Dáil Éireann debate -
Wednesday, 10 May 2000

Vol. 518 No. 6

Private Members' Business. - Non-Consultant Hospital Doctors: Motion.

Mr. Shatter

I propose to share my time with Deputies T. Ahearn, Connaughton and Bradford. I move:

"That Dáil Éireann:

–deploring the failure of the Government to make reasonable proposals to resolve the current dispute with non-consultant hospital doctors,

–alarmed at the continuing deterioration in our health service at a time of unprecedented economic prosperity,

–acknowledging that the hours presently worked by non-consultant hospital doctors detrimentally impact on doctors' health and undermine their ability to provide proper patient care,

–concerned at the inability of the Health Service Employers Agency to constructively address and resolve industrial relations issues within the health service as evidenced by its failure after six months of negotiations to make any substantive proposal to resolve issues in dispute relating to non-consultant hospital doctors,

–conscious of the serious damage to the health service that will result from strike action by non-consultant hospital doctors and the effect of such a strike on patients resulting in the further escalation of the in-patient hospital waiting lists,

–acknowledging the crucial role played by non-consultant hospital doctors in our hospitals,

–agreeing that the hours presently worked by non-consultant hospital doctors are totally unacceptable and are inadequately remunerated,

–deploring the fact that some non-consultant hospital doctors have been forced to take legal action to secure overtime pay ments due to them and that substantial arrears of remuneration for overtime hours worked are presently payable to non-consultant hospital doctors,

–noting that 98% of non-consultant hospital doctors voted for industrial action for higher overtime rates, shorter working hours and better staffing ratios,

–condemns the failure of the Minister for Health and Children to intervene at an early stage to facilitate the reasonable resolution of the issues in dispute, and calls on the Minister for Health and Children to immediately enter into substantive negotiations with the Irish Medical Organisation in order to resolve the current dispute and to avoid a damaging strike occurring."

Political brinkmanship, crisis management and industrial relations ineptitude are the hallmarks of the Government's approach to our health service. Last October, the Government's failure to engage in constructive dialogue in negotiations with the nursing unions resulted in the first ever nurses' strike in the State. In the past six months, the Irish Medical Organisation, in discussions with the Health Service Employers Agency, has attempted to resolve a number of serious difficulties that affect non-consultant hospital doctors. This has proved impossible and we are now confronted with the possibility of non-consultant hospital doctors taking strike action on 17 May next to force the Government to resolve genuine grievances which in justice must be addressed.

The present Government and both the current Minister for Health and Children and his predecessor have failed to realise that our health services have entered not only a new millennium but a new era. Nurses have already fought part of the battle to force the Government to recognise this fact. Junior doctors are now fighting on another but related front. Their fight should not be categorised as simply an industrial relations dispute; it is more than that. Like the battle fought eight months ago by the nursing unions, it is concerned not simply with working conditions and remuneration but about the type of health service we should have in this State and crucial standards of patient care.

Our hospital service is consultant-led. There are currently 1,250 consultants in hospitals throughout the State and 2,700 junior hospital doctors. It is now widely acknowledged that our consultant numbers fall far below what is required to provide proper patient care and it is estimated there is a need to appoint an additional 800 consultants to properly meet patients' needs and to bring to an end the escalating waiting lists crisis. Without the 2,700 junior hospital doctors in our hospitals, we would not have a functioning health service. The reality within our hospital services is that junior doctors are expected as a minimum to work a 65 hour week. This is supposed to be their maximum working time. In fact, a substantial number of junior doctors are on continuous duty for up to 36 hours and work between 80 to 100 hours per week. The hours junior doctors are currently required to work detrimentally impact on their health, impair their capacity to make clinical judgments and, as the doctors themselves accept, put patients at risk. The hours currently worked by junior doctors are totally unacceptable and should not be tolerated by either the medical profession or by the general public.

For some time now there have been discussions at European level about the Working Time Directive and its application to non-consultant hospital doctors. While final decisions have yet to be made as to the exact date by which the 48 hour week will be extended to junior doctors, it seems that at European level, from the date when the directive comes into force, a gradual reduction of working hours will result in taking a nine year time span before the working week for junior doctors is reduced to 48 hours. There is no commitment from the Government to do better than that. Fine Gael believes that there should be commitment to a speedier time frame by which junior doctors will not be obliged to work in excess of a 48 hour week. In moving towards the reduced working week, a junior doctor should not be required to work in excess of a 65 hour week or be required to work the excessive hours previously referred to. Essentially, an 80, 90 or 100 hour week is a consequence of the failure of the State and of this Government to ensure our hospitals have available to them the crucial number of required consultants in a variety of specialities, including consultants who specialise in accident and emergency procedures.

The pay currently received by junior doctors for work in excess of 48 hours in any week is equal to half the basic hourly rate paid to them for normal work. They receive a salary scale known as "half time". No one else within the public or private sector would work overtime for half their normal hourly working pay. To add insult to injury, we learned in recent weeks that hundreds of junior doctors throughout the State are due overtime arrears payments going back many months and some have been forced to take legal action against their employers. A number of hospitals have been named and shamed for failing to pay junior doctors the miserly salary to which they are entitled for overtime hours already worked. These include, St. Vincent's Hospital, Dublin, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Cork University Hospital, Galway University Hospital and Limerick Regional Hospital.

In what other area of the public service would a State employee tolerate being required to work excessive overtime for a half time payment which is not even made? In years gone by, we watched in wonderment, scenes from the old Soviet Union and then in the newly reformed Russian State where State employees took to the streets to demand pay State bodies had withheld from them for many months. The manner in which junior doctors have been treated by the Department of Health and Children by health boards and hospital administrators has much in common with the treatment of Siberian miners by the old Soviet administration. Since the naming and shaming of the various hospitals, some of them have cried foul. Are they to be believed? An independent inquiry conducted by the ICTU former president, Mr. Philip Flynn, found that non-consultant hospital doctors in one of the country's biggest hospitals, University Hospital Cork, were required to work unrostered hours for which they were not paid. He recommended in his report that compensation payments be paid to the doctors concerned.

University College Hospital, Galway, is currently facing a number of Labour Court actions from non-consultant hospital doctors demanding adequate pay for overtime worked. One case was already before the Labour Relations Commission just last week. The commission gave the hospital three weeks to resolve matters and presumably to make payments that are clearly due. From my contact with a number of different doctors, it is now clear that hospitals and health boards have consistently failed to honour the 1997 NCHD agreement. Junior doctors, on whom the functioning of the health service is dependent, are entitled to be angry.

The lack of insight by the Department of Health and Children, health boards and hospital administrators is extraordinary. It is almost beyond belief that at the very time non-consultant hospital doctors were balloting on proposed strike action, health service employers were depriving them of basic salary entitlements. Under Partnership 2000, the 1% increase in basic salary was due from 1 April. This should have been added to the most recent pay cheques received by junior doctors. However, reports from Cork, Galway, Limerick and Dublin show that payments have not been made. Neither health boards nor hospitals are entitled to ignore partnership agreements. Neither are they entitled to withhold overtime payments due to doctors for hours worked.

The Fine Gael motion before the House this evening in acknowledging the crucial role played by non-consultant hospital doctors in our hospitals not only seeks agreement from this House that the hours currently worked are totally unacceptable, it also asks the House to agree that junior doctors are inadequately remunerated. Proper pay scales must be put in place to adequately reward doctors for the overtime hours worked by them. Immediate action must also be taken by the Minister for Health and Children to require that all arrears of remuneration of overtime already worked, which is currently outstanding, be paid immediately by the health boards and hospitals liable for such payments. If our health boards and hospitals have been so under-funded by the Government as to render it impossible for them to discharge their salary obligations, the Minister should provide immediately the additional funding required to resolve this extraordinary problem.

No junior doctor anywhere in the State should be forced to take legal action or to bring an application to the Labour Relations Commission to obtain from his or her employers, money due for overtime worked. In this context, junior doctors have been treated scandalously. Instead of being given the respect to which they are entitled, they are being treated with contempt by their employers. They are effectively being exploited.

Junior doctors have other concerns which are not selfish but which are of great importance to a properly functioning health service. These include the essential need to receive well structured, audited training. Many rightly regard their present training as inadequate. For too long doctors have been forced to work abroad for between five and ten years prior to their having any possibility of a consultancy appointment in an Irish hospital. There is something seriously wrong with a system of medical education and training which compels doctors to leave the State and which renders it impossible to obtain a consultancy appointment if they do not do so. Non-consultant doctors have been used and abused by the health service, which has depended on them to provide a cheap acute hospital service at a cost to their well being and training.

For six months the Health Service Employers Agency, on behalf of the Minister for Health and Children, has been engaged in discussions with the IMO about the plight of junior doctors. It is astonishing that during that time, a substantive offer of any kind does not appear to have been made to resolve the issues in dispute. The Minister, like his predecessor, has also failed to take the action necessary to bring about a resolution and to ensure that an unnecessary strike will not seriously damage our health service.

Serious questions must now be asked as to why the Health Service Employers Agency appears incapable of constructively addressing industrial relations issues within the health service within a reasonable time frame and why it is addicted to confrontation rather than committed to dispute resolution by conciliation. The former Minister, Deputy Cowen, sat on the sidelines engaging in megaphone diplomacy in the six months lead-in to the nurses strike and only engaged in substantive negotiations with the nursing unions after strike action had taken place. The Minister, while making more moderate and conciliatory public comment on issues affecting junior doctors than we came to expect from his predecessor, has not done anything to date to effect a resolution of the dispute and to avoid a strike. His meeting last Thursday with the IMO was apparently a mere listening exercise. Seven days before the junior doctors are due to strike, neither the Health Service Employers Agency nor the Minister has made any substantial proposals to the IMO to address the grievance of junior doctors.

On previous occasions in this House I criticised the Government for effectively institutionalising a two tier health service – one for the rich and one for the poor. At a time of unprecedented economic wealth and with a first world economy, near the top of the OECD economic ladder, we have a public health service for a second world economy. We spend less of our GDP on health care than any other OECD country, with the exception of Poland, Mexico, Korea and Turkey. Even such developing economies as the Czech Republic, Portugal and Hungary spend more. Difficulties experienced by junior doctors, the frustrations and problems experienced by patients attending the accident and emergency departments in the acute hospitals, the pain and suffering of patients on the in-patient hospital waiting lists are a consequence of this. Another consequence is the death of patients on waiting lists who are awaiting essential cardiac operations.

Not only is our health service under funded, there is a lack of essential vision. Since his appointment, the Minister has been talking about the health service. In a speech delivered by him on 17 April, he spoke about nurses and nursing as a profession being grossly undervalued and he promised to effect change. We heard similar things from his predecessor two years ago. In his speech to the IMO conference on 14 April, the Minister spoke of health as "the central enabler in our fulfilment of our potential as a nation" and committed himself to "a radical overhaul of Ireland's health care systems" saying such an overhaul was overdue. The Minister has been in Cabinet for almost three years and his fine words bear no relation to decisions made by the Government on the delivery of health care during its term of office and for which he, as part of the Government, is responsible.

A reshuffle of Cabinet duties does not relieve the Government or Ministers from responsibility for past failures. If the structure, organisation and medical manpower in our hospitals is in need of urgent reform, the urgency results from this Government during its three years in office, failing to make many of the crucial decisions necessary for proper patient care and for failing to ensure the speedy implementation of decisions made. If the industrial relations within the health service are in a shambles it is the fault of the Government and the Minister.

The Health Service Employers Agency as a body appears incapable of constructively addressing genuine industrial relations problems within our health service. If the Minister sits back, like a spectator at a football match observing what is happening and doing nothing, the problems that result are his responsibility. Every few days he issues a script proclaiming reforms he believes are required in the health service. A health service cannot be built by proclamation. What is required is action, not words.

A one day strike by junior doctors on 17 May will result in 7,500 out-patient appointments being cancelled or postponed, up to 40% of which will affect new patients, who may have been waiting for many months. On 17 May also, 700 people scheduled for elective surgery throughout the State will have their operations postponed and will continue to languish on the in-patient waiting lists. Many of those whose operations will be postponed will already have been statistics on the waiting lists for well in excess of one year, some for two years and some possibly, in the context of ear, nose and throat operations, for up to three years.

The most effective action the Minister can take today with regard to the health service is to immediately enter into substantive negotiations with the IMO to resolve the current dispute with non-consultant hospital doctors and to avoid a damaging strike occurring. If he is not willing to enter directly into such negotiations he should compel the Health Service Employers Agency to make specific proposals to the IMO to resolve all issues currently in dispute. In the absence of specific proposals being made, either by the Minister or the HSEA, there is no basis on which the Labour Relations Commission can constructively intervene in the present damaging dispute.

We know that non-consultant hospital doctors do not wish to be on strike. We know the strong sense of obligation and commitment they have to patients throughout the country and to those who require their medical care. We also know that many of them have studied long and hard for many years to practice as doctors. The last thing any of them want to do is to withdraw a service that they have dedicated themselves to provide.

It is a scandal that for the second time within a period of 12 months, the Government has allowed a situation to arise whereby dedicated health care professionals feel the only way their genuine grievance can be listened to is to force a Government response by taking strike action so that problems in the health service will be addressed and patients can obtain the care to which they are entitled. We will be confronted by a one day strike on 17 May, which will retain 700 people on the in-patient hospital waiting lists. We will be confronted by a two day strike the following week, which will ensure that another 1,400 people on the elective surgery waiting lists will have operations postponed.

It is time for the Minister to stop talking about the need for reform as if he was an Opposition politician without power to implement decisions. It is also time he did something to bring to an end the rot in the health service, to restore public confidence in the public health care system and to recognise the difficulties and problems confronted by health care professionals, and, especially in this instance, by junior doctors.

It is the Minister's job to ensure these problems, which should have been addressed weeks ago, are now addressed. This debate should not be necessary and the threat of industrial action should not be hanging over this House. Some 98% of the junior doctors who balloted on this issue should not have been forced to vote in favour of strike action because they felt no other course of action was open to them. The Minister has an opportunity this evening to say something constructive and I ask him not to simply urge the junior doctors to go to the Labour Relations Commission. I ask him to specifically set out the Government's proposals to resolve this dispute and, if they will allow the Labour Relations Commission to make very real progress and will allow a strike to be avoided, the Minister will be acting in the public interest. If the Health Services Employers Agency cannot do its job properly, it is the Minister's repsonsibility to intervene and talk directly to the junior doctors. He should not wait until we have had a one day strike, nor should he allow the current difficulties to continue to fester and place the care of patients at risk.

Mrs. T. Ahearn

It is almost impossible to comprehend that the Government has for months ignored the warning signals that a strike by non-consultant hospital doctors was inevitable unless some meaningful effort was made by the Minister to resolve the dispute by engaging in consultation on the major issues involved.

I thank Deputy Shatter for introducing this motion to the House at a very opportune time and allowing the Minister the space to ensure that the strike scheduled for 17 May does not proceed. It is also impossible to understand that the Government did not learn any lessons from the first ever nurses' strike in this country. When the then Minister for Health and Children, Deputy Cowen, succeeded in getting the nurses back on the wards he was satisfied that he had got the better of them. It must be accepted that patients did suffer during that strike and that the entire health service was seriously affected. Although six months have passed since that strike occurred, the wounds still remain and the anger and sense of grievance live on. This will happen again if the Minister allows the forthcoming strike to proceed.

Nurses continue to be dissatisfied and aggrieved and are still awaiting the fulfilment of the agreement which was intended to end the dispute. The effects of the nurses' strike will have very serious consequences into the future. The Minister is aware that there is currently a shortage of nurses in this country. Young people are very reluctant to pursue a career in nursing and there is an alarming exodus of qualified nurses to alternative career opportunities. Worst of all, there is a feeling of hopelessness among those who continue to work in our hospitals.

Deputy Cowen may have succeeded in getting the nurses off the street and back on the wards but he broke their spirit and killed forever their sense of vocation. Nurses know that there is little, if any, appreciation of their contribution to the health services. The antagonistic attitude shown by the Government towards the nurses is further evident in the blatant refusal to give student nurses parity with all other third level students in regard to free fees. I cannot accept that the Minister is actually willing to put his energies into recruiting nurses overseas. Each step he has taken has been a negative one and he is killing the nursing profession in this country.

The tabling of this motion confirms that the Government did not learn any lessons from the nurses' strike. The Government is again prepared to take on another section of the medical profession, put patients' lives at risk and reduce the quality of medical care rather than take realistic and positive steps to resolve the issues at the centre of the dispute. A strike is inevitable unless the Minister takes action now.

We all know that junior doctors are over-worked, exhausted and stressed out. They simply cannot keep going. Is it fair to expect any human being to deliver a quality medical service for up to 100 hours per week? The minimum requirement is 65 hours per week but the reality for almost all junior doctors is that they work far longer hours than that. Junior doctors are expected to care for patients who are seriously ill. They are expected to make accurate clinical judgments and serious decisions. In many cases, a patient's survival depends on decisions made by junior doctors. We must not allow potentially brilliant and successful doctors to be forced out of medical careers through exhaustion, nor must we allow patients to be treated by over-worked and tired staff.

It is to their credit that junior doctors have tolerated intolerable and inhumane conditions for so long. It is further to their credit that they have managed to work exceptionally well and to deliver good patient care in appalling circumstances. They have also managed to avoid a catastrophe. It is to their regret and against all their medical principles to be at a stage where they simply do not have any option but to take to the streets on strike. Is the Government prepared to allow this to happen? Is the Government prepared to inconvenience patients and cause disarray in hospital schedules? Patients must be cared for and the price is too high to allow this strike to proceed. It is not worth the risk.

There are many serious problems throughout the entire health services. Why would the Minister want to add to them? Recent newspaper reports and the woeful recollections of families at the Lindsay tribunal surely provide sufficient evidence that we should direct our energies and resources towards the improvement of our health services rather than use them in conflict and dispute. Does the Minister realise that our hospitals simply cannot function without the contribution of the 2,700 junior hospital doctors? Does he realise they have a justified case? Is he prepared to put the health of our junior doctors at risk by forcing them to continue to work in appalling circumstances?

I urge the Minister to respect the role of junior hospital staff and to allow them to pursue their training, develop their skills and succeed in their careers. After all, our future is dependent on them. The future of medical care in our hospitals is dependent on our junior doctors. I urge the Minister not to allow this dispute to proceed and not to allow our junior hospital doctors to take to the streets. I appeal to him not to kill their ambition, determination, spirit and vision. He should assist them to become confident, fulfilled, caring, contented and dedicated doctors. The future of our health care system is dependent on them.

We should respect the role played by junior hospital doctors and their contribution should be acknowledged. The Minister now has an opportunity to do this by entering into negotiations with them. I urge him not to spare any effort or resources in ensuring that our junior doctors do not have to go on strike on 17 May, thereby preventing many patients from experiencing difficulties. The Minister must prioritise the future of our health services and should encourage and support our junior doctors.

Mr. Connaughton

I, too, thank Deputy Shatter for tabling this motion although I regret that it was necessary so close to the impasse with the nursing profession.

I did not think we would allow it to happen that the other major branch of the health carers would have no alternative but to go out on strike. We cannot blame the Government for everything that has happened because it has not been in power for very long. However, there must be a way out of this dispute. It cannot be allowed to drag on because of the Government's attitude that, as far as it is concerned, others will have to do the job. If the Government continues to think along those lines, it will have a strike on its hands. If it learns from this debate and the views of the public, it will quickly take action after tomorrow's vote.

The proposed strike by the junior hospital doctors is a sad reflection on how our health service operates. There must be something rotten in the set-up somewhere along the line. It is about time it dawned on the Government and the health service employers that we cannot deliver a service for the new millennium based on structures which barely worked 25 years ago. This has not sunk in with the Government and the health authorities. Nurses and junior doctors are at a crucial contact point with patients. They are the first people likely to come in contact with patients. As a lay person I cannot understand why these workers are either ignored or belittled. They provide a crucial service. The nurses had to go to extreme lengths seven or eight months ago to make that point. It is obvious that nobody learned a lesson from this.

Junior hospital doctors must work scandalous hours. The Minister, myself and many of our colleagues often work 80 to 100 hours a week. However, ours is a different type of work. I would not like to be the patient attended to by a junior doctor if I knew they had worked 80 hours. I would rather be diagnosed by the porter. It is unfair that they must work 65 to 80 hours a week. There will be a public revolt on this matter and I do not know how this will be resolved by the Minister. It must be demonstrated to junior hospital doctors that their work is valued; this is normal for other workers . It takes a great deal of perseverance and money to become a doctor. It is a difficult process. Doctors deserve better than the way they are treated in the workplace. The Minister would do well to take heed of what is being said here and outside. The public are fed up and the more they know about hospital conditions, the more criticism they will have.

There has been a general breakdown in the delivery of services. I do not know if this is because of money or administration but every week at my clinic – I am sure the same is true for the Minister – I receive letters and telephone calls from people who have not been treated properly. Last Friday I received a letter from a constituent, a 65 year old woman, who, in January 1999, sought a consultation for severe arthritis in her knees. She recently received a letter from the Western Health Board stating that it was likely she would get an appointment in the next five or six months. I would like to see me or the Minister waiting for 18 months with arthritis in our knees. I would not accept that in any circumstances. Perhaps the woman is waiting because she has a medical card. If this strike goes ahead and there is more unrest, how much longer will that woman have to wait? The only people hurt will be that woman and the thousands like her.

Everyone knows the Minister has great negotiation skills and now is the time for him to demonstrate them. If the dispute is not resolved, we will have to acknowledge that neither the Minister nor the Government is able to deal with the matter. The Minister will learn a serious lesson if he does not solve this problem.

Mr. Bradford

I support my colleagues on the motion tabled by Deputy Shatter. I wish the Minister well in his endeavours to bring this possibly dangerous situation under control before 17 May. This is his baptism of fire in his new ministry. The only occasions on which we get an opportunity to discuss health issues in Dáil Éireann is when we are trying to avert a crisis. We never seem to have time to discuss health policy and management or chart a new agenda for the future. We are always dealing with crisis management. The dispute involving the junior hospital doctors which the Minister must now try to bring to an end is almost a carbon copy of the nurses' dispute.

As my colleague, Deputy Theresa Ahearn said, the then Minister for Health and Children, Deputy Cowen, brought the nurses' dispute to an end, but at a high price as far as morale is concerned. We do not want the same bitterness among junior doctors on 18 or 19 May we saw with the nurses. The Minister's immediate intervention in this dispute is urgently needed. Unfortunately, the efforts so far have been unsuccessful. The cause is obvious and justifiable. Nobody should expect people to work 100 hours per week in the delivery of health care services.

When the public read about this dispute, they find it inexplicable and inexcusable at a time of record national resources because of the Celtic tiger, although record resources may not be available to the Department of Health and Children. As one of my colleagues said, we appear to have a Third World health care system in a first world economy. This is unacceptable. I am aware of the position in Cork – as is the Minister – which was outlined by my colleague, Deputy Shatter. This cannot be justified and cannot be allowed to continue. We cannot allow the dispute to go ahead on 17 May. The Minister has had direct talks but he must return to the table. The direct intervention of a Minister is not always necessary but the Minister of Health and Children is facing a crisis which requires it. A clear statement from the Minister indicating that he does not wish the dispute to go ahead and that he will put an offer on the table is the minimum we can accept.

I support Deputies Shatter and Connaughton on the wider aspect of our motion which concerns the health care system as a whole. As constituency representatives, daily we are made aware of the most bizarre cases of the absence of health care. We find it difficult to explain to our constituents why they, their elderly parents and relatives must wait 18 months, two years and more for the delivery of such services. These issues need urgent attention. The public is demanding a response from the Minister in his new role. I wish him well and I look forward to what he has to say – I hope it is positive.

Minister for Health and Children (Mr. Martin)

I move amendment No. 1:

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

Dáil Éireann:

–endorses the Government's handling of the present dispute with non-consultant hospital doctors;

–urges the Irish Medical Organisation to agree to third party mediation to resolve outstanding issues;

–acknowledges additional resources which have been made available for improvements in the health service;

–recognises that the Government is committed to implementing structural changes in the medical workforce in hospitals;

–having regard to the negative impact the proposed strike would have on patient care and the offer from health service employers to independent third party mediation, calls on the Irish Medical Organisation to call off the threatened strike and to pursue their case through the normal industrial relations mechanisms.

I wish to share time with Deputy Batt O'Keeffe. I thank Deputy Shatter and Members of Fine Gael for tabling the motion, thereby facilitating a debate on this issue.

I wish to update the House on the latest developments. In view of the serious situation which would arise from the decision of the Irish Medical Organisation to proceed with industrial action, the Labour Relations Commission earlier today invited the Health Service Employers Agency and the Irish Medical Organisation to meet its chief executive and director of conciliation in the commission's offices. The purpose of the meeting was to initiate conciliation talks on the current issues in dispute. The commission has proposed the following agenda for these negotiations: the current contract and outstanding difficulties, including overtime payments; future contract negotiations, including rostering-shift arrangements; future overtime arrangements and the method and level of payments which may apply; and any other issues which the parties deem appropriate. The Health Services Employers Agency immediately responded and accepted the invitation from the chief executive of the Labour Relations Commission. It seems the Irish Medical Organisation did not accept this invitation from the Labour Relations Commission.

To progress this matter further, the commission offered elaboration on point one of its proposed agenda. It was also agreed that these issues relating to the contract, the previous contract and payments which were not made, must be addressed as a matter of urgency and the Health Service Employers Agency indicated it was prepared to honour in full its commitments regarding that contract and wished to ensure the existing contract is adhered to in future. The Health Service Employers Agency also indicated it was prepared to agree to a verification process under the auspices of the Labour Relations Commission in regard to any moneys which may be due under the terms of the 1997 contract as part of the negotiations. I wholeheartedly endorse this position in terms of endeavouring to resolve these issues as urgently as possible and honouring the commitments in the 1997 contract.

The commission is anxious that the parties commit themselves to achieving a comprehensive settlement on the above issues, is conscious of the short time scale involved, particularly in view of the one day strike threatened for 17 May, and the need to work with the parties over the next available days to assist in effecting a solution on the issues in dispute.

This is a complex and difficult problem to resolve. I acknowledge that non-consultant hospital doctors play a vital role in the staffing of hospitals and their participation in patient care is essential to the way hospital services are provided. Clearly, there are problems with the hours worked by some of our non-consultant hospital doctors and the issue of excessive working hours needs to be resolved for the improvement of patient care as well as the well-being of junior doctors. I am prepared to tackle the issues involved in a constructive way that will provide mutual benefit for non-consultant hospital doctors and the hospital system. It is acknowledged by health service employers and the Irish Medical Organisation that the current working hours arrangements are responsible for where we are today. There is a long history and culture attached to the way junior hospital doctors have been treated down through the years. That being so, more of the same will not do. Negotiations when they begin will have to include reform and changing the way we manage things in hospitals.

The origins of this dispute are partly historic. Like many sectors of society, the health service has undergone major change, much of it unnoticed. We take for granted new services, new drugs, new treatment regimes and so on. The new diagnostic and treatment equipment is always obvious. However, in the midst of this sea of change certain landmarks remain strangely familiar. One of these is the basic structure of the medical profession and how this is reflected in the way our hospitals are staffed and operated. In the medical staffing of hospitals, we still adhere to the hierarchy of consultant, registrar, house officer and intern.

On the other hand, the hospital system has encountered enormous change in recent years, especially in relation to the increased volume of patients who present for treatment. I accept that the staffing of our hospitals, that is, doctors, nurses, paramedics, etc., must be configured to take account of these changes. When I recently met the representatives of junior doctors, I accepted that because of the complexities involved in the issues of overtime and unrostered hours, these matters should go to third party mediation. The meeting was more than just a listening exercise. Repeatedly during the meeting I sought to arrive at a process with the junior hospital doctors by which these issues can be resolved. I have not been involved in a stand off with junior doctors. I have met them and contact has been maintained between them and my office, and the Government has been eager to resolve these problems. It is clear that the best vehicle to resolve the issue is third party independent arbitration, particularly through the Labour Relations Commission.

I referred earlier to changes that are necessary in the hospital system. This is especially true in the case of the medical staffing in public hospitals. The Medical Manpower Forum was established by my predecessor, Deputy Cowen, to investigate the medical staffing in our hospitals and bring forward recommendations.

One of the reasonable expectations of a patient entering hospital is that he will be looked after by medical and nursing staff who possess the skills and experience necessary to undertake the task. A patient in hospital should, at all critical points in the care process, be looked after by a fully trained doctor. The Medical Manpower Forum was established to focus on addressing the imbalance in hospitals between career posts and training posts, the need to improve postgraduate medical training to keep more Irish medical graduates in the country, and the need to provide the highest quality of medical care for those who require the services of hospitals.

Currently, there are approximately two junior doctors for every consultant employed. Non-consultant hospital doctors regard career prospects as poor and a large number emigrate. Young doctors tend to leave at the point where they have just acquired the skills and expertise and are ready to make a real contribution to Irish hospitals. Women doctors also leave the system and there is a need to examine the reasons this is happening so that solutions can be found to facilitate the optimum use of their skills and develop training structures to accommodate their needs. I am not happy to preside over such a system and I intend to make major changes in the way hospitals are staffed.

Other areas which require attention are the different needs of larger and smaller hospitals, combining other disciplines with medical staffing, for example, general practitioners and nurses, and coping with the demographic changes which have occurred in society.

The Medical Manpower Forum, in association with the various medical interests, will address: longer term contracts for non-consultant hospital doctors – I want to give greater certainty to young doctors as to where they will be working and what they will be required to do; a system of structured rotations that includes training in the larger teaching hospitals as well as smaller general hospitals – this will give young doctors a broad range of experience and make them fit to fill posts as consultants in the health service; revised arrangements for medical training and the need to take into account the requirements of women – there is much to be done here and I am anxious to get on with agreed improvement and make greater provision in the system for the needs of women; institutional structural reform to allocate clear responsibility for ensuring the quality of training in hospitals; and the need to place more fully trained doctors in our hospitals – this is especially needed at night and at weekends.

The Medical Manpower Forum seeks to propose policies that maintain and improve patient care while providing a satisfactory working environment and career structure for all hospital doctors. While the forum is expected to advocate an increase in the number of trained doctors-consultants, major changes are recommended to the structure of training for NCHDs as follows. Each hospital should have a training strategy and there should be development of training partnerships with UK and US hospitals, accreditation of training placements abroad, with training structures and opportunities made available in modular form, both full and part-time, forming part of an overall professional development structure that also meets the needs of nurses and other grades of hospital staff. The report will address the need for improved medical education, advocating the development of new training structures which allocate protected time to research, and the provision of career opportunities for Irish medical graduates with a research orientation, a five year National Research Strategy, development of links with private funders and exploration of role for senior medical researchers.

The Medical Manpower Forum has much to offer NCHDs and I hope it will be able to publish its first report shortly. One of the problems with industrial relations difficulties is that it keeps us from doing what needs to be done on the more strategic issues.

Another major influencing factor affecting working hours of junior doctors is the Working Time Directive. NCHDs as doctors in training were one of a number of groups excluded from the original EU Working Time Directive adopted in 1993. Other excluded groups were transport workers, sea fishermen and offshore oil and gas workers. Following adoption of the 1993 directive, the European Commission endeavoured to bring forward proposals to deal with the excluded sectors. The Commission recognised that there would be serious difficulties in bringing these sectors within the precise scope of the 1993 directive. Therefore, the Commission embarked on a series of consultative exercises to address the specific requirements of the excluded sectors.

Ireland has never opposed the idea of offering NCHDs a level of protection equivalent to that provided by the 1993 directive. However, any provisions covering hospital doctors would have to take account of the need to provide 24 hour medical cover for hospitals and to afford reasonable continuity of care to patients. There would also have to be a reasonable transition period to reach the objective of 48 hours per week without significant disruption to the existing medical career structure.

In November 1998 the European Commission published its proposals in relation to the excluded groups in the form of a draft directive to amend the 1993 directive. The Commission's proposals went to a Council working group for consideration. A number of member states had varying degrees of difficulty with the Commission's proposals. Eventually the German Presidency presented a series of compromise proposals to a meeting of Labour and Social Affairs Ministers held on 25 May 1999. These included a 12 year transition period with a progressive reduction in hours to 48 hours at the end of the period. The United Kingdom, which had been holding out for a 15 year transition period, proposed a 13 year period. Further debate in the European Parliament and at the Commission resulted in further compromise.

I am glad agreement has been reached on a formula which provides for a nine year transition period to apply the directive to junior doctors. I took the initiative to move from 13 years to nine years and I would like it noted that this is an indi cation of my goodwill in relation to junior doctors. Ireland has always stated that it will reduce junior doctors' working hours to an average of 48 per week at least as quickly as required by any European legislation. We want to do this in partnership with the IMO and all interests as fast as we can within the logistic capabilities of so doing. I am confident that, with the full co-operation of the profession, we can achieve that objective in the nine years allowed. As part of our preparations for this eventuality we are conducting a major study of NCHD working hours on a joint basis with the Irish Medical Organisation. The study is being undertaken at eight hospitals by PA Management Consultants. The report of the study will be available in June.

I turn to the issue of funding. The health budget this year is in excess of £4 billion. The increased investment in health funding under this Government is unprecedented. A major opportunity is opening up to bring about fundamental and lasting improvement in services. It will take sustained effort but the challenge is to deliver a service that has the confidence of the entire community where standards are uniformly excellent and where it is acknowledged that decisions, including those relating to resource allocation, are made wisely and on the basis of objective evidence concerning needs.

The Government has made available an extra £1,500 million to the Department of Health and Children since taking office. This is a 56% increase in the day to day resources for services and this level of increased investment will be sustained. An indication of the priority attached to health by this Government can be seen in the fact that the previous Government made available just over £400 million in extra funding. By comparison the additional £1,500 million allocated by this Government has allowed a long awaited acceleration in the development of the health services.

The Government has also recognised that, in moving forward, the current health infrastructure is inadequate for the delivery of a truly modern and efficient service. Under the national development plan, £2 billion in capital spending has been made available to develop health facilities of the highest order. The inclusion of health in the NDP was a statement of priority in its own right since it is recognition, for the first time ever, of the central importance of health facilities in the social and economic infrastructure of this country. The £2 billion being provided is almost treble the capital resources provided over the previous seven years. The record increase in funding offers an historic opportunity to fundamentally address the weaknesses within the system. The Government will play its part in working with all those in the sector to bring about the necessary improvements.

I would now like to give the House a detailed statement on the background to this dispute. The Irish Medical Organisation, on behalf of NCHDs, lodged a formal claim with the Health Service Employers Agency on 8 December 1999. The claim included a demand for the payment of overtime as is the case with nurses, payment for all hours on call in addition to hours worked, a pay claim in line with comparable grades in the health service, increases in annual leave, the payment of an unsocial hours premium as per nurses, a review of allowances, claiming here a parity with teachers academic allowances, improved and compressed pay scales for house officers, training grants for all NCHDs and relocation expenses, increased examination refunds and increases in living out allowances.

The HSEA and the Irish Medical Organisation met to explore the details of this claim. The HSEA gave a detailed response to the Irish Medical Organisation claim. Its response on salary levels was to point out that we are all parties to a national agreement which defines the parameters within which an offer could be made. The attempt to establish a link between nurses and NCHDs was not accepted. The HSEA proposed that overtime at nationally agreed rates could be paid to NCHDs in the same context as other health service grades. This development would of necessity involve a review of shift working and on call arrangements.

The IMO was reminded that under the early settlers clause of the Programme for Prosperity and Fairness it is due an additional 3% increase. This is in addition to the 2% increase which is outstanding from Partnership 2000 and which the IMO has not drawn down. This brings the total increase available under the Government's pay policy to 5%. Provisions on parental leave would be applied to NCHDs as they are applied to other health service grades. Unsocial hours payments would be paid to grades between 6-8 p.m. and were paid to grades where the shift encompassed the 6-8 p.m. time frame. The HSEA pointed out the unrostered hours mechanism had been used on two occasions since 1997 and could not be deemed a failure on the basis of its use in two instances.

The parties agreed, however, to jointly examine an appropriate third party appeal process in addition to the continued operation of the unrostered hours mechanism. The HSEA accepted that there was a case to be made particularly in regard to short rosters. A review of recognition of additional appropriate qualifications would take place. The HSEA was sympathetic, subject to detailed discussion to the extension of the training grant to all NCHDs. Travel expenses would apply as with other grades in the health service subject to local authorisation. The HSEA expressed itself sympathetic in principle to a payment on rotation where it is incurred by the nature of the contract, for example, as part of a rotation scheme. It indicated that it would examine examination refunds in the context of the training grant.

There exists a dual responsibility to ensure residences provided are of an acceptable standard and are maintained to that standard. I am com mitted to a refurbishment programme for these residences where they fall below acceptable standards. Medical indemnity is currently under review by the Department and its insurers. The HSEA, as the representative body for publicly funded health service employers, must conduct its negotiations with health service unions within the parameters of the pay agreement of the day and with due regard to Government pay policy. There is also a responsibility on employers and trade unions to conduct industrial relations in an orderly manner and, where agreement is not possible through direct negotiation, to avail of the State's industrial relations machinery so as to avoid exposing the health service to the very damaging effects of industrial action and the consequent hardship to the community at large.

It should be acknowledged that the Labour Relations Commission has considerable expertise in the field of industrial relations and has been successful in resolving many difficult disputes in the past. I appeal to the IMO again to enter into discussions in the LRC on a substantive agenda, which has been laid out by the LRC in correspondence with both the HSEA and the IMO. Two offers have been made in regard to the agenda. Very little separates the two sides in terms of a decision to enter the LRC. I am totally committed to resolving this dispute. I see absolutely no necessity for a strike and I mean that genuinely having examined the issues and talked through the issues with the junior doctors because they can be resolved.

There is a responsibility on all sides in the interests of the patients to give the LRC process a chance. I am absolutely convinced that if we enter into the LRC we will come out at the other end with a substantive and comprehensive agreement that will make a difference to the quality of life of junior doctors and as a result of which they will be held in high esteem. I want to make sure that in any agreement that emerges structures are in place which will guarantee its success in terms of its subsequent implementation at local level. I will spare no effort in trying to resolve this issue and to avoid the necessity for industrial action because there is none at this stage.

Mr. B. O'Keeffe

I commend the Minister for Health and Children, Deputy Martin, for his efforts in attempting to resolve the dispute involving the non-consultant hospital doctors. The genuine way in which he presented his case clearly indicated that he wishes to ensure that there will not be any disruption in the hospital system. It also indicated that there is a recognition of difficulties relating to an extremely complex issue which has been with us for many years. There is also a genuine willingness on the part of the HSEA to deal with the issues. That has emerged from the negotiations which have taken place with the Labour Relations Commission. There is an acknowledgement of the inherent difficulties to which this issue gives rise and there is a resolve on the part of the HSEA and that of the Minister to ensure that hospital services are not disrupted. No one, not the non-consultant hospital doctors, the Department of Health and Children or the Minister, wants to see such a disruption.

People must be constructive, stand back and take stock. In the interests of non-consultant hospital doctors, our hospitals and patients, every effort must be made by people on all sides to ensure that realism is brought into play and that there is no disruption in services which would have an adverse impact on patient care.

There has been a great deal of media speculation, and rightly so, regarding the plight of junior doctors. As already stated, this problem has been abroad for a long period but we must remember that the Minister is new to his portfolio. One of the things we tend to forget is that this issue has been exacerbated by the ever increasing number of patients with which hospitals are obliged to deal. This, in turn, has impacted on the number of hours junior hospital doctors are required to work. Everybody has a role to play, particularly the consultants in our hospitals. Not alone do these people have a responsibility in respect of their contracts, they also have a responsibility in relation to the contracts of non-consultant hospital doctors. Consultants are team leaders and they must recognise that they have a role to play in terms of providing leadership and arranging staff rosters.

The position in relation to junior doctors is that a system which included a basic working week of 39 hours and rostering of 65 hours was arrived at in 1989. This system was introduced in 1990 and gave rise to considerable costs because it involved increasing the number of non-consultant posts by 400. It is interesting to note that the number of junior doctors has continued to increase in the interim. It rose from approximately 2,000 in 1990 to 3,000 at present, an increase of 50%. Despite this increase, however, we continue to encounter problems similar to those which obtained in 1989. If that is the case, there is a need to fundamentally examine the structures which are in place and which were outlined by the Minister.

There is a need to develop solutions that reflect the current services on offer in our hospitals. The increase of 50% in the number of junior doctors has led to an imbalance in the number of trainee places on offer vis-à-vis consultant posts. One of the main reasons for the establishment of the Medical Manpower Forum was to examine the question of staffing in hospitals and to make recommendations as to how the underlying problems could be solved. The forum identified that there is an uneven distribution of hospital staff. For example, there are too many trainees, too few trained staff, a limited availability of senior clinical decision makers, shortages exist in particular areas of speciality, bulges and bottlenecks in career structures, problems in respect of out-of-hours cover and difficulties in relation to the level of medical cover which has impacted on the deliv ery of accident and emergency services in particular.

While the primary concern of all involved is an improvement in patient care in our hospitals, everybody would agree that this can best take place in the context of reform and enhanced training and career structures for hospital doctors. Certain recommendations made by the Nursing Commission and other changes that are taking place should be allied to this.

The Medical Manpower Forum has enabled the Department of Health and Children, the statutory bodies, the professional bodies, the voluntary hospitals and everyone involved to participate in building an agreed analysis of the plausible solutions to the problems that were identified. The forum's report will lay the foundation for a constructive resolution to the differing aspects of the hospital medical staffing debate. For example, it recognises the need for more and earlier opportunities for fully trained doctors to take on responsibility that is commensurate with their training, experience and expertise. Non-consultant hospital doctors have a desire to attain such opportunities.

The report also establishes that there is a requirement for more fully trained doctors. The need to enhance post-graduate training arrangements is also recognised. Furthermore, the need to give higher priority to the development and maintenance of research opportunities is part and parcel of the report's recommendations. The requirement for greater flexibility in employment arrangements to match need and availability is highlighted, as is a recognition that the competent discharge of an increasingly high volume of work arises from demographic and other changes. The apparent inequalities of opportunities highlighted by the changing gender composition of the medical profession is also recognised in the report.

Nobody wants a strike. I was interested to hear the Minister state that this dispute hinges on the fact that the IMO considers that the terms of the 1997 agreement were not honoured. There is a need for an unequivocal statement from the HSEA that it intends to honour that agreement. I was interested to hear the Minister state that, according to the Labour Relations Commission, this commitment has been given to the non-consultant hospital doctors.

It is important for negotiations to take place in an atmosphere of normality. In that context, it would not be conducive to have an ongoing dispute. Rather, the Labour Relations Commission must be allowed to take on board the commitment from the HSEA that it is willing to honour the commitments entered into in 1997. It is important that the HSEA, the Labour Relations Commission, the non-consultant hospital doctors and the IMO, having agreed to a process in respect of the additional hours worked, should reach final agreement regarding the amount of money owed to non-consultant doctors.

A dispute will affect the very people that the Minister, the Department, the non-consultant hospital doctors and everyone involved in the area of health want to help. No one wants patient care to be affected. We want to ensure that agreements which were entered into are honoured. The Minister accepts that a great deal of work remains to be done in respect of the career structure which applies to non-consultant hospital doctors. There is an opportunity for meaningful negotiation and a dispute will not help to further the cause of non-consultant hospital doctors, it will only hinder patient care.

Ms McManus

I wish to share my time with Deputies Penrose and Michael D. Higgins.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Ms McManus

I welcome the motion that has been moved tonight by Fine Gael, which is warmly supported by the Labour Party.

In his speech, Deputy Batt O'Keeffe began by stating – and I will paraphrase what he said – that if we did not have so many patients there might not be a problem. I have heard of passing the buck, but that is really stretching it to the limit. After three years of this Fianna Fáil/PD Government, it is interesting somebody from the Government back benches essentially discovering that there are problems in our hospitals and that the dispute that is threatening from the NAHD is symptomatic of those very serious problems. I would like to remind Deputy O'Keeffe that the Government was elected to tackle the waiting lists. In that regard he is right – there are now more patients on the waiting lists than when the Government took power three ago. That is not the patients' fault, however. It lies fairly and squarely with the Government.

The Minister's speech was startling in that it contained glowing comments about the employers – the HSEA. His sentiments are not shared by the non-consultant doctors, who have experienced extreme frustration and are now reaching breaking point. The IMO must make its own decision, and I respect that, on the proposals which have been outlined tonight. However, it is very damaging to say that this dispute is largely about the refusal of the HSEA to honour the current contract. If one tries to build a relationship based on trust, that track record is a serious impediment. Indeed, more may well be required of the Minister. Time will tell if he is doing enough. I hope he is but I do not have the confidence to say that this will be enough. He will be tested as to whether he can live up to his own rhetoric. If he does not do so, yet again a crisis is looming in our hospitals that will have profound effects. The health system is already under serious pressure. The crisis is not being caused by some natural disaster or a new epidemic; it is a man made crisis. The Minister must bear responsibility for the fact that this matter has not been dealt with. He appears incapable of dealing with the problem and we have a hospital management structure that has proven itself incapable of dealing with it.

This crisis is preventable and curable, yet all the signs so far are that it will, if anything, deepen in the coming days. Non-consultant hospital doctors have declared their intention of taking industrial action from next Wednesday. Time is running out. They have voted to do so not by a margin but by a landslide; 92% of those balloted voted for industrial action. Yet again we are seeing health workers doing what goes against their professional commitment to patient care but who are being forced, out of desperation, to take industrial action in defence of basic improvements in their working lives.

There is a terrible sense of déjà vu about this strike. The hospital service has still to fully recover from the effects of the biggest industrial action in the history of the State. Last October the nurses action lasted nine days. Its impact was unprecedented, both in terms of its effect on our hospital services and in terms of the sustained public support for the righteousness of the workers cause.

Now that non-consultant hospital doctors are due to take industrial action, the public is entitled to answers as to why the Government has done nothing effective, so far, to prevent it. The public knows only too well how indebted we are to junior hospital doctors. Anyone who has to attend a hospital can attest to the commitment and hard work of nurses. It is worth noting, however, that public recognition of the essential work of young doctors is equally well grounded. We have the good fortune of having excellent people working in and committed to our hospital service. The Government, however, seems intent on forcing those health professionals out of the hospital and onto the street before they can have their legitimate grievances addressed.

When the threat of a nurses strike became known last year it was understood by everybody that a deal would be struck. The only question was would the deal be struck before a strike or after the damage was done. The same inevitability is now coming into play in the case of this action being taken by young doctors. Again there is no doubt that a deal will be struck. The only question is will the Government have the wit, energy, commitment and good sense to provide a sound solution before the day of reckoning dawns. It may be that the Government is incapable of learning from experience. It may be that the new Minister is at heart no better than the last Minister for Health and Children or it may be that this Government is so punch-drunk from the sordid revelations that are tumbling out of the Flood tribunal that all its energies are concentrated on damage limitation measures and on holding the frail edifice of this Coalition together instead of tackling the problems of our health service.

This is a test and so far the signs do not look good. Exactly a year ago – 11 May 1999 – I raised the plight of non-consultant hospital doctors in this House on the Adjournment. This coincidence only reinforces the serious lack of progress made over the last year on the issue of doctors pay and conditions. On that occasion I drew on statements made by the Irish Medical Organisation that itemised the points at the heart of this issue, which have been repeated in the Minister's statement. They include excessive hours of work, pay, unrealistic rostering, on-call duties and the distribution of duties between junior and senior doctors. These issues were known about a year ago when they were outlined by the IMO. Twelve months later the problems, if anything, have become worse. We all know of doctors who are working over 100 hours a week, yet a year ago the IMO stated clearly that rostering doctors for more than 65 hours a week is dangerous to the physical health of NCHDs and has the potential to retard both the development of a quality health care system and to give rise to malpractice claims by patients. The IMO could not have spelt it out more clearly.

The practice of exploiting young doctors in training is dangerous to patient care. One year on, the Minister and his Department have not moved on the issue. That is why the junior hospital doctors voted for industrial action in overwhelming numbers. One year later, the employers organisation, the HSEA, has proved to be as intransigent as ever.

At the time I outlined the reality for young doctors as follows:

What this means is that doctors can and do end up working an intolerable number of hours. Indeed, there is evidence of doctors working up to and even over 100 hours a week. Regularly, junior hospital doctors do not get proper coffee breaks or even a chance to eat lunch. They may head into a day's work having been on call the night before and, following a day's work, having had only two hours sleep. If they want to take a holiday they have to make reciprocal arrangements with colleagues by providing cover for them. If someone is sick another doctor has to fill the gap.

The current blanket exemption from the protection of the EU directive on working time for these doctors is unacceptable and poses an unjustifiable risk to patients. It is only a matter of time before a major medical error is made by some unfortunate junior hospital doctor suffering from exhaustion. That is the nightmare of which junior doctors are conscious on a daily basis and one that must be addressed within the shortest time-frame possible.

It is unacceptable that any worker, but particularly workers who are dealing with matters of life and death, should be deprived of their legal right to rest breaks or minimum hours. We do not make the demands on lorry drivers or factory workers that are currently being made on junior hospital doctors manning our acute hospital services.

How relevant those words are still. On behalf of the Labour Party, I subsequently published a Private Members' Bill entitled the Protection of Patients and Doctors in Training Bill, 1999. This was done out of our concern for the plight of these doctors. While some climb down was made by the Government on the EU directive, the difficulties experienced by doctors were not addressed over the past year. We now have coming to a head a crisis that was forewarned by the doctors.

It is well known that we have a shortage of nurses and that this is having a major impact on service delivery. In an article by Dr. Mick Molloy published last month by the IMO, important points were made about a pending shortage of young doctors, which the Minister disregards at his peril. That Irish graduates are haemorrhaging from our health system has been, to an extent, disguised by the entry of non-national doctors. Standards set by the Medical Council have had an impact on this ready source of manpower.

However, a further point made by Dr. Molloy is that Irish graduates are increasingly, and at an earlier grade, being attracted to Britain and the US by shorter hours, better working conditions and better training and promotion prospects. We cannot afford to continue to lose our highly skilled doctors because the Government and the Minister cannot get their act together.

Dr. Molloy's prescription includes a ministerial body to be set up to deal with issues of retaining Irish doctors and attracting foreign doctors, as well as modernising the present system of training of doctors, which we recognise is serving neither those working within the service nor those availing of it. Does the Minister intend to take the doctor's advice on this matter or is he still depending on the outcome, whenever that will be, of the protracted deliberations of the medical manpower forum? There is a crying need for reform of the training structures for doctors and for a widening of the numbers of consultants employed to create a specialist provided service instead of the current consultant led one.

This Government has resources undreamed of by any previous Government, yet its failure to tackle the needs of health care has been absolutely dismal. Despite the increase in funding, all the Government has succeeded in doing is to increase the numbers on hospital waiting lists. Instead of the root and branch reform that the service so badly needs, we have pious aspirations from the Minister. While we expect a certain amount of pious aspirations from Ministers, we also have glib dismissal of serious proposals that set out to achieve the twin great aims of excellence and equality in health care

In particular, I am talking about the major proposal published by the Labour Party, which outlines in detail a substantial framework for the future of the health service. According to A. Dale Tussing, the eminent health economist who has studied both the Irish health system and international models:

There are two currents in healthcare reform in Europe and North America. One group of reformers seeks to address inequality of access to healthcare and seeks a level playing field, removing artificial distinctions based on income or social class. Another group of advocates seeks more allocational efficiency in the delivery of medical care and uses decentralization and market solutions as the principal device for achieving it. The Labour Party discussion document, "Curing Our Ills", focuses on the former set of goals but, in the bargain, manages to address and achieve the latter as well. It is a 21st century document.

Despite this endorsement from a very eminent man, the Minister has refused to even discuss the ideas we have published. Fortunately, others in the health services have been enthusiastically engaged in the process of debate. The Minister badmouths our proposals without having any serious proposals of his own to solve the central problems in health care – the requirements of excellence and equality. He spreads misinformation instead of delivering reform, in which he is ably assisted by his Cork batman, Deputy O'Keeffe.

Meanwhile, patients suffer and die unnecessarily because they cannot get into hospital. Some of those who have made it into hospital are being put at risk because of the enormous stress on young doctors in training. That these young doctors are now taking action to protect their patients is to their great credit. What is shameful is that the Minister for Health and Children has not yet taken the definitive action needed to resolve this dispute in the interests of patient care.

Mr. Penrose

I am glad to have the opportunity to contribute to this debate. The scandal of junior hospital doctors working around the clock can no longer be tolerated and the legal basis of it is questionable. For doctors to work up to 100 hours per week is a danger to their health. More crucially, they will readily tell you that, despite their best efforts, they are unable to give the level of patient care they would wish after being on their feet for hours on end.

Just over six months ago, as Deputy McManus said, nurses took to the streets for the first time ever. Despite predictions from some quarters that the lack of public support would force nurses back into the wards, the reality was that public support and understanding of the nurses' actions hardly dwindled throughout their strike. The result was that the Government was forced into dealing with the nurses' claim, as it should have from the outset. However, a number of outstanding matters have not yet been addressed, despite firm commitments given by the Government in that regard. I will return to that another day.

It is my firm belief that if the junior doctors are forced to strike, the public will offer its full support. Those of us who have been attended to in hospital by junior doctors know they work hard. They, like any other workers, deserve the kind of rest periods and breaks for meals which are provided for under the Organisation of Working Time Act. No member of the public wants to be cared for by a junior doctor who has been on his feet for 15 or 16 hours without a break and hardly any food to sustain his energy levels.

I am in favour of a world class health system and, to this end, I compliment my colleague, Deputy McManus, on her recently published radical document on the health services. Since moving to the Opposition benches three years ago, I have had to come into the House on more than one occasion to highlight the extensive inadequacies in the health service, particularly the failure by the Government to fund the completion of phase 2B of the Longford-Westmeath General Hospital. I have given an unequivocal commitment in the House that I intend to pursue the Minister vigorously to provide the finance of about £20 million which is needed to complete this development for the people of Longford and Westmeath.

I have tabled a host of parliamentary questions relating to constituents of mine who are on public waiting lists for essential operations and whose conditions are deteriorating by the day because of the delay in having their needs attended to. One example of the pain and suffering waiting lists have inflicted on people is a constituent of mine who was on a waiting list for an essential hip operation for some time. During the wait, his other hip deteriorated to such an extent that he and his family lost complete faith in the public health service and several weeks ago raised £4,000 for the essential operation to be carried out on a private basis. He is being operated on this week.

This is a scandalous system. It is all right if one has the money, but it is not so good if one does not. People who cannot afford to pay for essential treatment are being forced to do without. Given our healthy financial position, we should end the scandalous existence of a two tiered system of access to the health service. Those on low incomes find the nation's health service weighted against them. That is a scandalous way to enter the new millennium. The failure of the health system to look after people without financial muscle is shown by the waiting lists. There are about 38,000 people on the waiting lists for various specialities.

I will refer briefly to the provision of orthodontic services, especially for young people. I met a parent the other day whose 16 year old daughter has a severe problem with her teeth. The parents are in receipt of social welfare payments and are unable to afford the £1,500 required to ensure she receives appropriate treatment. Why can the outdated determinants of eligibility for the receipt of orthodontic treatment by young people, which were introduced in the 1980s, not be radically changed? Everyone with a modicum of common sense knows the embarrassment many young people feel at having to live with teeth outcrops and so on. Let us do the decent thing and give that service to all the people who need it.

Clearly, if one has money to pay for treatment one will get it, but if one does not one must suffer on. While the inequalities of our health service might have nothing to do with the impending action by junior doctors, they are symptomatic of the mess that is the Irish health system in 2000.

This week, I have had the opportunity to view some of the recommendations of a special project team which was established to assess the needs of Longford-Westmeath General Hospital. It is clear from these recommendations that not only are more staff, equipment and facilities required at the hospital, there is also insufficient accommodation available for junior doctors to take rest periods whenever they are lucky enough to get them. The report recommends that a total of 11 rooms are necessary to facilitate the current level of junior doctors on call at any given time.

Debate adjourned.