments are planned and implemented effectively.

The Government, unlike its immediate predecessor, will not rush into short-term panaceas for dealing with waiting lists and waiting times. We are dealing with the issue as a matter of priority and we are prepared to devote the energy required to address the medium and long-term requirements as well as those in the short-term.

The review group has moved the argument from anecdotal opinion to a comprehensive review of what needs to happen to shorten waiting times for those awaiting surgery. That systematic analysis had to be done first. I am now in a position to make the argument for an improvement programme which seeks not only more resources but holds out the prospect of achieving better results for that investment as well.

The last Government's response to growing waiting lists was to reduce the funding and do no analysis of what was happening. When this Government took office, I negotiated an Estimate for 1998 which increased the funding to £12 million — a 50 per cent increase — as an initial step to undo the damage done during the tenure of the previous Government. I have conducted an in-depth analysis and I am now properly armed with the arguments that can be made to Government. I am in the process of devising a comprehensive response to the major challenges highlighted in the review group's report.

As soon as the deliberative process is over and the Government has taken decisions in the context of Estimates and budgetary discussion I will, of course, make copies of the report available to all Members of the House.

The Opposition can be assured that it is not the intention of this Government to repeat its mistakes regarding the handling of this issue. The Government will not be complacent as its predecessor became. I am committed to giving public patients a fairer deal than they are getting at the moment. It requires focused investment in a range of areas and equally important, co-ordinated action across a number of fronts. The House can be assured that a response commensurate with the complex problem which we are discussing this evening will be forthcoming and it will certainly compare far more favourably with the inadequate and complacent approach of the previous Administration which can be clearly gleaned from the facts as I have outlined them.

Ms Shortall

I would like to share my time with Deputies Penrose and Howlin.

An Leas-Cheann Comhairle

The Deputy is sharing time with Deputies Penrose and Howlin.

Ms Shortall

I welcome the opportunity to speak on the motion before us tonight and I thank Fine Gael for using its Private Members' time to discuss the critical problems associated with the current hospital waiting lists.

Before the summer recess I tabled a Private Members' motion on the crisis in our health services. A month later, that crisis has worsened but the Minister has continued to sit on the fence. I welcome the opportunity to remind the Minister that we urgently need investment in our health services.

I thank the Minister for coming into the House tonight to debate this motion because it appears, of late, that he has been dodging debate. He failed to appear on a number of key current affairs programmes where health was one of the main topics for discussion. He has failed to attend in this House on a number of occasions when Adjournment Debates relating to his portfolio were being discussed. The Minister also suppressed debate and criticism from the Opposition by his failure to put key reports into the public domain. The reality of our health services, now more than ever, is that those who can pay get treatment while those who cannot must wait.

The Minister is presiding over a health service which is rapidly falling apart. Hospital wards are being closed, waiting lists are growing, there is a serious shortage of nursing staff and an acute shortage of nursing home places, yet no attempt has been made to ensure we are getting value for money.

Figures recently released by the Department show that one in every three patients on a waiting list has been waiting for treatment for over a year. Among these people on waiting lists are an unacceptable number of children — 2,413 children have been waiting for in-patient treatment for over six months while a further 1,721 children have been waiting for between three and six months.

Over 1,000 children are on hospital waiting lists in Temple Street Children's Hospital. That is an appalling indictment of the Minister's stewardship in the Department of Health and Children. If he took the trouble to visit Temple Street Children's Hospital he would see the deplorable conditions in which people are trying to work. Major problems are being experienced in relation to funding to cut waiting lists. As I said, over 1,000 children are waiting for procedures and various operations but it appears these are only figures to the Minister.

The Minister should think about the impact of recurrent tonsillitis or hearing problems on young children, the amount of time they miss from school and the suffering caused as a result. A person attended my clinic over the weekend whose child was put on a waiting list in Temple Street for a tonsillectomy at the age of ten months. The child will be four years old next month and that parent is still waiting to get on to the real waiting list. They were informed recently that all children likely to be called in the next two years have been notified, so the parent of this child cannot hope to be called in the next two years. The child will be six years of age before they are likely to be called; that is totally unacceptable. I ask the Minister to pay urgent attention to the fact that there are so many children awaiting hospital operations.

Every hospital in the country is being plunged into a crisis and they simply cannot cope with the numbers seeking treatments. One of the worst waiting lists cited recently was the 2,761 people awaiting operations for the removal of varicose veins at the University Hospital Galway; more than half those people have been waiting for more than a year.

In April, a review of hospital waiting lists was commissioned by the Minister. Despite the fact that the problem has become much worse over recent months, it appears the Minister is happy to sit on that report. He has had it for almost three months——

Mr. Cowen

Since mid August.

Ms Shortall

——and we have not yet seen it.

The Minister gave us some indication tonight of what might be contained in the report, but why is he keeping it quiet? Why will he not put it into the public domain, allow us have a proper debate and identify the underlying problems that have led us to this crisis? It does not make sense for the Minister to sit on the report. It is a report from an expert group and we should know what the experts say. We need to find out what is required and then see how the Minister fares in the budget.

I ask the Minister to give an undertaking tonight that he will publish the report as a matter of urgency and, more importantly, that he will take the steps necessary to implement its recommendations. We are facing into another winter during which the crisis will undoubtedly get worse. Little hope is being offered that there will be any improvement in the position until well into the new year. That is not good enough.

Many of the problems associated with the soaring waiting lists are due to the fact that insufficient resources have been made available to health boards and hospitals. The Minister was unfair in his approach to this in so far as he has attempted to hide behind the accountability legislation. Hospitals and health boards outline clearly the extent of their problems and the funding that is required to address them, but invariably the Minister's response is that they must live within their budgets. We all should live within a certain budget but the Minister is ignoring the fact that the budgets allocated to hospitals and health boards were inadequate. He did not get sufficient funding for the health services in the last budget and he is trying to force the hospitals and health boards to live within very inadequate budgets.

The Minister should stop hiding behind the accountability legislation. At this time of the year that legislation is kicking in and it is having a serious effect in terms of bed closures, etc. A person attended my clinic over the weekend who had an outpatient appointment for November. The person had waited nine months for the appointment and got a letter the other day stating that, regrettably, the hospital had to cancel it due to financial difficulties. The hospital was not in a position to indicate when another appointment would be made. Will we see not only inpatient services being reduced but out patient services also?

It is impossible for health boards and hospitals to meet the demands placed on them because of inadequate budgets. As we all know, hospitals have been forced to close beds simply to save money. When the country is awash with money and we hear stories about hugely inflated standards of living and vast amounts of money being spent, the public cannot understand how the hospitals are closing beds to save money. That exacerbates the waiting list problem and the numbers on the lists soar.

The summer is an important time for hospitals because it provides a breathing space from the huge pressures on the accident and emergency departments. The summer months should be used to make inroads on the waiting lists when there is not such pressure on the beds from casualty departments. Unfortunately that opportunity was missed this year and we face further chaos in the winter months. There was no progress because hospitals were forced to close beds. The hospitals did not do this for standard maintenance work, they were forced to close beds to save money because the budget the Minister allocated was inadequate. That is unacceptable in a civilised society.

Hospitals and health boards are being blamed for the lengthening waiting lists when quite clearly they are not at fault. The Minister has played both sides; he promised to go to the Minister for Finance to see how much funding he could get and he said he would fight his corner and do his bit at the Cabinet table. As public representatives we are all aware of the crisis in our health services. Surely the Minister's Cabinet colleagues are aware of it as well. He cannot play one side off against the other like that. Is the Government committed to doing something?

Mr. Cowen

I can assure the Deputy that we have given far more money to this area than the Government she supported.

Ms Shortall

We are talking about now, a time when the Minister is in charge. Stop talking about the past.

Mr. Cowen

We provided far more than the previous Government.

Ms Shortall

We expected the Minister to deliver and we are very disappointed.

Mr. Cowen

Where is the Deputy's political credibility?

An Leas-Cheann Comhairle

Deputy Shortall without interruption.

Ms Shortall

We will no longer accept the line about playing one Department off against the other. Is this Government committed to tackling the serious problems in the health services? If it is, surely the Cabinet can make the decision to provide adequate funding to make proper inroads into the existing problems. The idea of seeing what Minister McCreevy will give does not ring true.

An Leas-Cheann Comhairle

The Deputy should address her remarks through the Chair.

Mr. Cowen

I look forward to the Deputy's time in Government.

Ms Shortall

Either this Government is serious about tackling the crisis in the health service or not. Let us see the Cabinet take responsibility for it.

An area I have tried to draw to the attention of the Minister over the past year to which he seemed oblivious for many months, and to which he has only recently copped on, is the inadequate supply of nursing home places. I was amused to hear him mention a written policy on the discharge of elderly patients from acute hospitals, as if that will make a whit of difference. Has the Minister spoken to people in the acute hospitals?

Mr. Cowen

The review group is examining the issue. The Deputy is asking rhetorical questions. I am answering her. She should not on the one hand request the findings of the review group and dismiss them on the other.

Ms Shortall

If the Minister had spoken to anyone in Beaumont, St. James's or any of the large acute hospitals 12 months ago, they would have told him their most pressing problem was hospital beds blocked by people who are inappropriately placed. I do not know why we have to wait months for the report of a review group to tell us that when it was clearly the case. Action should have been taken last winter to ensure we would not face the same crisis this winter.

Mr. Cowen

What about the previous winter?

Ms Shortall

I am talking about this year.

Mr. Cowen

Amnesia, there is a waiting list for amnesia.

Ms Shortall

The opportunity has been lost this year because we will not be in a position to provide proper places. It is a disgrace that almost 500 people are inappropriately placed in acute hospital beds. That means 500 acute beds are blocked indefinitely. The priority must be to clear those beds by providing appropriate step down facilities for those patients. The Minister seems to accept that fact about our health services and is talking about doing something in the future.

During the summer a state of the art nursing home was completed by the Eastern Health Board in the Glasnevin area in my constituency. It is fully equipped, yet in the north side of Dublin, 25 per cent of operations are cancelled due to shortages of beds in Beaumont Hospital and the Mater Hospital because of bed blockages. Mean-while, a fully equipped, 50 bed nursing home lies idle in Glasnevin. That is a disgrace. It is an indictment of this Minster who has not got the foresight to see that providing the money necessary to open that nursing home — which could be opened tomorrow if the will existed — would allow 50 beds to be cleared on the north side of Dublin, allowing significant progress to be made on the extremely long waiting lists in that area. Does it take a review group to point out these self evident facts to the Minister? Was the review group set up to delay taking the necessary action? We were told at the start of the year when the problem came to notice, when the hospitals complained and the public was outraged, that this urgent review would be set in motion.

Mr. Cowen

Could we have some consistency in the Deputy's approach?

Ms Shortall

It is now October and we still have not seen that review. It seems it was a long fingering exercise to put off tackling the question.

Mr. Cowen

A sum of £3 million for the elderly——

An Leas-Cheann Comhairle

Will the Minister let Deputy Shortall continue?

Ms Shortall

With an ageing population the need to create these step down facilities was clearly evident. We all have access to the demographic figures and know what will be needed this year and next year. What planning has been done to ensure adequate places will be provided to deal with the elderly in particular?

Is there any point asking the Minister to give a commitment to open the new St. Clare's Hospital? I have asked on a number of occasions but it seems that the winter will be over before there is any chance of that happening.

There is huge unease among nurses over their pay, conditions and lack of career structure. Such is the unease that nurses are voting with their feet by leaving nursing and entering other paramedical areas. Young people are not entering the profession. The absolute minimum needed is the full implementation of the recommendations of the Commission on Nursing.

Many other things need to be done in relation to nursing. We must introduce the idea of permanent part-time nurses on a widespread basis. The majority of nurses are female and many female workers want the option of flexible working time; this is unavailable to most people but it must be introduced as a matter of urgency.

The Minister has completely neglected value for money. He has displayed a general failure to ensure accountability among our hospitals regarding cost. There are no clear indications available to the taxpayer regarding value for money in our hospitals. We do not know how much a hip replacement operation costs in Cork compared to Limerick or Dublin; we do not know the success rates of operations.

Given that he promised so much, the Minister has delivered very little. The time for defensiveness and the history lessons have gone. The Minister is in charge. It is his responsibility to tackle the problem. What is needed is action as a matter of urgency.

Debate adjourned.