Dáil Éireann debate -
Tuesday, 3 Jul 2001

Vol. 540 No. 1

Private Members' Business. - Health Services: Motion.

Mr. G. Mitchell

I move:

That Dáil Éireann, conscious that the voted Estimates for the health services as recently passed will not produce a health service which is fair, or accessible by all, irrespective of income, and which is both effective and efficient in terms of health needs, calls on the Minister for Health and Children to immediately introduce comprehensive measures to protect the rights of patients to due, adequate and timely health services, and calls for the appointment of a health ombudsman to oversee the rights of patients.

I wish to share my time with Deputies Crawford, McCormack, Deenihan, Burke and Timmons.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. G. Mitchell

The voted Estimates for the health services as recently passed will not produce a health service which is fair or accessible by all, regardless of income. The money contained in the 2001 Estimate does nothing to restore the health service spending to 1980 levels, despite the fact that the Exchequer has run budget surpluses of £6.4 billion. That is very regrettable. It is more than regrettable for the many thousands of people who are waiting for hospital beds. It is more than regrettable also for the doctors, nurses, therapists, paramedics and others who work within the health services and those people who rely on their expertise and care. It is deeply disappointing, as I have said to the Minister before, for all those people who believed the Minister's press releases and who expected a reforming and revitalising response. Instead of the stimulating injection expected, this year's Estimates will act as a sedative to the ailing health service, at best maintaining the current unacceptable status quo, at worst allowing a rapid deterioration of its critical condition.

It is estimated in a report published this evening that to meet the needs of the Republic on the same basis as the needs of those in Northern Ireland are met would require an additional 7,730 beds. There are only 3.12 beds in the Republic for every 5.12 in Northern Ireland. That is the kernel of the problem. Let us look at the facts contained in these figures and examine a few key areas which give the lie to any assertion of improvement. The total net increase in this year's Estimates over last year's is £850 million, an increase of 17%. So far, so good. When the detail is examined we discover that of the £850 million, 49.5% – almost half – £421 million, goes to pay salaries. The payment of salaries is an essential part of any Estimate and I fully concur with the need to pay good salaries. I take issue with what this Government has allowed for health spending after making provision for salaries. The increase is now reduced to just £429 million. The reality is that this year's Estimate simply aims to continue existing programmes and to pay staff. There is no sign in this year's Estimate of the financial outlay which would allow for the realisation of the reforming and revitalising zeal often articulated by the Minister. When asked to put his money where his mouth is, he fails miserably. This Government may have increased spending but it has not made any contribution to improving health care or reforming the health services. The Minister has increased spending but has not increased or improved health care. It is strategic planning which is lacking and there is no allowance in this year's Estimate for even the sign of that planning.

This is no more than we have come to expect from the Minister. In the Official Report of 8 May 2001, vol. 535, cols. 1236-37, the Minister said:

It is time for a strategic look at health services . . . Seven years after the previous strategy is an opportune time to look forward in terms of a new strategy.

In its fifth year in government, despite all the demographic changes and the rapidly changing health environment, this Administration has only now started to look forward. What a way to administer the health services. People's health needs are immediate and urgent but the Government has sat around noting reports, ignoring the evidence for the past four years and is only now starting to look forward. This laissez-faire attitude is totally unacceptable. The deluge of evidence of the need for rapid reform has swept on unnoticed by the Government as if it were a passing shower. There are well over 60 different reviews, examinations and standing committees working for the Minister. There has been no action. Everything that arises is under review.

Resources are part of the problem, but nothing short of major structural changes will bring about the health services required. Such structural changes should include a covenant of rights and responsibilities for patients; a dedicated health ombudsman to oversee such a covenant; an entirely new structure of health governance with hospital boards which are citizen-based and management which should have contracts of employment that are renewable on application every six or seven years. Results to be measured based on six criteria, health gain, fair and equal access, effective delivery of appropriate health care, efficiency, satisfaction levels achieved for patients and carers, and health outcomes.

Resources nearer the EU average spend on health – 8% of GDP compared to current 5.1% of GDP or 6.05% of GNP rate of spend – with value-for-money audits. I have made specific recommendations as to how the money can be used effectively – a universal health system with access based on need, not on wealth, and reform of primary care with Government investment.

Fine Gael will give back to our citizens trust in our health services. Trust in the health services has been eroded by the fact that our citizens cannot be confident of being treated in an appropriate way when ill, major health care services and providers have not justified the trust placed in them by our citizens, the poor, the elderly and many patients suffer second class treatment or, worse, receive no help when needed from the health care services, and a glaring lack of leadership and direction by the Government, now in its fifth year in office, in solving the critical problems in our health care system.

I am aware of an elderly, mentally handicapped patient who fractured her shoulder, was taken to a hospital and was left sitting all day long without anything to eat or drink. She was only eventually seen by a doctor very late at night. This was a patient with obvious special needs. What has gone wrong with our health system and what has the Minister for Health and Children been doing to correct that wrong?

The proposals put forward in the Fine Gael health plan are designed to restore trust in the health services. For this reason as well as for other reasons, Fine Gael will create a citizen-centred health service that will be trustworthy, effective, efficient and accountable to the citizens it is designed to serve. As the health plan proposed by Fine Gael is implemented, it will shape our new health care system with the following features. The new health care service will be funded to meet the health care needs of our population and will be fundamentally reoriented from curative to preventative services. This is long overdue.

Only £2.50 out of every £1 million in this year's Estimates is allocated to health promotion, despite the fact that the Minister has acknowledged the importance of health promotion. This is a priority area, yet it gets £2.50 out of every £1 million. So much for prevention and so much for priority. The new health care service will be needs-led, designed and based around evidence-based needs. It will be outcome-driven and services will be measured by health outcomes.

In 1980 when we were a much poorer nation, Ireland spent 8.7% of wealth on a GDP basis on health. By 2000, Ireland's spend had dropped to 5.1% of GDP. It has to be acknowledged that Irish GDP increased rapidly in recent years. Nonetheless, despite the rapid growth in the economy, Ireland is about 22nd in a list of 29 OECD countries in terms of health spending. From a low base in the early 1990s health spending has more than doubled, but it remains far behind the European average of more than 8% of GDP.

More than 60,000 nurses register annually in Ireland, only half of whom are in the health services. Nursing shortages leave some Dublin operating theatres closed for one week in four. Lest anybody thinks this is just a Dublin concern, 20% of all treatments in Dublin are for people living outside Dublin. Therefore, the acute nursing shortage in Dublin is a national issue. It is time for a Dublin weighting to be paid to nurses, together with an accommodation allowance to attract registered Irish nurses back into the system in Dublin where two-thirds of all nursing shortages exist,

If the Minister spent his energies trying to bring about practical solutions such as this, instead of massaging hospital waiting list statistics, real progress could be made in our hospitals. Cancer patients would not have to go to the courts to obtain treatment. What has happened to this country, the demarcation, the courts, the Executive, the Legislature? Ministers no longer make decisions. Judges make the decisions Ministers are paid to make. It was an insult in a week when such a court case was taken, that the Minister should seek to give the impression that all is rosy with hospital waiting lists. This seems to be a case of lies, damn lies and hospital waiting list statistics.

In the meantime, during the Government's term of office, what has happened to the health services? There were more than 1,800 bed closures cumulatively during 2000, more than 800 of which were due to nurse shortages. There are almost 30,000 people on hospital waiting lists nationally, more than 52% of whom are waiting for a bed in the Eastern Regional Health Authority area where the numbers on waiting lists are 19% higher than when this Government took office. Cancer patients have had their essential chemotherapy treatment delayed because of lack of beds. Four floors of a new hospital wing in the Longford Westmeath hospital, finished during the Rainbow Government's term, have lain empty for the past four years depriving the health service of 98 much needed additional beds because the Government cannot make up its mind what to do. The accident and emergency units of all hospitals are over-crowded. Medical and nursing staff are being forced to work in appalling conditions. Seriously ill patients are made to wait on trolleys for unacceptably long periods. People on modest incomes whose wage increases are almost wiped out by inflation are deprived of essential free health care by the Government. The current income limits for medical cards are so low that a husband and wife lose their eligibility if their income exceeds £144.50, or thereabouts, per week. A family with two children are excluded if their gross income exceeds £180.50 per week, and a single person cannot qualify if he or she earns more than £101 per week. As a result, only three out of four people, who qualify under the agreement which the Government has entered into with the IMO, receive medical cards because income limits are kept artificially low at a time of huge budget surpluses. It is the poor who wait on hospital waiting lists and who die younger. Fine Gael will double the medical card income limits to correct this injustice. There is under-investment in general practitioner care, and changes to the drugs payment scheme, instituted to save money – while we run budget surpluses of £6 billion per annum – mean that people with chronic conditions, such as asthma, have to pay more for their essential medication.

Fine Gael's comprehensive policy proposals, published in November 2000, are fully thought through and costed. Recognising the need for essential and far-reaching reform, we propose to double the income limit for medical card qualification; to extend free general practitioner services to children up to age 18 and over that age when in full time education; to extend it to all senior citizens over 65 years and to those with chronic disabilities; free medication for people with asthma; development incentives for GP's surgeries and pharmacies to encourage greater use of primary care and ease pressure on hospitals; to provide a non means-tested allowance to support persons cared for at home; to expand the number of public health nurses, home helps, speech therapists and other essential supports to carers in the community; to provide free health insurance for all with committed budgets to meet hospital needs; to increase the number of beds in the different care settings and appoint a health ombudsman who will oversee a covenant of patient's rights.

Fine Gael proposes a thorough reform of the hospital and health administration services to give citizens a real say and to provide for accountability as there is no accountability; a greater role for voluntary organisations and specific funding commitments to meet these objectives.

While accepting that there are no "quick-fix" solutions, it is clear the Government has no solutions at all. The four wasted years have put the development and reform of the health services back by ten years. That is indefensible. The approach of a general election is only now acting like a dose of salts to this sluggish Government.

It is a bitter irony that the Taoiseach could find the money and the time to fast-track his pet project, Stadium Ireland, to the tendering stage in a little over a year. Yet he leads an Administration which in its fifth year of office is still in the review stage for the health services. The facts speak for themselves. It is clear that while the Government has the resources at its disposal, provided by this House, it does not have the courage or the ability to make the fundamental changes which would deliver better health care for all. We should be ashamed that a cancer patient had to go to court to secure treatment. That is unacceptable. It is said that knowledge is power. If that is so, patients must be empowered through information so that they can understand and deal with their own health and care needs in a true spirit of partnership with the health care providers in primary, secondary and tertiary care. In the 21st century, many health professionals agree that patients can no longer be viewed as passive receivers of whatever the health care system deems to be in their best interests. Patients must be active participants in the process from start to finish. In most countries a major part of any empowerment in the information process is a so-called patient's charter or patient's bill of rights.

The original patients' charter for Ireland is minimalist and deals only with hospital in-patients and out-patients. It did not seek to enshrine rights for patients in a more formal way. It was and is often honoured more in the breach than in the observance. It is ironic that the Department of Health and Children is no longer able to supply printed copies of the patients' charter. The document is only sometimes found posted up on the notice board of hospitals around Ireland. It can be safely assumed that most patients are unaware of its existence.

The problem of vindicating patients' rights is difficult but by no means intractable. Equally, many patients are unaware that they have rights. Add to the equation that in the health system patients can be reduced simply to being a case to be dealt with. Individual patients may be too ill, insecure or uninformed to stand up for their rights. In recognising patients' rights, the partnership of doctor and patient can improve the quality and outcome of medical care. We should give statutory backing to a new covenant of rights and responsibilities for patients in a new health Act. A health ombudsman should be appointed to oversee that. Two or three years ago, I would have questioned the need to appoint another ombudsman. However, in view of the proliferation of tribunals, inquiries and commissions and the amount of money being spent by the Minister on up to 60 different reviews, it seems to me that such an appointment would be money well spent. A health ombudsman would also reduce the need for litigation, the fear of accusation of medical negligence and the difficulty which that creates for some doctors in terms of nervousness in carrying out some procedures.

Patients are, first and foremost, citizens. Fine Gael believes it is no longer enough simply to inject more money and resources into the existing system. We propose a complete, detailed and comprehensive reform of the health services. We have not waited until year five of this Government's term of office to make those proposals. Since 1987, Fianna Fáil has been in Government all of the time, with the exception of two and a half years and the Minister seeks to blame the Rainbow Coalition which was in office for two and a half years. He seeks to blame his predecessor, Deputy Cowan. He seeks to blame somebody, anybody other than himself; it was nothing to do with him, somebody else took the decision. I put it to him that he is the Minister for Health and Children. We know what a fright his party got in Tipperary South. There is a very much bigger fright waiting out there for the Government with its self-congratulatory approach and its efforts to be all things to all people. The Government should address the issues that really matter – traffic, housing and health. This Government is a dismal failure at a time when there is an abundance of resources available to deal with the problems. We have the resources. Where is the leadership and the strategy? They are lacking because this Government has not got a feel for the issues or the experience, the skill, the will or the sense of injustice to provide a decent system of which we could all be proud. I commend this motion.

Mr. Crawford

I thank Deputy Gay Mitchell for providing the opportunity to discuss this major issue. Any of us involved in the Tipperary South by-election got the message at first hand if we did not already know it. In the short time available, I wish to raise a number of issues concerning Monaghan General Hospital and I make no apology for being parochial. The ante-natal and post-natal services which should be available have been removed from that hospital despite the fact that the equipment and personnel are in Monaghan. Blood tests have to be referred to Cavan or Drogheda, although the equipment is there and the personnel is available. No junior doctors have been appointed. The health board placed a small advertisement in the newspapers for A&E nurses, but it was so small as to indicate that the board is not treating the matter seriously. Last week, a midwife had to deliver a baby in Monaghan General Hospital to a Latvian woman who had only been in the country for 24 hours. This was not a fix-up, as some people would like to portray it. If the woman had been sent to Cavan or Drogheda, she would have got no further than The Diamond in Monaghan.

The Minister claims he can only provide money for the health boards who make the decisions. In South Tipperary, the Government claimed full responsibility for last year's money for hospital care in that area and made further commitments for the by-election. The Minister went to Roscommon, took full responsibility for the money spent there and promised additional funds to finish the job. I believe he means well. I have asked him on a number of occasions to come to Monaghan, but he is conspicuous by his absence in Monaghan General Hospital. The health board claims to be waiting since last January for a decision by the Minister on whether restructuring and extensions can go ahead.

I criticised the Minister last week in the House on the issue of medical cards and I welcome the fact that he got a ninth hour agreement with the doctors for over-70s. When will low income families get medical cards? Deputy Mitchell has given the figures. A person with £102 per week is not eligible. That is a disgrace at a time when the country is awash with money. We heard that again from the Taoiseach today. I know of an old couple who were granted two hours of home care per week recently. That is completely unacceptable for people who have given a lifetime's work to the country. I know of two cases where young handicapped persons were sent home from a respite home because of lack of staff, despite a promise that they would be there for the rest of the week. In one case, the parents were taking a well earned four days rest in Gal way for the first time in years. This shows a total lack of management and care for such people. Can the Minister imagine what it is like for a couple to look after a handicapped person, week after week and then, having got a break for the first time in ages, to get a phone call to return home and collect their son immediately? That is not a health service of which we can be proud.

Mr. Deenihan

I support this motion. There is need for a health ombudsman. A health ombudsman would certainly not tolerate what is currently happening in Kerry. While I do not wish to be parochial, this is an opportunity to point out to the Minister what is really happening in the health services in County Kerry. Last week, eight women who had been called to Tralee Hospital for hysterectomy appointments were sent home because of shortage of beds and staff. This very morning, people who had been called in for gynaecological procedures, ENT procedures and various surgical procedures, were also sent home for the same reasons. That is just not acceptable.

The Minister should undertake a major review of the situation in the Southern Health Board region. County Kerry is being totally and absolutely ignored. With the exception of Bobby O'Connell, a member of the board from Kerry, the Cork members are running rings around the other Kerry members who are all of the Minister's party. In the national development plan, only 3% of the total budget was allocated for major capital works in Kerry. That is a total disgrace. Young people in Kerry are waiting three years for orthodontic treatment. For normal, simple surgical procedures, such as gallstones or varicose veins, people in Kerry have to wait five years to be seen. That is factual information from people who are in a position to know what is happening. The subsequent surgical procedure follows on somewhat faster, but first there is a five year wait to be seen by the surgeon. That is the reality.

A health ombudsman would certainly not tolerate that standard of health service for a county as large as Kerry, which will have a population of 135,000 to 140,000 in ten years' time on the basis of recent census reports. The county is totally underfunded in terms of medical services and care. Every year almost two million tourists come to it. The services available for them – emergency services are always in demand because of accidents, etc. – are inadequate to meet the massive demand. The health board arrangement whereby the county is lumped in with County Cork is not suitable for a county of its size and the increased numbers in the county during the summer.

A health ombudsman would look very seriously at what is happening in County Kerry. I would like the Minister to visit Tralee General Hospital.

Mr. Martin

I have.

Mr. Deenihan

I would like him to order a special report from the health board to confirm what I am saying.

Mr. U. Burke

I support Deputy Mitchell's motion. The Minister's tenure in the Department of Health and Children has been one of reports, strategy documents, steering groups, project teams, consultative fora, submissions and partnership facilitators. They are all a mechanism to avoid and delay the delivery of services. The Minister has failed to tackle obvious unbelievable shortcomings in the service.

Elderly people are fearful of hospitalisation. If they are told by their general practitioner that they must be hospitalised, they are afraid of going to an accident and emergency department, spending hours on a trolley and being seen after that time and told to go home, that there is no acute bed in which to accommodate them for a night or the duration of their sickness. How can we expect elderly people to have confidence in a Minister, Government or health board which delivers such a service? They are simply afraid, and the Minister must be aware of this and have seen it. If he has not witnessed it, then it is time he went to the coalface to see what is happening to patients. Elderly people are wishing to be left and die in the comfort of their own homes. It is sad at a time of plenty, and in the era of the Celtic tiger, that this is the best we can do to deliver a service to the elderly.

A couple of months ago the cardiovascular health strategy was announced in a blaze of glory. The reality is, as the Minister must be aware, that it is now in a shambles. It will not be proceeded with because the Minister is not prepared to get the funding from his colleague, the Minister for Finance, for the hospitals in order that they can provide the infrastructure necessary to deliver the service. Why then do we wonder at the high rate of coronary deaths? We do not have a service to deliver. There is an inequity between the east and west. We do not have the service or infrastructure to deliver it in the west. The Minister will respond by establishing a new consultative forum which will produce another report.

We are told the report resulting from the consultative process which has taken place for a new service is with the Department. It highlights the very matters about which we have spoken for the past four years in the House. There is nothing new, and the Minister and his predecessor have failed to tackle them. The Minister is afraid to take on the vested interests of those who deliver health services. There is a two tier system, a problem the Minister has failed to tackle. I am confident he will not tackle it in the next couple of months which may remain in the lifetime of the Government as it is election time. He wants to say there is a consultative process and a new plan, which will again end up on a shelf gathering dust.

Mr. Timmins

Each time the Minister comes to the House for a debate on a Private Members' motion on health – the same was true of his predecessor – he reams out the same statistics and outlines the amount of funding allocated to the Department as opposed to the previous Government. It reminds me of the politician who, when accosted by their spouse as to the reason they are never home, responds by saying, "Did I not take you to the chamber of commerce dinner? Should that not do you?" That is not a satisfactory answer from the politician, and it is not satisfactory for the Minister to tell us tonight how much money he spends. If he examines the speeches made by Deputy Cowen when Minister for Health and Children, he will see they are exactly the same, as very little has been done apart from money being allocated. For example, Deputy Deenihan referred to a three and a half year waiting list in the south eastern region for orthodontic services. In the ERHA area the waiting times can be up to seven years. Recently I encountered a parent whose child was told in 1996 they were in category one. In fairness the child has been seen, but only in the past couple of days. I realise there is a difficulty in recruiting professional staff, but has the Minister advertised abroad to fill these positions? Each time the response is that certain measures have been taken, but the positions have not been adequately filled.

I wish to refer to expectant mothers, an issue dear to my heart. Under the health services in-patient regulations of 1991 a consultant's public patients must ordinarily be accommodated in public beds. This recommendation was made by the commission on health funding and included in the Health (Amendment) Act, 1991. For the life of me I cannot understand the reason an expectant mother who wishes to attend in a public capacity cannot avail of a private bed if she so wishes, and pay for it, when the time for delivery comes. I would like the Minister to examine this and make a special case for expectant mothers. It should not be too difficult to overcome this problem.

Section 2 of the charter of rights for hospital patients introduced in August 1992 states that each person shall be given an individual appointment time, a matter on which I tabled a parliamentary question. I do not know what that means as in the hospitals with which I am familiar public patients are not given an individual appointment time. If the Minister visits the Coombe or Holles Street hospitals, or the hospitals in Kilkenny or Clonmel, he will find that expectant mothers who are public patients are allotted group times. I ask him to re-examine this with a view to people being given an individual appointment time.

I represent County Wicklow and part of County Carlow. We are probably unique in that we do not have a general hospital. The hospitals in Loughlinstown, Naas and, to a lesser extent, Tallaght serve the area. I do not know if the Minister has visited Loughlinstown hospital, where there are many problems. It is an old union house in which it is very difficult to accommodate modern needs. I realise the Minister has allocated some funding for it, but we can see what has happened in Naas where it appears the programme for development will be inadequate when completed in the next year or two. There are already indications it will not suffice in terms of the needs of the area. I would appreciate if the Minister would examine the idea of Tallaght Hospital serving the needs of south and west Wicklow while Naas Hospital is under construction. Currently, it is operating out of cabins.

The Ombudsman appeared before the Strategic Management Committee last week, dealing with health. He pointed out a few cases where patients believed they had not been treated correctly by consultants. That day I said that many patients approach consultants in an Oliver Twist-like manner. The time when people were subservient to the professions, be it doctors, solicitors, consultants or whatever, should be past. It is time the Minister took this on board and stopped consultants dictating to the Department and patients about what can be done.

I wish to share my time with Deputy McCormack.

An Ceann Comhairle

There are just 30 seconds left.

Mr. McCormack

I will have to make do with 30 seconds. This is a very serious motion and in 30 seconds one could not do it justice. I have a desk full of replies from the Minister dating back to January 2000, in which he informs me he has approved the appointment of a second consultant urologist at University College Hospital, Galway. A year and a half later no-one has even been recommended for the position. I ask the Minister to cut out the red tape facing Comhairle na nOspidéal when making appointments of consultants to hospitals so that we can get the consultants on the ground and allow them to do the work necessary. It is a joke considering the conditions—

An Ceann Comhairle

I ask the Deputy to conclude.

Mr. McCormack

I will have to conclude before I start.

Minister for Health and Children (Mr. Martin)

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"–commends the Government for its unparalleled increases in health funding;

–fully supports the robust targeting of these funds which will lead to substantial improvements across the wide spectrum of health and personal services; and

–continues to endorse the process adopted to facilitate the development of a new health strategy which will be the focal point of the delivery of health services in the next five to seven years".

I congratulate Deputy Mitchell and his colleagues on producing a motion for debate which so succinctly manages to summarise the key issue which lies between the Government on the one hand and the Opposition parties on the other. The contrast is between a policy based on credible planning, a comprehensive agenda and unprecedented resources, one which is based on the vain political hope of an Opposition that its buzzwords will be enough to distract the public from a complete lack of substance.

The Opposition has said it wants to use health as a political wedge issue. As a result much of this debate will inevitably be taken up with the business of politics. So be it, if the Opposition wants a political debate, it can have it. However, I make it clear that the Government will continue its work on completing the most comprehensive and far-reaching series of health reforms seen for over three decades. In the few weeks since we last debated health in Private Members' time, there has been unprecedented expansions in resources, new staff have been hired, waiting lists reduced and the reform agenda progressed. Waiting lists have been reduced by a further 1,500 since our last debate and medical cards have been introduced for all people over 70 years of age.

With respect to Deputy Deenihan's comments, I wish to put on record that the waiting list over the past year in Tralee General Hospital has declined from 457 to 134, a drop of 323, which by any standard is a very significant decrease in the waiting list of a single hospital.

Mr. U. Burke

They have gone elsewhere.

Mr. Martin

It really shows the distorted picture that Opposition Deputies always try to create without in any way focusing on some of the good work being done in many hospitals.

Mr. G. Mitchell

This is a pathetic speech.

Mr. Martin

Over the course of this three hour debate we will hear repeated attacks and a continuation of the basic approach of the Opposition, which is to roar crisis at everything, deny there is progress in any area, pretend there is a simple solution to all problems and, most of all, refuse to answer questions about the choices made by it when in government. I know that the Opposition would prefer I did not keep raising such an uncomfortable issue, but once again I ask it to explain to the House why we should believe it can be trusted to cut waiting lists when its record shows it cutting waiting list funding. I have been trying for a year to get an explanation. Three hours is more than enough time for Opposition Deputies to get their act together and utter even a few words of explanation.

The then Minister for Finance, Deputy Quinn, and Minister for Health and Children, Deputy Noonan, sat down and discussed their priorities. They discussed what they wanted to do with the health system and made decisions. The key decision was to cut by 20% the funding dedicated to reducing public waiting lists. The men who now say this is the number one issue which takes priority over everything else put it at the bottom of the pile and, even though they were engaged in a failed attempt to spend their way back into power, chose to implement a decision which directly disadvantaged public patients.

Mr. U. Burke

What will the Minister do?

Mr. Martin

What is more, on the night of 22 January 1997, Deputies Mitchell and McManus went through the lobbies of this House to support the cutback. The Government is willing and able to justify its record. It is about time the Opposition showed some semblance of bravery and explained its decision.

I welcome the continued series of debates which we are having in this House about the direction of our health services. It is striking that this motion contains less detail than anything previously tabled by the Opposition. Deputy Noonan has set out the basic policy of his party very clearly. Health is to be treated as the all purpose electoral and political football. Any promise, any attack and any policy U-turn required are to be deployed. Deputy Mitchell has been told to follow his leader and say and do anything necessary, and he is loyally following orders.

The result has been a policy which is a mile wide and an inch deep with a heavy reliance on good, old-fashioned, deliberate misrepresentation and distortion. I have no doubt that in the next 12 months we will see a virtuoso demonstration of political ambulance chasing dressed up in the cloak of a lightly given and easily discarded empathy. In the few weeks since we last debated health policy we have seen this approach in action with a vengeance. My personal favourite has been Fine Gael's ever flexible policy on health service funding. On 2 February last year, Deputy Shatter, who was then in charge of Fine Gael health policy, said to the House:

Whether the necessary reform can be brought about by the introduction of a universal health insurance system is questionable. What is needed is less, not more bureaucracy.

Soon after Deputy Noonan's palace coup he began to try to love-bomb the Labour Party and announced on RTE that his party would adopt Labour's policy of moving to a universal private health insurance model of funding.

Mr. G. Mitchell

It has been policy since November last. The Minister is misleading the House.

Mr. Martin

However, once the many fundamental problems with this proposal began to be reported by some commentators, Deputy Noonan began a rapid and skilfully executed retreat. As quickly as 28 May he told the Irish Independent that he was not now proposing to move immediately to such a system.

Mr. G. Mitchell

That is in the document as well.

Mr. Martin

This was, he said, because to do so would cause chaos. Instead he was now proposing that new capacity would be built, new staff hired, all the problems would be solved and then the system would, at some point in the far distant future, move to the universal private health insurance system he had previously been so enthusiastic about.

Mr. U. Burke

The Minister is wrong.

Mr. Martin

In other words, he now believes – it is the policy of the main Opposition party – that the existing funding system can deliver all that is needed and, at the same time, it has to be replaced to deliver what is needed.

Mr. G. Mitchell

Did the Minister ever read the document?

Mr. Martin

I look forward to the next instalment of the evolving epic that is Fine Gael's desperate search for a health policy.

Mr. G. Mitchell

There has been no mention of health.

An Ceann Comhairle

Deputy Mitchell must cease interrupting.

Mr. Martin

Not quite as good as this, but good nonetheless, have been the contortions which the Opposition continues to get itself into on how best to criticise the Government on spending levels. The initial critique was that we were deliberately underspending. In the face of continued unprecedented expansions in spending, the Opposition started to move away from this. On 27 February of this year a Fine Gael motion, supported by Labour, signalled a dramatic shift of attack, with a move to one based on the idea that there is loads of money going but we are not getting anything for it.

Mr. U. Burke

The Minister is only now realising he has been handed a poisoned chalice.

Mr. Martin

Leaving aside for one moment the basic factual inaccuracy in the idea that real service improvements are not being realised from investment, the Opposition has not been able to hold to a consistent line on this matter. The Labour Party has criticised the Government for not agreeing with the recommendation of the European Commission to hold back spending on services, but Deputy McManus returned, as recently as last week, to the idea that the reason there are problems in health is that we do not spend enough.

Deputy Noonan has told this House that the budget day spending announced by the Minister for Finance, a large proportion of which is going into health services, was excessive and would, "put our prosperity at risk", yet he and Deputy Mitchell are now saying that we do not spend nearly enough on health. They have also continued Deputy Bruton's favourite criticism that there is a lack of efficiency within the system which, they say, has meant there is nothing new coming out as a result of new spending inputs.

Mr. G. Mitchell

This is a terrible speech even by the Minister's standards.

Mr. U. Burke

The spin doctors have been very busy.

Mr. Martin

This has been a consistent criticism for over two years, but the extraordinary thing is that no member of the Opposition has ever pointed out an area in which they think we are spending too much. They have not mentioned any group, sector or even unit in the system which they believe is inefficient. On top of this, any time we introduce policies which require change in existing practices all we hear from the Opposition is that we are trying to do it too quickly and should not be upsetting anyone. The only thing that is clear—

Mr. G. Mitchell

What about the Minister's constituency office?

Mr. Martin

I did not interrupt the Deputies when they were making their contributions.

An Ceann Comhairle

I again appeal to Deputies not to interrupt the Minister. Deputy Mitchell will have a right of reply and should wait until then.

Mr. Martin

I wish to share my time with the Minister of State, Deputy Moffatt.

The only thing that is clear is that the Opposition will continue to change tack depending on where they think the political opportunity is. The only consistent policy on spending has been from this Government which, from day one, has followed an approach of delivering sustained and major expansions in health funding.

Almost every day we hear statements from the Opposition claiming that things have never been worse. Last week Deputy McManus said "the system has got worse" and "the crisis is deepening rather than lessening". We are still waiting for Deputy Noonan to justify his statement on RTE that "the health services were significantly better . . . four years ago when I left the Department of Health than they are now . . . Now you can check that out objectively with anybody".

Was it better that 90,000 fewer treatments were carried out in 1997 than last year? Was it better that there were 3,500 fewer residential, day and respite care places for people with disabilities? Was it better that there were 400 fewer community nursing unit places for older people? Was it better that there was no capital modernisation programme under way? Was it better that there were fewer doctors and nurses in our hospitals?

Continually, and with determination, the Opposition refuses to acknowledge any improvements whatsoever, no matter how clear. Last year there were over 4,000 more doctors, dentists, nurses and paramedics working in our system than there were in 1997. These are real professionals delivering real quality care to real people. The Opposition needs to learn that progress is made in steps. It is our job to make sure that these steps are made in the right direction and that they will deliver us all to the destination as quickly as possible.

Mr. G. Mitchell

Why does the Minister not do it?

Mr. Martin

The games played by the Opposition would be funny if they were not also distracting people from a meaningful debate on how to build on progress.

A dramatic example of this can be seen in the behaviour of the Opposition last week on the issue of the extension of medical card eligibility. This is a move which is fully in line with the Government's long stated policy—

Mr. G. Mitchell

We voted it through the House.

Mr. Martin

—of ensuring that there is a secure base of supports for older people. In this case, it is a move to ensure that no one over 70 years need fear whether they will face mounting bills if they have to visit their general practitioner frequently. The Government has been clear on this policy and it has delivered.

Mr. U. Burke

That is as far as they will get. There are no hospital beds.

An Ceann Comhairle

I will have to ask Deputy Burke to leave the House if he persists.

Mr. Martin

In response to a media report, the Opposition parties engaged in an indecent rush to try to hop on what they hoped to be a passing bandwagon. They dashed out breathless denunciations of the Government using a wide variety of attacks. These were duly reported and almost as soon as Deputies McManus and Mitchell had reached their peak of righteous indignation, they lapsed into a deafening silence when they heard that the policy was being delivered and delivered on time. The bandwagon ground to a halt as soon as they jumped on board. Once again it was shown that it was not the substance of the issue which drove their policies and commentary but crude political opportunism. That is what drove their reaction to the issues of last week.

Mr. G. Mitchell

We allowed the Minister to introduce a technical amendment.

Mr. Martin

One of the other more novel arguments being used by the Opposition at the moment was also outlined by Deputy McManus last week. She stated, with all of her usual self-control and lack of irony, "comparing the Rainbow Government and this Government is like comparing the 18th century and the 21st century." Apparently, we can be held accountable for our record but they cannot be held accountable for theirs. I agree with the Deputy that her Government's policies have more relevance to historical inquiry than contemporary realities. It is a pity she did not realise this when supporting them only four years ago.

If one wants to look at the difference in policies the most obvious area for comparison is hospital treatments. The extra 90,000 treatments carried out last year show progress, but we are determined to go significantly further.

Mr. U. Burke

When?

Mr. Martin

The starting point is the obvious fact that too many people have to wait for important treatments, and too many people have to wait too long for important treatments. Unlike Deputy Noonan's praise for his own stewardship as a golden era, we have never claimed that everything has been achieved.

Mr. U. Burke

What are the Minister's achievements?

Mr. Martin

As has been widely recognised, waiting lists are not uniquely Irish and they have not emerged recently. In spite of the major increases in hospital activity and the numbers of people receiving treatment, waiting lists are still there and they remain an issue which must be tackled. They are being tackled, and that is the difference between us and our predecessors. Our increased population and, in particular, our increased number of people in groups likely to require hospital treatment, has been a key driver in the continued existence of waiting lists. There has also been a lack of bed capacity and the difficulty in catching up with previous under-investment.

Our policy has been very clear. We have shown a consistent commitment to improving the position in relation to public waiting lists. The figures show that the waiting list at the end of March was 4,101 lower than it was in June 1997. The proper comparison should be with the figure at the end of 1997 because this more accurately reflects the results of the Quinn-Noonan health settlement of January 1997. This figure shows that the lists are down by 5,854.

I have heard Deputies McManus and Mitchell come up with ever more ingenious ways of trying to pretend that the lists are worse today than they were when we took office, but no matter what way they try to twist the figures, they cannot get away from the fact that they are down. I give a particular mention to Deputy McManus's extraordinary innovation of last week where she said that the proper comparison was between the latest figures and those of December 1996. Even for the Labour Party this requires some neck. Apparently we are to be held accountable for the major increases which came about in the waiting lists at the end of the Quinn-Noonan health partnership which, as we know, resulted in a 20% cutback in waiting list funding in the 1997 package.

Perhaps this finally provides the answer to the question of why Fine Gael and Labour voted through the cutback in waiting list funding which directly led to the lists becoming longer by thousands. It was our fault, we forced them to do it and we forced them to increase waiting lists by an unprecedented 6,600, or 27%, during their period in office.

Mr. G. Mitchell

Sounds like a resignation statement.

Mr. Martin

Ours is a health system which has evolved at varying paces over the last two centuries. It is now three decades since the last significant structural reform of the system and there is no doubt that the level and quality of care which our people have a right to expect requires a significant programme of reform and development. The health system is not a simple structure with basic levers to be pulled whenever a given output is required. Delivering a responsive, equitable and high quality hospital system for example, does not just require a reform of hospital care, a range of structural issues have to be addressed, including primary and continuing care systems and basic manpower deployment, contracts and planning.

What the public want are not promises but action and they realise that anyone who says "we have all the answers, here they are" cannot be trusted. Sustainable action which will deliver on the ground requires not just one move, but dozens of interrelating initiatives. If one is going to build a new system, one needs foundations and this requires a progressive programme of research and negotiation which was completely absent until the change of Government in 1997.

The Opposition's attack on our process for delivering a new health strategy has been to say that we should have done it before now. We could have produced a strategy by now. We could have cobbled something together a few years ago and published it with a great fanfare but if we had, we would have repeated the basic flaws of the 1994 document published under Deputy Howlin's stewardship. It had strengths, but very few people were consulted during preparation and it set out no agenda for investment and development.

Mr. Howlin

That is not true.

Mr. Martin

It talked about equity but said nothing about how to achieve it. When Deputy Noonan's golden era followed, there was no new approach and no attempt to begin the work to develop one.

A programme of fundamental research and negotiation has been ongoing and is already making a difference. The starting point for the development of the new strategy has been a series of crucial reports which examine in great detail fundamental issues relating to the future of our health system. The medical manpower report and report on junior hospital doctor working practices have shown the way forward to a radical improvement in the level and quality of hospital care. A consultant led, round-the-clock service in our hospitals will make a huge difference and would represent the most significant development in hospital care in many decades.

Nurses have to be central to developing our health services. There are more working in our system than before, but we have to help them to make the full contribution at all levels which they are ready and able to do. The Commission on Nursing has shown us what we must do to attract, train, utilise and retain nurses of the highest calibre.

A detailed study is showing us how to work to significantly improve the effectiveness and accessibility of the full range of primary care services. A value for money audit is, for the first time, detailing exactly how resources are deployed and utilised within the system and, vitally, a detailed strategic assessment of the capacity of our hospitals is being finalised. I do not know how a programme of development and reform could be developed in the absence of this work – these are the fundamental building blocks of reform which we have developed and initiated – but apparently the Opposition thinks it can be.

Perhaps the biggest point where we disagree is that we think it is worthwhile to ask health professionals and the public what they think should be done.

Mr. G. Mitchell

Now that there is an election coming.

Mr. Martin

We believe they have a right to be consulted. Government must decide and take the lead, and we are doing this, but we will apologise to no one for running the most comprehensive and detailed consultation process in the history of health policy development in this country.

Over 2,000 submissions have been received from the public. In addition, a national consultative forum has been established representing a large cross section of stakeholders. Its sub-groups have worked extensively on detailed areas and a further meeting of the full forum will take place next week. At the same time, work is being completed on how to bring together diverse needs into a coherent short, medium and long-term strategy. We have also brought together a group of independent international experts to evaluate the strategy as it develops. The lessons of the Opposition's various health policy documents demonstrate clearly that our approach is the more credible and effective. While Fine Gael continues to make it up as it goes along, Labour simply cannot seem to decide whether its is a policy document setting out its intentions or a discussion document requiring major work before it can be finalised. When it wants to claim it has the answers it says "we have a plan, we will do this". When it wants to avoid answering difficult questions it says "this is only a discussion document, come back to us when it is a definite policy".

Mr. G. Mitchell

That is more than the Government has done after four years.

Mr. Martin

Deputy McManus recently indicated Labour's intention to produce a second document and I am sure everyone in the House looks forward to it providing answers to questions which have been left hanging in the air for the past year. The strategy we will launch will build on the visible progress to date and will show the way forward. It will also set out the manner in which we intend to develop services but I caution people against relying on spurious spending comparisons, particularly where the figures are three years old and redundant due to subsequent increases.

Mr. G. Mitchell

This is the worst ever speech by any Minister for Health. The sooner the Minister is redundant, the better.

Mr. Martin

According to 1998 data, Ireland ranked 16th among OECD countries. Per capita spending increased by 18% between 1990 and 1998 and by 55% between 1999 and 2001, a dramatic increase compared to the previous decade.

Mr. G. Mitchell

The Dáil increased spending but no matter how much funding the Minister gets, he still cannot get it right.

An Leas-Cheann Comhairle

The Minister, without interruption.

Mr. Martin

The statistics which emerged this morning in the media are out of date and do not bear any relation to reality in terms of Ireland's dramatic economic growth and the dramatic increase in health spending.

We must realise that reform means that many people from the top downwards will have to change the way they do business. As I have said on many occasions, the status quo is not an option. We cannot do everything at once. We simply do not have the capacity or the resources, fiscal or personnel, to move on every single issue at the same time and at the same speed. This will be the case no matter what resourcing benchmark one adopts. We must all work strategically and systematically to identify our priorities and address them in a more focused way than hereto fore. The Opposition's approach of pretending one can have it all and have it now, lacks even the most basic credibility.

Reform is a challenge for everyone at every level of the system. We must be in a position to say to the wider society that we will use the resources we are given to the greatest possible effect to tackle the issues of most concern to the public.

Mr. G. Mitchell

Tell that to the lady who had to go to court to ensure she will receive cancer treatment.

Mr. Martin

I am very encouraged by the people's responses during the consultation process for the strategy, particularly in terms of the development of quality, care-driven accountability systems. The Government is not interested in wasting years chasing the end of a health care rainbow and losing the opportunity to get moving on a more challenging systematic development and reform of the system.

The only proposal – which is not a new one – in the motion before the House relates to the establishment of a health ombudsman. The establishment of a health ombudsman may be an important initiative in assisting the development of a patient-centred system but such a person could achieve little or nothing in the absence of the necessary resources and reforms we have outlined. The establishment of an ombudsman will be considered in the context of the forthcoming health strategy.

Deputy Noonan said he wants an election with health as the issue. I have every confidence that next year's election will give the public a clear choice on the issue of health. The choice will be between a Government which has shown real progress across a wide range of issues, one which has set out a detailed and comprehensive plan for the future—

Mr. G. Mitchell

Which Government is that?

Mr. Martin

—and an Opposition, driven by opportunism, running away from its own record and trying to sell simple solutions. I have no doubt about the approach the people will support.

Mr. G. Mitchell

Is the Minister familiar with Tipperary-South?

Mr. Ring

God help the sick.

Minister of State at the Department of Health and Children (Dr. Moffatt)

It gives me pleasure to set out the real improvements effected by the Government in the area of health since 1997. At that time, the people passed their verdict on the Fine Gael-Labour coalition's record on health; they put it out of office.

Under funding was the Rainbow coalition's hallmark in the area of health and neglect was the hallmark of their services for older people. This was the Government which provided the most meagre pension increases, averaging just more than £2 per annum. This was also the Government which failed older people's health needs.

When the Government took office in 1997, there was an urgent need for investment in services for older people, services which Fine Gael and Labour totally and incredibly neglected. We created an additional 800 posts in services for the elderly, 400 additional long-term care places and 1,000 day places. Subvention rates have increased by 25%. Spending is up from £10 million in 1997 to £57 million in 2001.

Had the Opposition parties invested and spent in this area and started to train professionals when they had the power and money to do so, they could have alleviated much needless anguish. Instead, they abrogated their responsibilities and it was left to this Fianna Fáil-led Government to make reforms and improvements.

Mr. Ring

The Minister of State, as a doctor, cannot seriously believe what he is saying.

Dr. Moffatt

Deputy Ring need only look at County Mayo to see the increased funding provided and improvements made since the Government took office. Last year's winter initiative at a cost of £25 million alleviated some of the urgent pressure on acute beds by placing older people in more appropriate facilities such as nursing homes. We are determined to automatically provide medical cards to people over 70 years of age and we reached agreement last week with the IMO on this issue.

Spending on palliative care has increased from £3 million to £15 million in 2001. Palliative care services will be extended this year in all health board areas and the report of the national advisory committee on palliative care will be published.

The Government is enhancing existing community care services and developing new ones and is placing special emphasis on rehabilitation and stroke care services. Opposition Deputies criticised the Government for its lack of a prevention programme. We have put in place programmes for the elderly in regard to osteoporosis, glaucoma, accidents at home, dietary deficiencies, diabetes, blood pressure and stroke prevention. This is the kind of action required in the area of health. The Government has substituted the lack of will and inclination which characterised the previous Government with commitment and reform.

Where was the leader of the Fine Gael Party in the mid-1990s when older people received meagre pensions and when health services for the elderly were completely inadequate? As Minister for Health, he was based in Hawkin's House but he did nothing.

Mr. Ring

At least he was not at the tribunals.

Dr. Moffatt

The Deputy should look at his own party's record before he says too much about tribunals.

Where was the leader of the Labour Party? As Minister for Finance, he was based in Merrion Street but he did very little. He decreased health spending.

Mr. Howlin

That is not true.

Dr. Moffatt

The Government had money but did not spend it. It did not listen to the opinions expressed by health professionals and failed to meet the needs of older people. I welcome the Opposition's Pauline conversion; it is not too late to its mistakes and to come on board.

Mr. Ring

Rise and follow Charlie.

Dr. Moffatt

Not alone is the Government providing funding, it is putting in place a health strategy which will serve us well over the coming decade.

Ms McManus

I wish to share time with Deputy Howlin.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Ms McManus

I do not intend to come between two Mayo men. I know how to look after myself but not that well. I will comment on the Minister's speech which was the most defensive, petty, cowardly, dishonest piece of propaganda I have witnessed from any Cabinet Minister since becoming a Member of this House. Considering the record of Fianna Fáil Ministers in particular, that is saying something. The Minister for Health and Children is deep in his bunker and does not intend to come out of it and, unlike him, I do not intend to waste my time on inaccuracies and petty mindedness.

I welcome the opportunity to speak to this motion. The Labour Party fully supports the call by Fine Gael for the introduction of comprehensive measures to protect the rights of patients to due, adequate and timely health services and the call for the appointment of a health ombudsman to oversee the rights of these patients. This unity of purpose between the main Opposition parties stands out in sharp contrast to the definitions and confusion evident on a daily basis within the Government on a number of vital political issues. There is no more vital political issue today than health and health care reform. There is no more indictment of Government failure than the long queues of sick people waiting for treatment in care, the number of over-stressed and over-worked staff who try to provide excellent medical care in less than excellent conditions and the growing injustice in our health service that militates against those who are sick and happen to have low incomes. This is an injustice that would be considered barbaric in any other European country, yet it is not only tolerated but is being actively exacerbated by the Government.

Despite the good work done by the thousands of doctors, nurses and highly trained professionals, the average life expectancy of an Irish baby boy is 73 years, lower than the EU average and much lower than countries such as Italy, Sweden or Britain. An Irish baby girl has a life expectancy of 78.6 years compared to an EU average of 80 years. Our record on infant mortality is no better. The death rate among babies under one year is the fourth highest in the EU.

We are one of the richest countries in Europe yet, paradoxically, we are one of its sickest. Instead of investing properly in our health service, the current Government policy ensures that Ireland lags behind other EU countries in terms of money, medical staff and facilities. Even today after four years in office at a time of unprecedented wealth, the Government refuses to invest sufficient money in our health service to meet the needs of our sick and elderly.

When the country was on its knees economically, we spent more on health proportionately than we do today.

Mr. Howlin

That is the truth.

Ms McManus

Today, in effect, the Government spends less of the country's wealth on the health service than was spent, for example, in 1980. That is an utter disgrace. At a time when we have fewer consultants and general practitioners than the EU average and only over half the EU average number of hospital beds, less than two-thirds of the EU average per capita is spent on health services. The effects of that are evident in the daily suffering and pain of thousands of people. Almost 27,000 people are still waiting for treatment, an estimated 150,000 people are waiting for an appointment to see a specialist, 54% of adults on the waiting list are waiting longer than 12 months and 74% of children are waiting more than six months. There are also the individual scandals. Janette Byrne had to go to court to get a hospital bed and cancer treatment; a constituent of mine, a young man from Wicklow who was diagnosed as having cancer eight weeks ago, is still waiting for access to chemotherapy and radiotherapy; and a child in Waterford was in the news recently because he is waiting five years to see a specialist.

The pressure on resources is now so great that, for public patients, routine treatments must often wait until they become an emergency, but we all know that private patients can fast track access to a hospital bed. Meanwhile A&E departments are chronically overloaded by the demand. Seriously ill patients, many of them elderly, must often wait on trolleys in corridors for admission and sometimes they wait for days.

The crisis is not confined to the hospital service. Ireland is seriously under-provided with general practitioners, the front line of health care. The World Health Organisation defines the primary service of GPs as "the central function and main focus" of a country's health system, yet primary care is still under-funded and under-developed here and it is still not viewed as central to our system of health care.

Money alone will not solve the health crisis but it is needed as part of the solution. The need to tackle the gross inequality within our health service is self-evident, yet the Government has been unwilling or unable to state how it would deal with the greatest political challenge in health care reform, the provision of a guarantee to all our citizens of medical care when they need it, regardless of their income or geographic location within a reasonable time and distance.

That failure by the Government has been perceived as caution, timidity or lack of political direction or know-how on the part of a Taoiseach and Cabinet who are concentrated on priorities other than the needs of our sick and elderly people. While Bertie concentrates on the Bertie Bowl, his Minister for Health and Children gets a clip around the ear from the Minister for Finance for having the temerity to seek additional funding for the health service. The media spin has been created, primarily by the Minister, Deputy Martin, that he is the people's champion when it comes to health.

The Government announcement in the budget that it intended to give medical cards to all people over 70 years of age was made without any preparation or prior arrangement with the medical profession. Inequity is inherent in a policy of giving medical cards regardless of income to the over 70s while maintaining income limits at an atrociously low level for anyone younger than 70. As one Cork GP put it, "the merchant princes are getting medical cards while the gardeners working for the merchant princes are not". We supported the provision because we wanted it to be extended to any group in our society at present—

Dr. Moffatt

Does Deputy Ring agree with that?

Ms McManus

—but we challenged and continue to challenge the Minister and the Government for refusing to deal with the low levels of medical card eligibility. Anyone who voiced concern at the time this change was announced was attacked, as I was, by the Minister of Health and Children and his dutiful Fianna Fáil backbenchers, as taking the doctors' side on the issue. That was the spin – we were all in league with the doctors.

The Government refused to address the issue of inequity when it was raised and the doctors inevitably went for the jugular. The Government was easy meat, as far as the IMO was concerned, when it came to striking a deal. The deal has been struck and the sheer hypocrisy of this Minister for Health and Children has been laid bare. Not only has he failed to tackle inequality within our health system, he has connived with the powerful medical lobby to strike a grubby deal which will have financial and social implications in any future negotiations with general practitioners.

(Interruptions.)

Ms McManus

Let me speak, Minister. Shame on the Minister. He capitulated to the doctors to save his face and to save the Government from further embarrassment. Far from standing firm, the Minister for Health and Children was desperate to make a deal, any deal, to deliver on a budget promise. The result is that doctors are to be incentivised to treat the over 70s who are coming into the GMS for the first time now and who, by definition, are better off, some of them substantially better off, than those who already have a medical card.

The Minister has created a two tier medical card system in a health system already riddled with inequalities and based on a medical apartheid that is an affront to all decent people. He has introduced apartheid into the GMS. Doctors will be rewarded by a figure, which has been publicised as £345, for caring for these new "gold card" over 70s patients while they will be inevitably penalised conversely for caring for their poor patients over 70 who currently have a medical card. The terrible truth is that these are, generally speaking, the patients who need more medical care because of their social and economic circumstances.

This is a despicable and shameful deal. No weasel words from nice Minister Martin can disguise the ugly reality – this deal is a Government surrender to vested medical interests. The doctors saw their opportunity and took it. The deal has been done because this is a desperate Government in all senses of the word. After more than four wasted years, Fianna Fáil is about to face an electorate that has not ever been so well versed in the inadequacies of our health service. The public is well versed because it consists of those who are forced to wait for life-saving treatment and frustrated health professionals unable to do their jobs properly. They know other countries provide health care on the basis of need, not on the disgracefully unjust basis whereby, when it comes to obtaining health care, money talks.

With the introduction of the new two-tier medical card scheme, money is talking even louder. Deputy Martin bears responsibility. He will leave a legacy as the Minister who deepened the divide in the Irish health care system at a time when he had unprecedented resources that could have transformed it. He could have chosen to pay doctors extra money while maintaining equity in the GMS scheme. However, he chose to deepen the divide, and in doing so, set a negative precedent for any further negotiations with doctors.

The Government has not provided for a health service that is fair or accessible to all, irrespective of income. It did this knowingly. It chose to have priorities other than the provision of essential high-quality services delivering excellence to all. It is the poor and the sick, however, who have paid the price of Fianna Fáil and PD politics.

The Labour Party is committed to a new start in health care and to delivering a fair and good service. It is committed to ensuring high morale among those who deliver health care. It is not being prescriptive. The Minister for Health and Children insists on twisting our words, but I realise he is desperate and has to say something. The Labour Party has always said that its intention is to provide a universal health care service of excellent quality. Such changes will be made on the basis of meeting people's needs. We have described how we will do that. If someone thinks of a better method, we are more interested than anybody else to hear it. Nobody has thought of one. The Minister has remained silent, and tonight he has disguised his silence with bluster. He refused to even begin to address the problem of inequality in the health service or state how he might do so. That is a shameful and despicable position for a Minister for Health and Children to be in, given that he has unprecedented resources.

After being entrusted with the task of improving the health service by the Irish people more than four years ago, the Government has failed, and failed disastrously. It is time for a new start in health care, but it is clear that we need a new Government to deliver it.

Mr. Howlin

I hope it is not indicative of my contribution that the Minister for Health and Children leaves as I begin. I do not take it as a personal insult as I have some understanding of his role, as does the Leas-Ceann Comhairle. I have had the great honour of holding that office for 22 months.

I am interested in hearing the contribution of the Minister to this debate. The clear, overwhelming view of the people, expressed in South Tipperary, Wexford, Mayo, Dún Laoghaire and wherever one listens, is one of total dismay at the quality of the health service. The constant repetition of the mantra that we are spending more money or that there are so many millions of pounds available is meaningless to people who are in desperate need. The people are not fools. They plainly see that the health service they require and demand is not available to them and theirs. The Government must be held accountable. Petty bickering is not the way to resolve complex issues.

The stewardship of the current Administration has proceeded for four years, longer than the terms of the two previous governments. It was an unprecedented period of wealth that could have brought about root-and-branch change. In this light, I found it instructive and somewhat amusing that the cornerstone issue enunciated by Deputy Martin was the waiting list initiative. I pioneered and introduced that when I became Minister for Health to tackle problems of waiting times in 1993.

When I introduced that innovative scheme, for which I travelled the country negotiating with health boards, it was not designed to be ongoing. It was meant to address the problems of inadequate beds, equipment, operating theatres and all the other deficiencies that we identified. We put in that investment so the medical profession would engage as they had not ever done before in tackling the problem of waiting lists. It did so in the subsequent 18 months, but we have not seen the transformation afterwards.

It is interesting to hear the Minister for Health and Children talk in terms of the health strategy that I introduced. He and his immediate predecessor, Deputy Cowen, did not see any deficiencies in it. I have been at many public fora where he or Deputy Cowen quoted the health strategy "Shaping a Healthier Future" as the blueprint for health service delivery. They are putting in place this new strategy belatedly. The Minister should be generous enough to acknowledge the work that was done before him.

I smiled wryly when I read a comment by former Minister Máire Geoghegan-Quinn in The Irish Times that I had wasted my time on a health strategy. The fact that she was in the Cabinet that voted it through was unimportant. The strategic involvement of a plan in health service delivery is recognised even by the most recalcitrant and backward-looking Members of the Government.

Will the Government provide an answer to two problems in the South-Eastern Health Board area pertaining to oncology and rheumatology services? There is no consultant oncologist in the South East. People are being sent to Cork and Dublin to add to already overburdened waiting lists. It is not good enough that other Deputies and I should have to deal directly with the families of people waiting for cancer treatment who cannot get it. Their case is unanswerable and it shames me as a Member of this House.

Where rheumatology services are concerned, I have a letter from Dr. Darragh Foley-Nolan, consultant rheumatologist, to Mr. Richard Dooley, manager of Waterford regional hospital. It states that the waiting time for a first consultation is two years and nine months. It is absurd for the Minister of State to speak of services for the elderly when people in the South East, as a matter of routine, wait nearly three years for a first consultation to deal with rheumatism and its attendant pain and suffering. If I had time, I would read the letter because it speaks of the possibility of missing treatable malignancies. I want the Administration to answer these questions, not bluster a minute longer.

Debate adjourned.