I agree with Deputy Gay Mitchell's comments on the abuse of alcohol. It is the downside of the tiger economy that so many young people are abusing and being encouraged to abuse alcohol. Given the chronic damage that can and will be done as a result of this, we are storing up problems in the long-term with regard to the provision of health services. We need to address the issue.
The Labour Party wants to support this Bill, especially its provisions on cigarette smoking, which are modest but welcome. However, we are dissatisfied with other aspects. These need to be amended.
The Bill also contains provisions to amend the Health (Nursing Homes) Act. Nursing homes play an important part in the overall provision of services to the elderly. That is recognised in the existence of the subvention system, which will be regularised by this legislation.
For many elderly and frail people a nursing home provides a safe haven and a home from home. The regulations governing private nursing homes ensure that standards are maintained for those fortunate enough to access the care they need. This is progressive legislation in ensuring that standards are applied and maintained in private nursing homes. Before its enactment there were at times abuses, standards were not maintained and care for very vulnerable people was not properly provided. Demand for nursing homes is growing and demographic factors will ensure this will continue.
There is also a growing need for step-down facilities for patients who block beds in acute hospitals. Low-tech step-down facilities are not available. The pressure on acute hospitals, especially over the winter months, is not a new phenomenon. Greater sickness and demand on A&E departments in winter are to be expected. What is not, and should not be expected is the ineffectiveness of the Minister in dealing with this crisis, indeed ineffective is too kind a word.
The Minister's predecessor did nothing to address this problem. Like a hibernating animal he disappeared in the winter when the crisis was at its worst. The Minister has adopted a different approach. His response to the winter beds crisis was announced with the usual PR spin we associate with him. However, it is worse than a sham because it creates as many problems as it will solve.
In his press release the Minster said an additional 500 nursing home places will be provided. However, he is not creating new spaces but commandeering existing beds within the scarce pool of existing nursing homes. When I asked him by way of a parliamentary question how many new step-down facilities had been created this year and how many had been lost in the system he could not supply the information because his Department does not collate it. Since then I have received a couple of sporadic missives from various health boards and hospitals outlining their position, but the information obtained is very patchy and unsatisfactory.
It is incredible that officials in the Department do not know how many set-down facilities there are in the country at a time when the need for them is critical to resolving the winter beds crisis and to managing the use of the acute hospitals to best effect. Despite this the Minister is intent on selling his flawed initiative as a panacea for the crisis. He made an announcement about 500 additional beds but they are hired rather than additional. They will no longer be available to elderly people who are not using the hospital services but who are in need of nursing home care.
In a radio interview the Minister tried to present his plan as providing benefits for public over private patients. That is not true. Some 80% of elderly people are on medical cards, whether they are seeking nursing home places or hospital services. To present this as some kind of benefit for public patients is disingenuous. The Minister is similarly disingenuous in stating that the appointment of 25 A&E consultants and 15 anaesthetists will assist in the winter beds crisis. They will not because they will not be appointed in time. It is unworthy of the Minister to attempt to dress up a perfectly good initiative which we would all welcome wholeheartedly if he did not try to present it as something it is not to make him look better.
I am concerned about some aspects of this Bill and wish to refer specifically to the amendment of the 1970 Health Act. This amendment will incorporate in primary legislation provisions which are already provided for by way of regulation. Some aspects of this amendment are anti-consumer, particularly the agreement with pharmacists. Article 10 provides for this change in regard to pharmacies, presumably because there are legislative difficulties which must be addressed. The Minister should not proceed with this amendment until the serious concerns which have already been put on record by consumer groups, the Competition Authority and Dr. Peter Bacon, in his report on supply and demand in the sector, are addressed. I realise this Minister did not make the agreement, which was a good one in many of its facets. As time passes, deficiencies in regulations and legislation often emerge and demand attention and this is one such case.
The regulations, as they currently apply, are quite protectionist in nature and prevent the normal competition to which the public is entitled. I urge the Minister to establish a review which would deal with any existing deficiencies in order that this issue could be progressed. In terms of the promotion of pharmacist professionalism, there have been some benefits. It is clear pharmacists are key participants in primary care and I argue that they could play a greater part. Pharmacists ensure absolute accuracy in terms of prescriptions and ensure that there are no contraindications for patients. Patients who are prescribed a six week course of treatment and who may feel slightly better after three weeks or may not like the medication simply stop taking it. Somebody needs to identify those people because when patients do not follow through on a course of treatment which would deal with their problems, they can become even more ill and end up in hospital. A simple phone call from a pharmacist would ensure that courses of treatment are completed. Pharmacists would like to see more formalised contact between general practitioners and the other key players in the provision of primary care.
I am concerned that the agreement militates against an even and satisfactory spread of pharmacies nationwide. It prevents the growth of new pharmacies in areas where they are required and prevents newly qualified pharmacists from building up a business. Some pharmacists have certainly benefited from the current arrangements but others have not and the public interest has not always been served.
Pharmacists serve local communities and obviously have a disproportionately elderly and sick customer base in comparison to other services. These customers often suffer as a consequence of the regulations' limits. The town of Knock in County Mayo is one example of where this has happened. It has received a great deal of publicity because of the high numbers of visitors to the village which does not have a pharmacy. The village of Roundwood is my constituency does not have a pharmacy either. As a local TD, I am aware of the problems this causes. Roundwood, which is described as the highest village in Ireland, is a considerable distance from any urban centres in which pharmacies operate. The lack of access to a local pharmacy causes distress and inconvenience to local people, particularly for those who depend on a very limited public trans port service. It is not that nobody wants to meet their needs. A young pharmacist applied to open a pharmacy in Roundwood but was refused. In Wicklow town, there is a purpose built pharmacy building adjacent to a very busy health clinic. This is an ideal arrangement in terms of patients being able to access a full range of services from a GP or physiotherapist in the pharmacy. Again, it is not a case of nobody wanting to open a pharmacy in the building as a person who is already running a pharmacy in a nearby town has expressed interest in doing so but the regulations prevent that.
I do not understand this protectionism. No doctor can prevent other doctors erecting a nameplate on their surgeries and inviting patients. One could say that the GMS entails certain restrictions but even those are less restrictive than these regulations. From where does this protectionism come and does it comply with EU free market criteria? I do not know the answer but I know that a demand for a very essential service is not being met. If it transpires that such a service cannot be sustained commercially, so be it, but the evidence suggests that because the regulations are so restrictive, that proposition cannot even be tested.
The 'flu vaccination programme has been in operation for a short period. Problems were experienced in obtaining stocks of the vaccine and these resulted in supply shortages. It would be appalling if this were to happen again. I support the 'flu vaccination programme 100% but the Department should have ensured the availability of adequate supplies prior to its commencement. A GP in the Dublin area contacted my office saying that war had almost broken out in his surgery over the health board's failure to ensure full provision of vaccines. I understand the vaccine is not even included in the drugs refund scheme and I would like to hear the Minister's view on that exclusion.
The fact that vaccination programmes run concurrently rather than consecutively places additional pressures on the system. The meningococcal vaccine is currently being administered but I suspect the level of take-up will not be as high as it could be. The pneumovax vaccine, which was to commence at the same time as the 'flu vaccine, did not commence until a later date and that creates its own inefficiencies.
This Bill contains some positive provisions, among them its anti-smoking provisions. We all know that cigarette smoking is the single most preventable cause of death. It has been clearly identified as a major health risk and a significant cause of lung cancer, cardiovascular disease, stroke, respiratory illness, peptic ulcers, emphysema, osteoporosis, mouth and throat cancer, peripheral vascular disease etc. Smoking affects pregnant women detrimentally, in addition to affecting the babies they carry. Smoking has been described as being more addictive than heroin and, unlike many other addictive substances, presents an environmental risk to non-smokers as well as smokers. It results in enormous cost at a personal and societal level. The graveyards are full of the bodies of people whose lives were shortened by smoking. What is at issue is a dangerous drug which can have lethal effects. Some people manage to escape but others, sadly, do not. There is no doubt that the drug would be banned if it were to appear today for the first time on the market. However, that is now not feasible and would not work.
It is important that everything possible is done to reduce the levels of smoking and there is a genuine consensus in the House which wants to ensure that happens. Too many people smoke for too long, and it is clear the black market would mushroom if there was an attempt to have an outright ban on tobacco.
We are agreed that a multi-dimensional approach is required to include preventative measures, personal development, education, restrictions on sale and advertising, fiscal measures and medical and therapeutic treatment. The report initiated by Deputy Shatter and accepted by the Oireachtas committee set out a very good framework for action.
The earlier people start smoking the more likely they are to become heavy smokers. Approximately one in every three young people who become regular smokers dies prematurely as a result. In Ireland, up to two-thirds of children have experimented with tobacco before they reach adulthood. Interrupting the cycle of childhood addiction requires decisive and effective action. The Slánú research shows that 40% of females between 18 and 34 years of age smoke as compared with 38% of young males. This shows an inordinately high level of smoking among young people and also a new and disturbing increase in the number of young women smoking. It is also significant that despite a drop in smoking here since the 1970s, there has been an increase in smoking levels since 1988.
The Minister for Health and Children has rightly made smoking a target for reduction from 30% to 20% over ten years. It is very ambitious, but if achieved it would have a tremendous impact on the general health status of the population. While there is no real evidence that such a goal will even begin to be reached under the Government, we will support every effort made by the Minister. However, we will not support any attempt, to which the Minister is prone, at hyping or exaggerating the effectiveness of measures he takes on this or any other issue.
It is a modest Bill which was due to come before the House in any event, with the anti-smoking measures simply tacked on. Presenting a portmanteau Bill is hardly an auspicious start to a crusade to tackle nicotine addiction. That said, the measures are welcome as far as they go. However, one wonders how far they will go. How will the regulations be enforced and how effective will they be? What mechanisms will guarantee results?
A recent report from the Western Health Board says that 98% of tobacconists surveyed in Roscommon, 61% in Mayo and 30% of those in Galway were found to be selling tobacco to children under 14 years of age. Even without the Bill, such activity is illegal. There is no doubt that respectable shopkeepers are systematically breaking the law, it would appear on an ongoing basis. It is fair to assume this law breaking is not restricted to one part of the country.
It augurs badly if the changes proposed in the Bill are being introduced in an environment and culture which tolerates on a wide scale the sale of cigarettes to children, even though it is illegal. The lesson is clear. We must ensure that laws enacted are implemented and accept that legislation without education is severely limited in its effect. Educating, not just shopkeepers, but young people at risk, should be a fundamental pillar of any new strategy.
However, it must take on board the actual experience of young people rather than imposing a view. In particular, the rise in smoking among young girls signals that we must address the underlying reasons why young girls are choosing to take up smoking. An example I often give is that it might be as much benefit to bring Weight Watchers or some similar organisation into schools to encourage young girls to manage a good diet so they do not feel uncomfortable about weight issues. Obesity is growing very fast across the western world, including in Ireland and it is clearly a strong factor in why some young girls, who are insecure about their self-image, take up smoking.
When the EU Commissioner, David Byrne, spoke at the recent North-South conference organised by the BMA and the IMA, concern was expressed by health professionals at the deeply contradictory approach adopted at EU level. On the one hand there is an agreement on anti-smoking measures, including a ban on advertising, but on the other hand the EU continues to subvent tobacco growing to the tune of 2 billion ECUs per year. Many subsistence farmers in Greece and Italy depend for their livelihoods on growing tobacco, but this cannot be a justification to continue such a policy in future. Those visiting Greece see widespread advertising and constant promotion of smoking, which is bound to create and maintain a high level of addiction.
In Ireland we reflect an EU average of about 30%, and the rate is growing. By contrast, the US is approaching a level of 20%, which tells us something. The US is libertarian in its outlook, with individuals having the right to carry a gun but not allowed to smoke a cigarette in most circumstances. This shows the possibilities of creating a new climate which can address the addiction. We do not have the same cultural and historic attachment to the idea of individual liberties and personal freedoms, and it should, therefore, be possible and easier for us to ensure the level of cigarette smoking is reduced, particularly among young people.
The North Western Health Board has shown a way forward in terms of education. From the evidence produced by the board it is clear that school health promotion programmes work and that young people absorb the messages they are given. We must examine this carefully as there is always the danger with blanket campaigns that the anxious healthy people take up the message rather than those who actually need to listen to it.
Social class is also an issue, as it underlines all issues relating to health. Slánú research has shown over and over again that poverty creates ill-health and is a key factor in terms of health status.
Finally, I wish to again refer to private nursing homes. Convalescent homes should be subject to regulation. My understanding is that health board welfare homes do not come within the provisions of the existing legislation. Who is in charge of maintaining and ensuring standards in welfare homes which care for the elderly? In terms of general health provision it is astonishing that anybody can come to the country and set up a private hospital and that all they need is planning permission and a fire safety certificate. That is untenable. There are issues regarding standards in hospitals, nursing homes and welfare and convalescent homes.
It is quite clear that the issue raised by Deputy Mitchell is a very stark feature of quite a number of our hospitals, which are still unnamed, namely the horrifying extent of MRSA which cannot yet be pinpointed because the information has not been released as to which hospitals are at fault and how the matter is being addressed. The idea of sending patients home rather than keeping them in hospital sounds like good common sense. If a person can be cared for at home or in the community they should not be retained in hospitals. Generally speaking, acute hospitals are not safe places to be when one sees the levels of MRSA.
I lost a dear friend who had a most horrific death having suffered for a long period because she contracted MRSA. This happened in a private hospital. The serious aspect of hospital accreditation and maintenance of standards needs to be tackled, but perhaps not in this Bill. The work done in relation to standards in private nursing homes has been beneficial, particularly for the residents. The same approach needs to be extended beyond private nursing homes. I have no doubt we will return to that in the future.
A number of issues will be raised on Committee Stage. It is not satisfactory that we are dealing with three different areas of health care in one Bill. It would be much more satisfactory if smoking, pharmacists and nursing homes, which are in no way related to one another, were each given their own Bill. It would be a better practice and less likely to lead to difficulties in the future. That said, I hope we will be able to progress this Bill and improve it when the time comes.
