Dáil Éireann debate -
Tuesday, 1 Feb 2000

Vol. 513 No. 3

Private Members' Business. - Health Services: Motion.

Ms McManus

I move:

That Dáil Éireann:

(a)deplores the continuing deterioration in the acute hospital services which is causing suffering and hardship for thousands who are ill and great distress for their families;

(b)condemns the failure of the Government to honour the commitment made in An Action Programme for the Millennium to "tackle the crisis in the hospital waiting lists" and notes that in most cases waiting lists have lengthened significantly during the lifetime of this Government;

(c)expresses concern at the crisis in many accident and emergency units since Christmas; the closure of hospital beds; the non-use of operating theatres; the cancellation of many elective procedures, which have led to the further lengthening of waiting lists;

(d)notes that the current two-tier system of medical care discriminates against those who are unable to pay for private cover and condemns the fact that public patients with life-threatening conditions are left on waiting lists for long periods because they are unable to pay for private care;

(e)calls on the Government to deal with the crisis by:

(i)immediately increasing resources and staff levels, improving bed numbers and providing additional step down facilities; and

(ii)committing itself to the introduction of a universal health insurance system which will ensure that access to health care is determined by medical need rather than ability to pay.

I wish to share my time with Deputies Penrose, Broughan and Gilmore.

An Ceann Comhairle

That is agreed.

Ms McManus

The Labour Party tabled this motion to confront what has been the Government's greatest failure since taking office. I welcome the Minister for Health and Children, Deputy Martin, to his new portfolio and wish him well. Welcome as he is, what the health services need more than anything is not a new face but a new direction.

On the day of the Minister's appointment, a woman was interviewed on the RTE news at 9 o'clock. Adele Murtagh is an ordinary member of the public, yet her story tells more about the failure of the Government than any list of statistics possibly could. Six months ago her mother was diagnosed as having fluid on the brain. She has been on a priority list for surgery ever since, but the long wait has weakened her to the point where she is too ill to undergo surgery. Care for that woman comes too late. At a time of such prosperity it is incredible that our modern health service cannot deliver treatment to someone so desperately in need of care. However, what is insupportable is that were Adele's mother a private patient she would have had her operation in time.

Let us be clear about this – Adele's case, tragically, is not unique. There are patients dying as they wait for treatment or for whom treatment is so long coming their lives are shortened dramatically. That is the reality of a health service which is not working for many thousands of people. The Labour Party's determination in tabling this motion is to drive forward the change that will meet the health needs of all citizens. If the chronic problems besetting the sick and those availing of our hospital services, in particular, and those who provide those services are to be addressed, there must be a radical, root and branch reform.

Reform is needed because the current system is failing so many. The hospital system is characterised by instability, inequality and inefficiencies. When it comes under seasonal pressures, as we saw recently, patients suffer needlessly and terribly as a result of Government inaction. Regardless of whether they are public or private patients, the misery suffered by patients in overcrowded accident and emergency units is the same. It is profoundly disturbing that sick and elderly people have to wait many hours for assessment or have to wait on a trolley or in a wheelchair for days before accessing a bed or being sent home without the necessary back-up care. That would be unacceptable in a society with a modest level of economic growth, but in one like ours that has world beating economic growth rates it is an obscenity.

On radio last night the Taoiseach said it was ridiculous that we are top of the OECD growth league, yet we do not have national stadium and that he intends to spend hundreds of millions of pounds to provide one. I have never heard the Taoiseach speak with such passion about the need for a decent, good quality health service. I have not heard him say once that since our econ omic growth is so good he will build a health service on the twin principles of excellence and equality. On the need to create a health service capable of meeting the urgent needs of thousands of people, the Taoiseach has nothing to say.

The health service is in real trouble. The stark fact is that while there has been approximately a 45% increase in health funding, the crisis continues to grow in our hospitals and the waiting lists lengthen inexorably. In its programme for the millennium the Government undertook to tackle waiting lists. In its mid-term review it promised to tackle waiting lists. On taking up his new portfolio the Minister yet again promised to tackle waiting lists. Yet, since taking office, despite all the promises and despite the surge in Exchequer funding, while it is difficult to know the up to date figures, the latest figures show that the Government has succeeded in adding at least an extra 5,200 people to the waiting lists with the total number moving towards 40,000. These are the people on the waiting lists – we are not talking about those who are on a waiting list to get on to these waiting lists. Despite the increased funding fewer cardiac surgery procedures were carried out nationally in 1998 than were carried out two years previously. In the Mater hospital alone the figure was down by around 20%.

There are 391 patients waiting to attend the pain clinic in St. Vincent's hospital. These are people whose suffering is so great that normal treatment has failed to assuage it. Even for this last resort type of care, there is a waiting list. Over Christmas in one hospital the position was so bad there was a waiting list to get into the morgue. When the position has deteriorated to this level it is tempting for an Opposition party to simply catalogue the disasters and leave them to fester at the Government's door, but reform of our health services requires fresh thinking and an intelligent, imaginative approach. The Labour Party is committed to providing the leadership that is required to meet that challenge.

In this context, we framed this motion in the form of a twin track approach. First, we must ensure a significant increase in health care investment. Whatever funding the Government puts into health must be measured by the yardstick that applies across the EU. Ireland has the fastest growth rate and a reported per capita income higher even than Germany's. Yet, when it comes to the percentage of our GDP spent on health, Ireland is at the bottom of the league. Germany spends approximately 10%, Britain spends approximately 8%, yet Ireland's percentage has plummeted during the Government's term of office. In 1997 it dropped from more than 7.3% to 5.3% and it is now at 5.5%, which is remarkably low in European terms.

While Government investment in health care is not enough, it is not effective in terms of measured health outcomes. We have the highest death rate in the EU from cardiovascular disease and to date our cancer services in terms of outcomes do not compare favourably with other EU countries. We are near the bottom of the list with Britain. The chance of a person's survival in Ireland once he or she has been diagnosed is a direct reflection of the underdevelopment of our cancer services.

Most complaints Members hear from their constituents relate to accident and emergency units. These units are the gateway for most patients to our hospital services and it is where the greatest pressure is evident. We know that greater resources at general practice level in terms of training, resources and beds in low-tech local units will reduce significantly the attendance at A&E units. That is well known, yet the increase in funding in general practice in 2000 is insignificant – it is less than inflation. We also know that more than 200 acute hospital beds at any time in the Eastern Health Board region are inappropriately occupied because the Government has not resolved the shortage of step-down beds and has not put in place the necessary supports for the elderly in the community. We know A&E units would provide a better and a faster service if they were fully staffed by A&E consultants, yet there are only 18 such consultants in the country and the majority of A&E units have none. Doctors in training deal with emergency cases in a way that often leads to inefficiencies and overuse of diagnostic facilities. Our young doctors are overworked, our nurses are alienated and we are not appointing enough consultants. Most importantly, we are not moving significantly towards a consultant provided service and away from a consultant led one.

Is it that we care less about our sick and elderly than other Europeans? I do not think so. Is it that we do not have a tradition of excellence in health care, the infrastructure for it or the educational capability? Hardly. What is lacking is political courage. The idea that because we are wealthier today we should spend less proportionately on our health services is one the Government is satisfied to promote, but it is not shared by the public who are bewildered at the state of our health services. Undoubtedly, the Minister will list figures when he speaks later – sometimes Ministers count them twice – but this is meaningless if at the end of the day we are not investing in a way that establishes once and for all stability, equality and efficiency in our hospital services.

We have excellent people working in health care who draw on a fine tradition. Yet the service provided for the elderly and less well off has been christened a Mickey Mouse service not by an Opposition Member keen to score points, but by a leading consultant physician. As recently as 10 January, 30 patients spent the night on trolleys in the accident and emergency unit in Beaumont Hospital, which is a flagship hospital. Ennis General Hospital had one third more patients than it had capacity for and there were 162 patients in the 129 bed Limerick Regional Hospital. In many hospitals elective cases were cancelled and patients were added to the waiting list over that period. According to the Department of Health and Children, there was no flu epidemic. This is disputed but if it is true, one can imagine what havoc a flu epidemic would have caused.

Propping up an inherently unstable system by blindly injecting it with more money will not change the fact that it is a system caught between a long-standing chronic lack of resources on the inside and ineffective attempts to control unmet demand through waiting lists on the outside. The current two-tier system of unequal access is virtually in-built into the structural interdependence of public and private care. Public budgets depend on a certain number of people paying for their own care, although they are entitled to it already. The fact that the same personnel and facilities are used to treat public and private patients is often seen as an advantage in terms of consultant care.

The adverse incentive within such a system, however, lies with forcing greater numbers into taking out more private insurance. In effect, the longer the waiting list, the greater the potential income from fee-paying clients. It creates a serious problem in cost containment in that, other than the professional and humanitarian impulse among professionals, there is little impetus for consultants to treat a greater number of public patients. Without the advantage of accessing care there would be little incentive for subscribers to take out insurance. Yet, without it our public system would be so encumbered as to be rendered inoperative.

The central challenge, as the Labour Party sees it, is to progress beyond the current system not by eliminating the advantages provided by health insurance but by ensuring that those advantages are extended to all our citizens. We have no interest in or desire to re-apportion scarcity more thinly. That would be pointless and extremely damaging to our health services. We recognise that health funding in Ireland is not drawn from bottomless sources, but we are also keenly aware that we have a historic opportunity to transform our health service to meet the needs of the 21st century.

In education, the area for which the Minister previously had responsibility, the principle of equality was established by previous Governments. We take it for granted that all children have a right to good quality education regardless of whether their parents can pay. The same principle needs to be established in health. Placing greater value on health means establishing equal access to quality care as a fundamental right. It means introducing legislation to protect that right and appropriate funding and structural change to bring it about. Some 42% of the population already pays private health insurance while 58% does not pay for such insurance. We must work from that basis and move on to deal with the deficiencies as we see them. It is clear that the best way to develop a fully comprehensive system which provides primary and secondary care is to introduce, or at least set about introducing, a universal health insurance system.

A properly designed universal health insurance system will ensure the stability of the system as well as equality within the system which are lacking at present. It will also create a dynamic which hospitals are denied because of the strict budgetary controls that exist at present which lead to closed wards and blocked beds. There are many models to which we can look, particularly in the European Union where insurance based systems are standard and where equality and excellence are established principles. The system we are proposing would marry the benefits of State financing and regulation, which are vital to ensure universality, social solidarity and equity, and the benefits of consumer choice and competition, which has the power to enhance quality and cost effectiveness within our health system.

The State would have a central role in planning the system, defining cover of care, acting as a regulator and ensuring that those who cannot afford to pay themselves are looked after, in part or totally, as well as providing necessary capital. The Labour Party will soon publish its proposals for such a universal health insurance system. We are doing so because we are deeply committed to the transformation of our health service. We are conscious that it is in everyone's interest that a new initiative is taken to overcome the deficiencies and faults in our current system. If they are not confronted, they will not only impact on public patients but on those who are already beginning to experience problems within the private sphere in terms of costs and waiting times.

The Labour Party is in Opposition, it is limited in terms of resources and we do not claim to have all the answers. Even if we thought we had them, we would still want to engage with the public and all the key players in the health services. We want to open up the public debate in a way that confronts the necessity for radical reform. Equality must be a fundamental guiding principle in access to health care for every individual, regardless of income, geographic location or social status, and excellence must be the measure of the quality of that care. I am convinced that universal health insurance is the key that can deliver both as long as such a system is properly designed and formulated.

We cannot fulfil the task on our own. My party's approach is open-ended to ensure that all the key players in our health services, including patients, are involved in the debate that can lead to a fully comprehensive policy. In the Department of Education and Science, the Minister worked within a system where the principles of equality and excellence were already well established. The challenge now presented to him by my party is to bring about those principles in our health care services.

A senior cancer specialist recently described our health system, in comparison to other European systems, as clearly and measurably deficient and characterised by profound intrinsic structural flaws. He argued for a universal health insurance based system, and the Labour Party agrees with him. Our position is clear about the way forward. We have a world-class economy, it is time we had a world-class health service. I also wish to share my time with Deputy Ó Caoláin.

An Ceann Comhairle

That is fine.

Mr. Penrose

I am glad my party tabled this important motion on the health services. The Labour Party feels strongly about the health system and the Minister will hear much from us about it. The purpose of the motion is not only to remind the Government that the health system has deteriorated to a level where people cannot afford to pay for essential treatment and are being forced to do without it, but also to remind them that we are now in a position to make choices about how our health system develops. We are in a position to ensure that no one, regardless of income, is forced to suffer or face fatal consequences because our health services are inadequate or incapable of catering for their needs.

The Government can decide if we should pump more money into tax reductions, thereby increasing privately held wealth, or improving essential universal services. Health is obviously one of the most important services. Given the growing length of waiting lists, the Government to date has embarked on a mission to improve private wealth, particularly among those who are already wealthy, and to minimise health spending. The burden of taxation in Ireland is low by EU standards but the percentage of total taxation paid by PAYE workers is high.

The decision in the recent budget to give huge breaks to those liable for capital gains tax is indicative of the Government's approach to taxation. However, those whose incomes are derived from profits and property also have been given many opportunities to minimise their tax bills. As a result of exempting so much income from taxation, the burden on the PAYE sector and the low paid is excessive. There are few low and middle income earners who would trade fully accessible world class facilities for an extra few pounds per week in income tax concessions. They understand that an extra few pounds per week in after tax income will not buy them faster access to medical treatment or pay for increasingly expensive private health insurance. Should their child be mentally or physically handicapped it will not buy a place in long-term or respite care. Only increased public expenditure will improve many aspects of the living standards of ordinary workers. It is clear that the highest living standards in the EU are enjoyed in the countries with the highest level of public spending. That may hit a raw nerve somewhere.

While overall public spending in Ireland is low, spending on health care as a percentage of GDP has uniquely, in the EU, been declining. In 1985 Ireland ranked fifth in the EU on health spending as a percentage of GDP. We have since declined to 11th place and only three member states, the UK – the Labour Government is trying to reverse the awful trend in Britain – Luxembourg and Greece spend a smaller proportion of their GDP on health than us. Ireland is one of only four EU states which spends less than 7% of GDP on health. These figures show that spending on health care in Ireland is not excessive by any standards. It is hardly surprising that we have up to 40,000 people on waiting lists for hospital treatment and that some public patients have to wait five months for an appointment with a dermatologist, eight months for an appointment with an ophthalmologist and six months for an appointment with a gynaecologist while those in need of hip operations have to wait two or more years to be called.

I turn to the issues that affect real people on the ground. In a written reply to me on 26 January, the then Minister for Health and Children, Deputy Brian Cowen, indicated that at the end of September 1999 the total number waiting to be called for treatment in the various specialties in the Midland Health Board area was 2,108. This figure is an indictment of the abject failure of the Government to ensure that the people who need attention and seek those vital specialties such as ENT, orthopaedics and vascular surgery are left to suffer and their condition deteriorate. This is a rerun of the old saying in my part of the country, the poor can suffer and wait. It is an absolute shame, at a time of plenty when the Government boasts about its £6 billion in the coffers, that ordinary people with a medical card have to wait while their health deteriorates.

Can one imagine the pain and debilitation suffered by a person awaiting a hip replacement operation? What level of deterioration is associated with more than a two-year wait for such an operation? One of those on such a list is Robbie McAuley. A woman in her seventies came to see me in my village of Ballynacargy. She asked how she could borrow the money to get into hospital and how much it would cost. I said it would probably cost £5,000. She said she could raise £2,000 and that if she got in they would have to keep her. I advised her to go ahead and told her I would be with her if they put the law on her. I told her to borrow the money from the credit union, to stay in that hospital bed and squat if necessary. In the name of God, it is time a concerted attempt was made to ensure people have to wait no longer than a maximum of six months for those vital operations.

I come to a local question about which I will be on the Minister's tail. It involves the equipping, staffing and fitting out of phase 2B of Longford-Westmeath General Hospital. I am proud to have beside me Deputy Howlin a former Minister for Health who continued the great Labour Party tradition of providing essential services. Another former Minister, Barry Desmond, provided the funding for phase 2A. Some £25 million has been spent on this hospital development to date and another £12 million is all that is required to complete it. Why can this money not be provided immediately? It is abundantly clear the amount required is less than 0.75% of the budget surplus of £2 billion. It is vitally important that this work is completed, staff is provided and 260 medical beds are provided on completion. Based on the outbreak of flu during the Christmas period these medical beds cannot be provided too soon. Mullingar hospital which has 50 medical beds had 130 medical patients in mid-January, an occupancy rate of 220%, while we have an empty shell. The people of Westmeath and Longford are angry. I am with them 100% and will ensure this job is completed.

Mr. Gilmore

I thank Deputy McManus for sharing her time with me and congratulate her on presenting this Labour Party motion to the House. I draw attention to the kinds of cases which are being brought to my attention by my constituents not for particular action on their own behalf but because they want these issues raised to ensure that nobody else has to endure the same suffering. For example, a woman who contacted me gets a routine mammography examination every two years. The consultant radiologist in a particular hospital wrote to her as follows:

Your doctor has written to us requesting an appointment for screening and routine mammography. Unfortunately, our appointments for mammography are filled by patients considered to be at high risk of breast cancer. We have written to your doctor informing him of the above. Please contact him again if you are worried that you might have breast cancer.

This is no way to run a screening service. This woman wanted this issue raised so that the matter would be addressed not on her behalf but on behalf of all patients.

There is the case of an elderly man who is now deceased. In the advanced stage of illness he was brought to a hospital by ambulance at 7 p.m. and not seen by a doctor until 10.15 p.m. His niece wrote to me as follows:

If this was not bad enough we were then told that they had no bed for him. He could stay in casualty where he was but there was no bed in a ward. At over six feet in height, his feet were hanging off the edge of the trolley. He had been given injections by the GP for pain but she wanted him to be in the hospital so that he would be comfortable. Instead he was brought back home by the same two ambulance men who brought him in and I was handed suppositories with rubber gloves and gel if he had pain. This had to be the final insult. I would really appreciate if you could do something to ensure that this never happens again. It is too late for my uncle.

I could give examples of numerous cases of children waiting for orthodontic care, elderly patients waiting for geriatric treatment and elderly people who, because they have a small occupational pension, are denied a medical card and are afraid to visit the doctor because of the cost element.

I ask the Minister to address one issue of health care that affects my constituency. We want a proper regional general hospital located in Loughlinstown. There are large general hospitals ringed around the city – Beaumont, Blanchardstown and Tallaght. In the southern end of Dublin, the motorway ring as it will be, there is no general hospital. There is no general and regional hospital between St. Vincent's Hospital and Wexford town. People from Wicklow and north Wexford travel to what is a small district hospital in Loughlinstown for care. In an area with a growing population and huge needs, that is no longer acceptable. I ask the Minister to address this matter and take this opportunity to congratulate the new Minister of State, Deputy Hanafin, my constituency colleague, who I have no doubt will advance this case in her Department. We want a proper regional general hospital located in Loughlinstown to provide a better quality of service for the people in that general area.

Mr. Broughan

The cost containment culture which was fostered by the cost efficiency drive launched in the period 1987-92, in particular, during the Fianna Fáil-Progressive Democrats Government of that period is unfortunately still the overriding determinant of health policy. There is a sense of déjà vu when one hears constituents tell of the length of time people must wait for desperately needed operations. Once again the Fianna Fáil-Progressive Democrats Government is delivering this cost containment culture in a way which is brutally harsh on our constituents.

When a medical practitioner is put under pressure to resign when he resists the Department of Health and Children's drive to reduce bed occupancy times, as recently happened in the Lourdes Hospital, the reason cited was failure to follow agreed budgetary guidelines. If that is the case, then the Department of Health and Children is still stuck in the 1980s mind set. Unfortunately with a significant increase in the working population, which should be seen as the basis on which to increase the level of per capita health expenditure in real terms, we are still witnessing this 1987-92 culture.

As my colleagues, Deputies McManus and Penrose, stated earlier, recently there was astonishment in the United Kingdom at the proportion of national income spent on health compared to that spent elsewhere in Europe, but Ireland's expenditure on health is in the same bottom of the league class despite the fact that the economy is surging towards the top of the league. This is something which the new Minister, Deputy Martin, should address urgently.

If one wants to guarantee a quality health service, it requires an increase in the quality of service delivered to the public patient via the Exchequer and the social insurance system. This will allow the insurance funded private health cover to remain affordable to an increasing number of workers as real incomes rise. The increasing workforce provides a unique opportunity for the new Minister.

The way in which the health system has evolved in recent years is systematic of a Government which has lost real contact with people. The people in my constituency are still struggling to sustain decent livelihoods in an economy where the right to housing has become a thing of the past and the right to basic health services is only accessible to those who can pay. The man or woman who spends his or her entire working life paying taxes and contributing to the social insurance fund is finding out that he or she must wait two, three, four or even five years for essential operations and treatment.

I represent a constituency, much of which is working class, where the people do not have private health insurance and did not think they ought to have it, because they pay their stamps and understood that their health needs could be catered for through the public health system. However, that public health system is on the brink of collapse, as the Minister, Deputy Martin, takes over the Department. He should be aware that the failure of the health services to meet basic demands is one of the biggest scandals of the roaring economy.

I was struck by the arrogant reply which his predecessor gave to my colleague, Deputy McManus, at Question Time last November. When she rightly criticised him for the 40,000 people on the in-patient waiting lists, the then Minister, Deputy Cowen, stated that journalists should sometimes recognise that individuals have a vested interest in suggesting that the numbers are higher than they are in an attempt to obtain more funds for their members and are not as objective as they claim to be. What on earth is that supposed to mean? Instead of dealing with an outstanding major problem, he sought to shift the blame to journalists, administrators and health board officials.

My constituency mail bag, like those of my colleagues, is full to the brim of incredible accounts of people's experiences in hospital. Recently I received correspondence from distressed patients of my local hospital, Beaumont Hospital, who informed me that, on admission, they have been consigned to trolleys on public corridors for days. Others were shifted from bed, to chair and back to bed again, and spent more than two days in their dressing-gown in the middle of the accident and emergency department. How can the Government stand over a situation where such constituents are waiting many years for an essential artery bypass operation? Where is the comfort for them in the arrogance which was shown only last November by the then Minister, Deputy Cowen, who denied in effect that there was a crisis.

I also wish to bring the attention of the Minister, Deputy Martin, to an issue which was raised last year regarding one of the hospitals in my constituency, that is, the situation at St. Joseph's Hospital, Raheny. When it was faced with closure, and patients and 130 jobs were at risk in the argument between two multi-national companies, one of which owned the hospital and the other of which owned the service provision, neither the Minister's predecessor nor the Tánaiste and Minister for Enterprise, Trade and Employment, Deputy Harney, would take responsibility. Each of them stated that it had nothing to do with them. Therefore, one of the issues at the top of the Minister's agenda might be the regulation of the private hospital industry.

Caoimhghín Ó Caoláin

I thank Deputy McManus and her Labour Party colleagues for the opportunity to record my support for the motion. A year ago I opposed the motion of confidence in the then Minister for Health and Children, Deputy Cowen. At that time I joined other Members in deploring the desperate situation in the hospitals as waiting lists grew and as patients faced delays which were damaging their health.

If anything, the situation has deteriorated since then. Since the vote of confidence in February 1999, there has been the nurses strike, which was one of the gravest situations ever faced by the health service. The massive public support for the nurses was a vote of no confidence by the people in the Government's management of the health services. It was a scandal that the nurses should have had to strike at all. What greater service can any person give than to care for the ill, the elderly and the infirm. This service deserves the fullest possible remuneration. The failure over many years to properly remunerate the nurses is central to the grave problems now afflicting the health services, including long waiting lists, closed wards and state of the art surgical facilities in some locations which cannot be used.

Nurses and other health professionals have been leaving the public health system. There continues to be a disincentive to young people to enter the nursing profession, seeing as they do the inhuman working hours and pressurised conditions faced by nursing staff in the hospitals and also the attractions of employment in other sectors. While the resolution of the nurses' strike may have addressed this to a certain extent, the shortage of nurses is still causing daily crises in the hospitals. Only last week student nurses had to demonstrate outside Leinster House to demand the abolition of the £2,500 fee for their fourth year of nursing studies and the payment of a subsistence grant. These students are discriminated against and here we have another disincentive to young people taking up careers in nursing. I urge the new Minister, Deputy Martin, to address this without delay.

A glaring example of the flawed approach to the health services by the Government was the dictatorial decision of the outgoing Minister, Deputy Cowen, to restrict the medicinal herb, St. John's Wort. Account was not taken of the thousands of people who used the product safely and beneficially, nor was account taken of the growing herbal medicine sector. This decision can only benefit the large multi-national pharmaceutical companies who seek to monopolise health care. I urge the new Minister, Deputy Martin, to address this issue urgently and respond to the needs and the reasonable expectations of people throughout the State by reversing that decision.

Mr. Martin

Sinn Féin is definitely blocking the agenda.

Caoimhghín Ó Caoláin

Another priority for the new Minister, Deputy Martin, must be the dangerous situation with regard to HIV and AIDS. I hope this is not nearly as humorous for the Minister as the last point I raised. As recently as Sunday the director of the HIV/AIDS support group, Cairde, stated that the Eastern Health Board, where 90% of cases occur, has no real HIV strategy. A new national strategy is promised and this must be expedited. Some 38% of infections are caused by intravenous drug abuse and this highlights the failure of successive Governments to provide proper treatment and continuing after care for drug abusers, and to tackle the heroin problem and the climate of social exclusion in which it thrives. Tonight my colleague councillors in Dublin are attending a remembrance service for the young people in this city who have perished and continue to perish every week in the heroin holocaust.

I am glad the motion concludes with positive proposals, which I endorse totally, and I urge the Minister, Deputy Martin, whom I have already sincerely wished well in his new post, to take them on board and not make narrow or particular political capital. These are important issues of which I know the Minister is cognisant. I ask him to adopt a new and positive approach which can provide the people with the health service which they need and certainly deserve.

Minister for Health and Children (Mr. Martin)

I wish to share my time with Deputy Pat Carey.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. Martin

I move amendment No. 1:

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

Dáil Éireann:

(a)welcomes the substantial increase in capital and revenue resources that are being committed by this Government to the development of acute hospitals and all other aspects of the health services;

(b)commends the significant progress that is being made in developing services through a comprehensive series of strategic initiatives in areas such as cancer services and cardiovascular disease;

(c)endorses the Government's ongoing strategy of dealing with waiting lists and waiting times in a structured, co-ordinated and multi-disciplinary manner, involving all relevant aspects of the health system; and

(d)welcomes the intention of the Minister for Health and Children to continue to progress the development of a quality-based, patient-focused, well managed and closely integrated service for acute hospital users.

I welcome this opportunity, so soon after my appointment, to address the House on a vital element of the Government's health policy. I particularly welcome this as an opportunity to outline the way that I believe we should be talking about the future of our health services. One element of this has to be to confront the Opposition with the basic fact that the Government has already put in place a range of programme improvements and funding expansion, which means that today there are more people being treated by the health services, there are more people employed in the health services and there are more capital projects under way than at any time in the history of the health services.

The Government is absolutely committed to ensuring that we have a health service which is responsive and effective in meeting the needs of our people. To achieve this one needs a balanced programme and more funding to tackle structural difficulties. Most of all, one needs to realise that if the answers appear simple, then one does not understand the questions. As public policy makers it falls to us to try to develop a constructive debate on all the issues. Ignoring advances, simplifying problems and endlessly grasping at headlines does nothing to help an individual receive better care.

Unfortunately, the Opposition has shown itself determined to roar "crisis" at every opportunity and to pretend that nothing is being done. This is highly ironic, given that this Government replaced one whose health policy was characterised by complacency and which actually implemented a cutback in the only dedicated programme designed to tackle public waiting lists.

If one was to take much of the Opposition's attack seriously, one would have to believe that the Government is responsible for every problem common to almost every health system in the western world. We are not responsible for medical inflation in America, 'flu in Britain and waiting lists in Holland. However, we are responsible for unprecedented increases in funding, for hiring more health professionals and for recognising that as a country we need a balanced and ambitious programme to address long-standing problems in the health service.

Mr. Neville

The Minister has the same scriptwriter as his predecessor, Deputy Cowen.

Mr. Martin

Because of the nature of the Opposition's approach to this debate, I feel I must devote a significant part of my speech to refuting their charges against the Government's record, rather than solely concentrating on the policies we need for the future. This said, we not only have a record of which we can be proud, but we also have policies which can address the problems we continue to face.

We have to get some things straight. The number of people now benefiting from treatment in the acute hospital sector is greater than ever before. Contrary to the impression the Opposition wants to give, the acute hospital system treated 25,000 more patients on an in-patient or day-case basis during 1998, than in 1997. Similarly, over 18,000 more patients were treated in accident and emergency departments, and over 50,000 more patients were seen at out-patient level than in 1997.

This trend in overall activity continued during 1999. During the first nine months of the year, overall discharges, in-patient and day-cases were up by over 4% on the same period in 1998. Crucial to this has been the Government's major programme for renewing and developing health services throughout the country. The OECD recently reported that the performance of the system measures up very well by international comparison.

In spite of these advances we are not complacent. We have provided a very solid basis for further developments. My predecessor as Minister, Deputy Cowen, was responsible for a number of substantial initiatives in the acute hospital sector, which will achieve measurable progress in reforming, reorganising and properly gearing the system to meet the needs of our population. He recently outlined these in detail. They include the cardiovascular health strategy which is aimed at achieving an integrated approach to the prevention and treatment of cardiovascular disease – the full cost of this will be £150 million; the investment of £14 million since 1998 in cardiac services, including cardiac surgery, to support the objectives of the wider cardiovascular strategy; the national cancer strategy which is already improving the availability of cancer treatment services throughout the country – a total of £34 million has been invested in the strategy under the present Government; the establishment of a medical manpower forum to review key aspects of medical staffing in public hospitals, which impinge in a fundamental way on the quality of service provided to the public; a range of other initiatives in such areas as acute hospital governance and management development, clinicians in management, laboratory accreditation and health technology assessment, and the implementation of a co-ordinated waiting list initiative, which I will return to later.

The Opposition parties like to try to give an impression of cutbacks – an unequivocal and deliberate distortion of the fact that the level and breadth of our increased funding of the health service dwarfs that of the Government they were involved in less than three years ago. Through a combination of the normal Estimates process and the national development plan, we have provided resources which will help to renew and develop health services in every part of the country.

Under the national development plan, £2 billion has been earmarked for health care which will enable substantial improvements in the physical infrastructure and equipping of acute hospitals and in facilities for the intellectually and physically disabled, the elderly, the mentally ill and children in need of care and protection. The plan also provides for investment in health centres and in information technology.

There is always a danger that the priorities for spending in the health system can be unduly influenced by those who shout loudest or are the most sophisticated lobbyists. While the acute hospital sector and related areas of the services tend to loom large in the public consciousness, the major progress this Government is making in the development of services for the intellectually disabled, is both badly needed and widely welcomed. The ongoing development of services to meet the identified needs of this group has been a top priority of the Government.

Total additional revenue funding of £38.7 million is being provided this year, increasing to £45.7 million next January. This funding will provide, at a minimum, over 550 new residential places, almost 200 new respite places, 700 new day places, health related support services for persons with autism, the continuation of the programme to transfer persons with an intellectual disability from psychiatric hospitals and other inappropriate placements and additional specialist and other support services.

This is the largest single new revenue investment ever made in the health services. The comparative amount for new developments provided by the previous Government in 1997 was less than one quarter of this figure. Furthermore, additional capital funding amounting to £80 million is to be made available over the next three years to speed up the process of putting in place the necessary infrastructure to support these services.

Waiting lists and waiting times are, of course, an international problem and we are not unique here in facing the challenge of reducing them. In-patient waiting lists represent 4% of the total discharges from acute hospitals. Having said this, the length of time that an individual patient must wait to gain access for a hospital procedure is of course a highly important indicator of how well the system is responding to demand and can be a more relevant measure than the actual number of patients on a waiting list.

Mr. Creed

What about the blood bank in Cork?

Mr. Martin

The problem of waiting lists in the acute hospital sector here is not new, although to listen to the Opposition one would think that we had recently invented them. There is no getting away from the fact that during the lifetime of the last Government the impetus behind addressing waiting lists declined. The numbers on waiting lists and the length of waiting times for many specialties rose by fully one-third. What is truly remarkable in light of this evening's rhetoric is that a Government led by Deputy John Bruton, with Deputy Quinn in charge of the Department of Finance, actually cut the funding targeted at reducing waiting lists for public patients by a third in its last budget.

Mr. Creed

That is because waiting lists were down.

Mr. Neville

In the first two years of this Government's term, they increased by 11%.

Mr. Martin

This betrayed a complacent health policy, with no strategic vision and no priority in financial resources. That is the bottom line – they cut back on the one dedicated programme to reduce waiting lists.

Dr. Moffatt

They have short memories.

Mr. Martin

Deputy Bruton recently published a document which stated that "waiting lists are a politically created phenomenon". Perhaps in their remaining speaking time, Opposition Deputies would explain if he was specifically referring to the policies followed by his Government because they were certainly very effective in cutting waiting list funding, while presiding over an increase in people on the lists.

Mr. Creed

That is not true.

Mr. Martin

We have set about redressing the results of this self-satisfied complacency in a comprehensive and structured manner. We have increased funding significantly under the waiting list initiative, providing £12 million in 1998, £20 million in 1999 and £23 million this year – a level almost three times that provided in the 1997 budget.

Mr. Rabbitte

And the queues are longer.

Mr. Martin

Crucially, however, we have also recognised that funding alone will not address the issue. Adequate funding for waiting lists is an important concern, but the underlying causes of waiting lists are considerably more complex. With this in mind, the Government commissioned an expert review group to examine these causes and to make recommendations on how to address them. The review group rightly pointed out that we must address the waiting list problem from a wide perspective, looking at those factors at the levels of primary care, secondary care and longer term care which can lead to unacceptably long lists. In particular, we must ensure that services at primary care level are properly structured to enable patients to be channelled to the most appropriate point of service as efficiently as possible. At secondary care level, we must develop our hospital based services in a way that manages admissions and discharges effectively and deals speedily with the needs of those on waiting lists. At the level of longer-term care, we must provide sufficient step-down and rehabilitation facilities so that those no longer needing acute treatment can be best cared for outside the acute hospital setting. This, in turn, frees up acute hospital beds for elective procedures, including those for which there is a waiting list, and results in the optimum use of hospital beds to the greatest benefit of patients.

The series of immediate, medium-term and longer-term objectives recommended by the review group form the basis of the Government's strategic approach to tackling the issue. A strong rate of progress is being made in implementing these recommendations. We are addressing the need to free up acute hospital beds by investing in sub-acute services. A range of measures for improved management arrangements and liaison with GPs are being put in place locally and the major funding available under the national development plan will help address the longer term capacity issues on the non-acute side.

In summary, the Government has approached the whole issue of waiting lists in a far more structured and comprehensive manner than any previous Administration.

Mr. Creed

The lists are longer.

Mr. Martin

In addition to the increased funding I have outlined, we are implementing a range of practical measures that will help to deal with the underlying causes of waiting lists.

Mr. Creed

That is a very scientific approach.

Mr. Martin

There were very encouraging signs prior to the nurses dispute that this approach was paying dividends. Just before the strike began, in-patient waiting lists as on 30 September had fallen for the third successive quarter. They were down 9% compared with the beginning of the year and the integrated strategy the Government had adopted was showing real success. While the lists rose again in the immediate aftermath of the strike, the challenge now will be to regain lost ground while taking strong encouragement from the very positive impact the strategy has had in the first three quarters of 1999.

Mr. Creed

Blame the nurses.

Mr. Martin

I will be seeking to build on that early progress with a view to achieving real improvements in the waiting times for access to services. This focus is being re-emphasised in my Department's discussions with agencies on their service plans for this year.

All acute hospitals experience a seasonal increase in activity during the winter, particularly in December and January. This is not a uniquely Irish phenomenon but is commonplace throughout Europe and most western health systems. The increase is largely attributable to elderly and other medical patients presenting with chronic illnesses, such as viral and bacterial infections and influenza, which can only be treated in hospital and which require a longer than normal hospital stay.

The first priority of acute hospitals providing accident and emergency services is to provide care and treatment for emergency patients. Due to the nature of the service, attendances at accident and emergency departments are difficult to predict accurately in advance.

Of over 1.2 million attendances in 1998, in excess of 540,000 of the total were to the accident and emergency departments of acute hospitals providing accident and emergency services in the eastern region. Hospitals located in the eastern region experience greatest pressures, in terms of numbers presenting at accident and emergency departments and their abilities to respond to these pressures.

If we are to manage our hospital services efficiently, it is important to ensure the most appropriate services are given in the most appropriate setting. We must ensure accident and emergency services are used only for emergencies. Inappropriate referrals to accident and emergency departments must be eliminated and self-referrals kept to a minimum. To do this, we need to have an adequate out of hours service by general practitioners. Regrettably, criticisms of the out of hours services being provided by GPs, not only in the Dublin area but throughout the country, are becoming more frequent. These criticisms relate to the unavailability of patients' GPs after normal working hours and to the slow response of GP deputising services. In addition, because of the perceived lack of knowledge by deputising GP services of patients' medical history, many patients are reluctant to avail of the deputising service. This has lead to a significant increase in the number of patients presenting in casualty departments when they should more appropriately be attending their GP.

Initiatives such as the DUBDOC GP out of hours project at St. James's Hospital, which works closely in conjunction with the accident and emergency department, and GP co-operatives in Carlow and in the North Eastern Health Board area will be evaluated carefully with a view to their development and extension throughout the country.

Mr. Creed

Blame the doctors, the nurses and the previous Government.

Mr. Martin

In consultation with the health boards, we are examining the adequacy and cost of GP out of hours service. I am determined that an adequate and cost effective service is provided by GPs, which will ensure a better quality service to patients, thereby eliminating inappropriate attendances at accident and emergency departments.

In recent weeks a significant increase in patient attendances at the accident and emergency departments of acute hospitals, particularly in the eastern region, was experienced, with an increase of approximately 25% in the number of patients requiring admission through the departments. The majority of these were aged 65 years and over and such was the nature of their illnesses that discharge after two to three days, as might be expected, was not possible. Their average length of stay was seven to ten days. This impacted hugely on each hospital's capacity to provide acute beds for the numbers attending each day who were deemed to require admission. At its peak, a total of 108 patients were awaiting admission in accident and emergency departments in the eastern region on 11 January 2000.

Each hospital providing accident and emergency services adjusts clinically to manage the situation, with many extra efforts to improve the flow of patients through the system. In circumstances where a hospital is operating at full capacity, it may be necessary to cancel elective admissions to free up beds for emergency admissions, thereby inconveniencing patients and perpetuating waiting lists. This has a particular impact on the length of time people are required to wait for elective procedures.

Hospitals efforts to cope with the increased demand for acute beds were also frustrated by bed closures brought about by a shortage of nursing staff. Nursing staff shortages are a feature of acute hospital provision generally, particularly in the eastern region. This factor, combined with high levels of sick leave due to the viral-bacterial illness presented, contributed to the difficulties.

The Government has provided additional funding to acute hospitals providing accident and emergency services to enable them to implement a range of initiatives in the medium term aimed at addressing the difficulties being experienced in their accident and emergency departments. These initiatives include the provision of step-down facilities, the provision of enhanced staffing levels, the development of rapid diagnostic systems for common emergency presentations, the continued development of treatment-observation areas in accident and emergency departments and improved access for general practitioners to urgent specialist opinion. An additional £2 million is being provided in the current year to enable hospitals to continue with these initiatives.

The increase in demand which has been experienced in accident and emergency departments in recent weeks has resulted in problems for many people presenting for care and treatment. I very much regret any distress or inconvenience to patients which has arisen.

I can assure the House, however, that in order to provide more effectively for an anticipated increase over the 1999-2000 winter period in attendances of persons with flu or flu-like symp toms at accident and emergency departments and to enable hospitals to respond to a surge in demand for acute hospital beds, the accident and emergency steering group for the eastern region was asked in March 1999 to suggest proposals which would effectively eliminate the "trolley crisis" in their accident and emergency departments during this period.

The steering group identified those patients admitted to hospital who have completed the acute phase of their illness and who require a level of care more appropriate to their needs as the single biggest contributing factor to the problem. The Eastern Health Board subsequently submitted a proposal which envisaged the provision of 235 step-down places. Funding has been made available to provide these facilities. It is important to note that had these additional step-down beds not been in place, the impact of the increased demand for services would have been significantly greater. It has been acknowledged by the hospitals providing accident and emergency services that a major crisis was averted because of this additional bed capacity. This enabled, and continues to enable, hospitals to cope with the situation, albeit not without some inconvenience to patients in terms of waiting times for admission. This, together with the dedication and commitment of hospital management and staff, ensured that a major crisis was averted.

Given the period of the millennium when the problem first occurred, the base nursing shortage at major hospitals, some complaints regarding a lack of adequate general practitioner services during the holiday period and the lack of notice and shortage of confirmation as to whether they were dealing with a flu epidemic, the accident and emergency departments should be congratulated on their performance.

Hospitals providing accident and emergency services have been seeking to manage seasonal surges by improved admission and discharges management, rostering of additional staff where feasible and through the provision of additional long-term care, sub-acute and convalescent beds. Our initiatives have had an impact, but we recognise that much remains to be done. One of my priorities will be to address the persistent problem of seasonal pressures on our accident and emergency departments.

Health care systems in the European Union contain a mixture of the various basic financing methods, for example, general taxation, social insurance contributions, out-of-pocket co-payments and private insurance, with a different mix in every country. No one method is accepted as the ideal. Tradition and the social development of each nation seem to be the major determinants of the system to be found in each state, with evolution rather than revolution being the accepted process for the reform of health care financing, particularly in relation to the source of general finance for health. The OECD has praised the Irish health care system in both its last economic reports on Ireland in 1997 and last year. The 1997 report concluded that the Irish health system, with its mixture of public and private care, had "resulted in good provision of health care at a relatively low cost to the taxpayer".

Mr. Creed

That was when Deputy Noonan was Minister.

Mr. Martin

The Labour Party has asked the House to support the introduction of a system which it has not costed and has not set out in detail. It is a classic example of an Opposition presenting something as a quick and easy fix. This is another policy which featured nowhere near the Labour Party's agenda when it controlled either of the Departments of Health or Finance. An insurance based health system is not a panacea, it would involve major dislocation, have an uncertain outcome and potentially be extremely costly. If this is to form the centrepiece of a replacement for the previously spartan Labour Party policy on health, it can be assured that we will not let it away with glibly presenting it as the answer to everything.

To give a simple example, Germany, with one of the largest social insurance based systems, is instituting major cost containment measures, including the introduction of global hospital budget limits and controversial drug prescribing limits. Hospitals in eastern Germany were only allowed a 1% increase in funding last year and major efforts are being made to reduce both the numbers of hospitals and hospital beds. Also, social insurance systems are usually heavily regulated and, frequently, unforeseen difficulties arise from contradictory effects of these regulations. An example is the increased use of hospital pharmacies following the introduction of prescribing limits for care in Germany. This means that the costs have simply shifted to a different part of the system.

The Labour Party might like to note that across Europe many sickness funds are running deficits which governments have had to support from general taxation. In Belgium, for example, the scale of government intervention has reached a point where as much as 45% of the funding for sickness funds comes from general tax revenue.

The concentration throughout the developed world is on improving the efficiency and effectiveness of health care delivery systems and on endeavouring to ensure that the systems' overall capacity better matches demand. There are no easy solutions to universal problems of financing health care. The way to radically improve the health of our society is to put a high level of resources into the services in a focused manner and manage those resources effectively. This Government is determined to commit the necessary resources and to get the needed results. The way forward will not be found through dressing up underdeveloped, uncosted proposals as the painless answer to everything. I suggest to the House that the major administrative costs which would be involved would be better applied to the improvement of the public health care system.

The developments I have described represent an enormous financial investment in our health care system. I intend to maintain the momentum for investment in health – and that is how it is rightly being seen – but I want to do more. I want the way the patients see the service to determine to a much greater extent how the care is delivered. This will mean devising new approaches to involve patients in the organisation and delivery of services. It will mean health providers making available much more and better information about what they do and how well they do it. It will mean, for example, putting in place formal patient advocacy structures on a much wider basis than currently exists. I want to proceed straight away with practical and imaginative projects in this area and will be looking to every care provider to make proposals in this regard.

Later this week I will be launching a major initiative in the development of an accreditation programme for acute hospitals. This programme is based on the concept of whole hospital evaluation and is in line with similar quality improvement mechanisms in a number of the most advanced health care systems in the world. I see an initiative such as this as being a powerful driver for a whole range of quality measures, from the way a hospital is governed at board level through its approach to clinical care and right down to its patient responsiveness. In time this programme is expected to expand beyond the acute sector across the system as a whole.

This Government is committed to developing a modern and responsive health service which has the resources and structures it needs to provide care quickly when the need is identified. Patients have a right to care using treatments based on best practice. They have a right to well co-ordinated hospital services that will quickly identify and provide their treatment needs and integrate with other parts of the system. At all times this must be underpinned by basic considerations of dignity for patients with courtesy to them and their families.

This is the objective facing everybody involved in the health system and the achievement of this objective requires a balanced debate about complex problems. Over less than three years, the Government has provided unprecedented resources to the health system and this has meant that more patients than ever are receiving the care they need. The largest programme of renewal and development in the history of Irish health care is well under way and is being felt throughout the system. In addition, a range of long-standing problems are being addressed through the implementation of considered and ambitious initiatives.

Unlike the complacent record of those we replaced and who are now attacking us, we know more needs to be done and we are committed to doing what has to be done. I am honoured to have been given the opportunity to work with the dedicated officials who make up the staff of my Department. I look forward to working with them and the thousands of health care professionals throughout the system in the coming years. I know that, working together and reinforced by the Government's ongoing commitment to the health service, we can go some way to ensuring that we are delivering the level and quality of service which our people deserve.

Mr. P. Carey

I congratulate the Minister on his appointment as Minister for Health and Children. I have no doubt he will do as good a job in health as he did in education. I also take the opportunity to congratulate Deputy Hanafin on her appointment as Minister of State at that Department. The debate developing tonight is interesting. The Labour Party has raised some important issues relating to how we manage and deliver a health service to the public. Its contribution, however, has been marked, as so often in the past, by a lack of policy, basic costings and an absence of vision. The absence of that policy in tabling this motion was clearly to try to catch our new Minister for Health and Children on the hop in his first full week in that office. How badly mistaken it has been.

Perhaps the Labour Party could for the purposes of this debate leave aside its usual rhetoric and outline to us its fundamental problems with the provision of an unprecedented level of resources for our health service and proper planning for the development of these resources for the improved delivery of services. This year the level of development funding provided for the acute hospital system stands at five times what was provided when the Labour Party was in Government in 1997 and had control of the national purse strings through Deputy Quinn. In that year, £100 million of capital funding was provided for health infrastructure. This year £230 million will be available under the national development plan. Capital investment in the health services will be treble what it was in the previous six year period.

The restructuring of the services in the eastern region will be actioned by the establishment of the Eastern Regional Health Authority in March. This will effect a meaningful improvement in the integrated management of the various components of the system in this region. A series of strategic plans and initiatives backed by real resources are in place to tackle major killers such as cancer and cardiovascular disease, to improve renal services, to achieve a quality driven hospital service accredited to highest international standards, to improve our emergency response services, to tackle the underlying causes of lengthy waiting lists, to enhance subacute and step-down service availability, to address issues relating to medical manpower, to improve management structures and involve clinicians in the decision making process. These are some of the major activities in which this Government is meaningfully engaged in the acute hospital system.

Where sits Labour Party policy on any of these issues? I have not heard it and there were no signs of it when it was presiding over the allocation of meagre development funding when in Government. The Government of which it was part introduced important legislation to provide for greater accountability and structured service planning in the health sector. The legislation was widely recognised as necessary against a background of spiralling debts being run up by agencies and it was supported by us in Opposition on that basis. This Government has been successfully applying this accountability legislation. In Opposition, however, the Labour Party suddenly discovered it did not like its legislation when it was applied last year.

The burden of rhetorical opposition rests very easily on its shoulders. What a shame for hospital users that responsibility in Government did not bring quite the same confident knowingness. Indeed, as the Minister pointed out, the Labour Party and its Government partners presided over a period of spiralling hospital waiting lists, prompted by their remarkable decision in 1997 to cut waiting list initiative funding by £4 million. That decision would have denied access to a hospital procedure to about 4,000 patients in that year. As the Minister outlined, the number of patients benefiting from hospital services under this Government continues to grow each year. For the benefit of the uninitiated that represents an expansion of service not a deterioration.

That service is being delivered in hospitals which are better equipped now than under the previous Government. The previous Minister for Health and Children, Deputy Cowen, introduced a dedicated replacement equipment programme for hospitals which meant that for the first time they can budget for the upgrading of equipment. As the new Minister stated earlier, the challenge lies in continuing to introduce improvements so that the service available is as good as it can be.

Mr. Neville

I wish to share time with Deputies Creed and Shatter.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Mr. Neville

I congratulate the Labour Party, particularly Deputy McManus, on tabling this motion which has given us the opportunity to discuss this important issue. I also congratulate the Minister and the Minister of State, Deputy Hanafin, and wish them well. I am surprised that when the Ministers were changed the script writers were not also changed.

Mr. Martin

The Deputy is wrong in that assumption.

Mr. Neville

One's health is one wealth. We have a healthy and vibrant economy but our health services are in a shambles. Each day the situation deteriorates. It is not fair that people in need of medical procedures, including cardiac surgery, orthopaedic surgery, gynaecological surgery, ophthalmological surgery and ENT surgery, but who cannot afford to pay for them must wait months, even years, to alleviate their suffering.

In the Mid-Western Health Board area, 51% of patients on the orthopaedic surgery list have been on it for over 12 months. Whey must people who are suffering pain and rendered immobile in many cases wait for relief for up to two years? It is not fair and it is negligent, at a time when, unlike heretofore, there are more than adequate resources available, to allow this situation to continue. It is difficult to understand the Government's rationale for doing this.

In the Eastern Health Board area, 55% of those on the waiting list for ear, nose and throat surgery have been waiting for more than 12 months and 67% of children have been waiting for more than six months. Our national ethos is to treat all the children of the State equally. However, the Government has failed to do so. For those whose parents can afford treatment, the procedures will be carried out. For those who cannot afford it, their children must wait. I have heard of many cases where GPs are encouraging people who do not have the wherewithal to pay for an operation or treatment to place themselves in debt, thereby inflicting unnecessary stress during a most difficult and stressful time in their lives. This matter was already referred to by our colleagues in the Labour Party.

Our health service must be patient-centred and must put patients first. Inadequacies in public hospital services 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 health care provision, doctors and nurses, are required to work under unacceptable and intolerable pressure. A democratic state that guarantees you right of access to a lawyer if you commit a crime should guarantee you the right to a physician, essential in-patient hospital treatment or surgery if you become ill.

It is clear from figures released by the Department of Health and Children that the number of patients awaiting admission to hospital for elective surgery is growing steadily. The Minister outlined a comparison between the previous Government and the current Administration. However, I will now remind him of the figures supplied by his predecessor last June. At the end of June 1999, the in-patient waiting list for public patients stood at 33,924 countrywide, an increase of 3,471 or 11% in the first two years of the Government's term of office. According to the previous Minister for Health and Children, following the first ever national nurses' strike, the waiting list figures at the end of October stood at 37,200, an increase of over 3,500 in three months. It is estimated that during that damaging and preventable strike, 3,300 people had their surgery or procedures cancelled. It is unsatisfactory that we will be obliged to wait until March to discover the waiting list figures for December. However, I suggest that these and the figures for January will tell a similar, damning tale in the wake of the large number of emergency admissions which resulted from the flu epidemic.

Many of those already on waiting lists are obliged to wait from between 12 months to two years for the treatment to which they are entitled. Some must wait even longer. 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 and, in some cases, years for elderly and infirm people. It is unacceptable and unjust that children should have their school attendance disrupted by ongoing bouts of debilitating infection while the waiting list for ENT surgery grows longer each month. It is unacceptable that the education of school-going children with hearing difficulties is being seriously impaired. I know the Minister, from his experience at the Department of Education and Science, will agree with that statement. It is shocking that cardiac patients are dying while on the cardiac surgery waiting list.

Despite successive attempts to reduce waiting lists through so-called waiting list initiatives, it is clear that simply ploughing money into short-term reductions in numbers is not working. Each winter the waiting lists grow longer and each summer there are unjustified bed closures. This see-saw effect exacerbates rather than relieves the problem it is designed to overcome. As a result of hospital bed closures during the summer months and further autumn cutbacks which hospitals throughout the State were obliged to implement to attempt to remain within their financial budgets, it is estimated that the number currently on the hospital in-patient waiting list can be properly estimated at over 38,000. This means that waiting lists have increased by 24% during the Government's term of office.

There are, in effect, two waiting lists for public patients. The 33,924 people who made up the waiting lists on 30 June 1999 were awaiting in-patient treatment for surgery. They have seen a consultant and have been examined and assessed as requiring hospital treatment. There are many thousands of people, adults and children, on another waiting list, namely, those awaiting initial appointments with a consultant. Remarkably the Department of Health and Children does not collate national statistics of those awaiting consultations, who are numbered in their tens of thousands. The 33,924 people to whom I referred represent only the tip of the waiting list iceberg.

Doctors in one Dublin city general hospital were shocked but not surprised that their patients were obliged to wait five months for an initial appointment with a consultant dermatologist, eight months for an appointment with an ophthalmologist and six months for an appointment with a gynaecologist. Several of their patients, for whom letters of referral were sent in August 1999, received appointments in June 2000. This situation is unacceptable. The problem is not unique to Dublin. There are more than 1,000 people awaiting neurological consultations in the Southern Health Board area, some of whom will be obliged to wait over 18 months for initial points with one of the three neurologists in that area which includes the second largest centre of population in the country, Cork city.

Such delays create unnecessary anxiety for people whose medical condition may already be a cause of concern. Such delays can place patients lives at risk. While acknowledging that money invested in the waiting list initiative has solved individual health problems for many thousands of people, such special financial allocations have not structurally resolved the waiting list problem. A great deal more action is needed.

To tackle the waiting list crisis a broad range of reforms is required which will impact on departmental, health board and Comhairle na n-Ospidéal procedures, hospital structures, the management of waiting lists and the manner in which general practitioners, consultants and medical staff work. The co-ordinated nationwide usage of the latest interactive communications as a diagnostic tool and for the administration and monitoring of the health services is also crucial in order to ensure a caring health service responsive to community needs which is equipped to meet the challenge of the new millennium. At a time of unprecedented economic growth, funds should be provided to put in place a comprehensive programme of measures which, once and for all, address the waiting list problem.

Experience has shown that piecemeal initiatives merely act as a palliative and a cure is needed. Fine Gael has proposed specific measures designed to tackle in-patient and out-patient waiting lists in a systematic and practical way to make acute hospital services more patient-centred.

Waiting lists in the Mid-Western Health Board flagship hospital, the Regional Hospital, Dooradoyle, Limerick, are totally unacceptable. Between June 1997, when Deputy Noonan left office, and June 1999, two years after this Government took office, there was a 36% increase in waiting list figures – an additional 415 patients.

In the mid-west, 142 adults are awaiting ear, nose and throat surgery, 55% of whom are waiting for over 12 months; there are 84 children on the waiting list, 67% of whom have been waiting for over six months; 424 women are awaiting gynaecological procedures, almost 30% of whom are waiting over 12 months; 613 patients are awaiting ophthalmology treatment, 78% of whom are waiting over 12 months, of which 522 require cataract surgery. It is unfair that elderly people cannot read newspapers or books or see television at a time when they could enjoy such pleasures after decades of contributing to bring the State to its current position. The Government has forgotten these people.

Also in the mid-west, 331 people are awaiting orthopaedic surgery, 51% of whom are waiting over 12 months. This condition affects the elderly in particular and it is scandalous that people have to suffer while waiting for hip or other replacement operations. Why should people suffer in this way because they do not have the personal resources to pay for treatment?

Orthodontic services in the Mid-Western Health Board region are a shambles and public representatives are regularly contacted about this. The Minister should examine this situation in particular as there is a problem. He would be well advised to ask his officials to speak to the consultant orthodontist and his staff who are extremely concerned about the position.

The Minister mentioned improvements to mental health services under the new plan. This area has been neglected for too long. Our psychiatric services have a Third World status for many reasons and languish in the 1930s and 1940s when psychiatric hospitals were known as "lunatic asylums". This is not a personal attack on the Minister as he has just taken office, but it is an attack on the performance of the Government. The report of the Inspector of Mental Hospitals for the year ended 31 December 1998, published last November, was most revealing. It highlighted the fact that a serious and disturbing situation has developed, with which I agree, and also referred to many serious deficiencies in the service. This is an indictment of the Government's treatment of one of the most vulnerable groups in society – the mentally ill. These patients have been neglected, ignored and stigmatised for decades.

A total of 5,101 patients have been treated in psychiatric units and acute hospitals over the past decades. The Joint Committee on Health and Children hopes to discuss this issue on Thursday and, hopefully, it will take these matters on board. I hope to raise this issue with the Minister in addition to the associated issues of suicide and attempted suicide.

Mr. Creed

I congratulate Deputy Martin on his appointment as Minister for Health and Children and Deputy Hanafin on her appointment as Minister of State and I wish them well. I note from press coverage that the Taoiseach's reasons for transferring the Minister have been cited as bolstering the Government's re-election prospects. There is no other reason the Taoiseach would have transferred a Minister who was successful in the Department of Education and Science and given him the poisoned chalice of the Department of Health and Children were it not for the fact that he felt he was the best man for the job.

All Members, including the Minister, have been inundated with complaints from constituents about the inadequacy of the health services. Last Thursday I dealt with the case of a woman in Mallow hospital suffering from multiple organ failure who was looking for a bed in Cork University Hospital. However, she could not get a bed or an ambulance to transfer her. I spoke to the admissions office in the hospital but was informed that there were no nurses or beds available. Yesterday in my constituency office I spoke to the husband of a woman admitted in an emergency to the Erinville hospital on Saturday night for a gynaecological operation. However, the position was the same – there was no bed available for surgery as of this evening and none is expected to be available until the weekend at least. Such cases are the tip of the iceberg and there are enormous problems.

The Government's amendment to the motion welcomes the substantial increases in capital and revenue. We cannot argue with facts and there are increases in these areas. However, the amendment goes on to endorse the Government's ongoing strategy to deal with waiting lists. No one could endorse a situation in which waiting lists have grown over the past three years. I was disappointed by the Minister's explanation is so far as he appeared to blame nurses and doctors. That is not a good start.

Mr. Martin

That is an inaccurate account of my speech.

Mr. Creed

If the Minister reads his speech he will see that he said nurses were to blame for the growing waiting lists and doctors were to blame for problems in accident and emergency departments. That is a pretty poor starting point. The Department of Health and Children is a poisoned chalice and every Minister, in good times or bad, has found it difficult to please everyone. I hope the Minister will have some success in dealing with the major problems.

I wish to raise the parochial issue of cardiac surgery facilities in Cork University Hospital where there is one cardiac surgeon who is about to retire. I have spoken to him previously about individual constituents but this is an appalling situation which needs to be addressed as quickly as possible. A second issue is the location of BTSB facilities in Cork. As Minister for Education and Science, Deputy Martin listened sympathetically to calls for such a service but he was able to throw his hands in the air and say that he would solve the problem if this matter came within his portfolio.

Mr. Martin

I never said that.

Mr. Creed

This issue is now part of his portfolio and people in Cork are waiting in anticipation. I will return to this issue in the future as I do not want to ruin the Deputy's inaugural appearance in the House as Minister for Health and Children.

I wish to refer to orthodontic services where guidelines are too restrictive and the cost of private treatment is beyond the means of many parents. This treatment involves far more than a cosmetic procedure. It has implications for personal development, self confidence and so on and we need to investigate why, for example, treatment is so much cheaper in Northern Ireland.

I also wish to refer to the care of the elderly. All Members receive representations from people who want the State to take responsibility for their parents and who do not want to take any responsibility themselves. We should encourage continuing care in the community as far as is possible. However, when people have to be institutionalised, particularly in private nursing homes, we must examine the level of the nursing home subvention. The maximum is £120, although it might be increased in some cases, but this is totally inadequate.

Debate adjourned.