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Dáil Éireann debate -
Thursday, 28 Mar 2002

Vol. 551 No. 4

Medical Practitioners (Amendment) Bill, 2002: Second Stage.

I move: "That the Bill be now read a Second Time."

I commend to the House the Medical Practitioners (Amendment) Bill, 2002, which addresses important issues relating to the registration of medical practitioners. It represents a first step in the ongoing programme of updating and revising the Medical Practitioners Act, 1978. The public health service is dependent, above all else, on the staff who provide a high quality service week in week out. The 1978 Act regulated the practice of medicine in Ireland through the registration of medical practitioners, to ensure that the service had access to doctors of the highest quality and that the interests of patients were paramount. The Medical Council, which was established under the Act, is the statutory authority that oversees the registration and regulation of doctors and evaluates the suitability of medical education and training provided by bodies in the State. The council's constitution and additional functions are outlined in detail in the Act.

Almost 25 years have passed since the Medical Practitioners Act, 1978, was enacted. The provision of health services in Ireland and throughout the world has moved on considerably in the intervening period. The need for doctors to keep abreast of new developments, the rights of patients to be informed about their treatment and public expectations have greatly increased since 1978. It has been recognised for some time that the Act no longer meets the needs of a modern health service and, in this context, the need for a comprehensive review, aimed at developing legislation to meet current and future requirements, was acknowledged. The Department of Health and Children has undertaken a thorough review of the Act in the past year, involving widespread consultation with the key stakeholders in the health service: patients, doctors, the Medical Council and health service agencies. The message from those consulted is that the 1978 Act needs to be updated. My Department has used the information in the submissions to prepare a structure for the development of the draft heads of a new medical practitioners Bill, to be published in the autumn.

In this regard, I wish to inform the House that new legislation to provide for the regulation of nursing and midwifery is under preparation and the draft heads of a Bill to govern the regulation of the professions allied to medicine is at an advanced stage. When passed, these Bills and the Bill to update the Medical Practitioners Act, 1978, will provide a legislative framework for the regulation of the health professionals and will ensure the highest level of competence among those who provide our health services. The national health strategy, Quality and Fairness – a Health System for You, launched by the Minister for Health and Children in November 2001, contained a commitment to undertake an independent audit of functions and structures in the health system.

The results of the audit of the Medical Council, Comhairle na nOspidéal and the Postgraduate Medical and Dental Board will have to be taken into account in drafting the heads of the new Bill. The Minister launched the national task force on medical staffing last year to examine the implementation of the medical manpower forum report and the Hanley report on the working hours of non-consultant hospital doctors and provide an overview of medical education and training. The work of the task force will have significant implications across the public health service. Any recommended changes will affect hospital doctors, general practitioners, nurses, hospital and health board managers, the training bodies, the Medical Council and, in the final analysis, the patient. It is for the purpose of delivering better, safer and higher quality health services for the patient that the Government has adopted this integrated approach.

The Medical Council has also brought forward a number of proposals for change. The council wants to improve its efficiency and delivery of services. It has also undertaken an exercise to set out a scheme of competence assurance for doctors. The proposed scheme will encompass continuous medical education, continuous professional development and clinical audit and peer review. The purpose of competence assurance is to ensure that doctors maintain the highest levels of competence and awareness of developments in their field of expertise.

The new Act will also address issues surrounding the area of fitness to practise procedures. The streamlining of procedures and the appropriateness of the committee structures will be examined. The provision of relevant information to the Minister, employers and the public will be provided for.

There are a number of priority issues that cannot wait until a new Act is passed and which must be addressed urgently to avoid any potential disruption to service delivery. It is for this reason that I present this Medical Practitioners (Amendment) Bill, 2002, to the House today.

The most important of the amendments being proposed today is the amendment of section 27(2) of the current Act. We have, at present. approximately 3,600 non-consultant hospital doctors employed in the health service. Of this number approximately 1,600 are temporary registered doctors who come from outside the European Union. These doctors provide essential services in our hospitals and in some rural areas these doctors constitute more than 60% of the non-consultant hospital doctors cohort. They may have lived and worked here for extended periods and may, in some cases, have taken out Irish citizenship. I wish to publicly acknowledge the quality and quantity of their contribution to the Irish public health service. We owe these doctors our gratitude and should value their expertise and experience.

As many of these doctors joined the Irish health service before the implementation of the temporary registration assessment scheme they have not sat the temporary registration assessment scheme exam. This has affected their ability to move from the temporary register to the permanent register. Under the 1978 Act, only qualifications and training can be taken into account when considering applications for the permanent register. The current legislation, whilst recognising the training element, does not permit the Medical Council to give due regard to the relevant experience gained while working in the public health service by doctors applying for permanent registration despite the fact that some temporary registered doctors can have spent up to seven years working in the Irish public health service. At the same time, graduates of Irish medical schools who have completed just one year of postgraduate internship can apply for permanent registration.

It should be noted that employers and regulatory bodies in other jurisdictions are only too happy to recruit and permanently register these doctors based on the experience they have gained while employed in the Irish health service. At a time when the Irish public hospital system is undertaking extensive recruitment initiatives to ensure that all medical posts are filled we must ensure that every effort is made to retain the complement of doctors currently within our hospital service. Many of these temporary registered doctors are reaching the end of the period of temporary registration and may be lost to the Irish health service if we do not take action.

In addition, changes in European Union law and a recent ruling of the European Court of Justice require us to take account of relevant experience gained within the EU when assessing applications from EU citizens for permanent registration.

The resultant benefits will mean that fewer recruitment and retention difficulties will be experienced by hospitals in relation to non-consultant hospital doctors. The temporary registration period for some doctors, especially those from non-EU countries, which lasts a maximum of seven years, will begin to expire from next June onwards thus requiring the doctors concerned to leave the Irish public health service system and potentially causing some hospitals to experience difficulties in securing their required number of junior doctors. This Medical Practitioners (Amendment) Bill, 2002, will ensure that doctors who may otherwise have had to leave the country will be able to remain here and to apply for permanent registration. This will result in continuity of staffing and the maintenance of service delivery in the public health service, while at the same time tackling certain inequities with regard to access to permanent registration on the register of medical practitioners.

We must also look to address anomalies within the current Act which prevent EU citizens who have graduated from European medical schools from completing their internships in Ireland. In 1978 it was not envisaged that there would be any interest from amongst EU citizens for internships in Ireland. The 1978 Act, therefore, restricted internship, or as it was called at the time "provisional registration", to graduates of Irish medical schools.

Nowadays more and more Irish students have decided to study medicine abroad within the EU. Many of these students would wish to return to Ireland for the purpose of completing their internship in an Irish hospital. In order to facilitate these and other EU citizens we propose to take the necessary steps to amend the current legislation.

The Minister for Health and Children has also been requested to address how the current Act might be amended to provide for both internship and temporary training to be carried out in a variety of health care settings. At present such training is restricted to training in the acute hospital setting. This requirement has the impact of restricting both the location and nature of training which can be undertaken and reduces the ability of the doctor in training to gain the widest possible experience. It is now accepted that there are a number of health care settings, such as community-based services and general practice, in which a doctor in training could and should gain very valuable experience.

It has also been brought to the Minister's attention that there is a requirement, in certain circumstances, for an appropriate form of temporary registration to be available where a doctor is in this country on a short-term basis, for example to demonstrate his or her skills to medical colleagues or to provide professional support at a sporting event.

The Minister, Deputy Martin, is concerned to ensure that appropriate safeguards are in place in certain areas of health care, such as cosmetic surgery for example, where doctors may be entering the jurisdiction for short periods in order to carry out such procedures.

Which did the Minister say, cosmetic surgery or cosmetic policy?

Cosmetic surgery. The Deputy does not need it.

This is a matter of some concern to the Minister and it is our intention to deal with it in some detail in the comprehensive Bill to be brought forward later this year. It is accepted, however, that some urgent steps must be taken at this time and these are addressed in the amending Bill.

The main proposal in the Medical Practitioners (Amendment) Bill, 2002, is to allow validated professional experience to be taken into account in the assessment of applications for permanent registration on the Register of Medical Practitioners. Under current legislation. only training and qualifications can be acknowledged when considering such applications. This Bill will enable the Medical Council to make rules regarding applications for permanent registration in which relevant, validated experience will be taken into account as well as, or instead of, prescribed courses of training.

The amending Bill will now allow doctors in training under intern registration and temporary registration to work in a variety of health care settings, to be specified by the Medical Council, whereas the current legislation confines these doctors to the acute hospital sector. The council will be enabled to make rules to regulate they type of health care setting where such training can be carried out.

The Bill provides for any EU citizen who has obtained a primary medical degree within the EU to be granted internship registration in Ireland. At present only graduates of Irish Universities can undertake their internship registration in Ireland.

The Bill provides for the indefinite extension of temporary registration for a doctor who has made application for permanent registration. The period of temporary registration, in this instance, is extended until such time as a final decision is made with regard to the doctor's application for permanent registration. The Bill also provides for the Medical Council to make rules regarding temporary registration for doctors entering the jurisdiction to work for short periods. The council will also be enabled to make rules regarding those who employ or contract the services of such doctors.

The staffing requirements of hospitals and the deployment of staff within hospitals is primarily a matter for local management having regard to the services which hospitals are expected to provide. Particular staffing difficulties have been faced by the health services in recent years across a wide range of areas, particularly in the medical, paramedical and nursing areas.

The Department of Health and Children, in conjunction with the Health Service Employers Agency, assists at national level with the development of a policy framework which will enable employers to identify vacancies, to locate, recruit and train suitable candidates for the vacant posts, and to retain the staff in whom they have invested significant time and resources.

In the health strategy, under the Action Plan for People Management, the Government set out its plan for the health service to become an employer of choice. In this regard the strategy commits the Government to investment in training and education for health sector staff; implementation of best practices in employment policies and procedures; building and enhancing tile management function; improving the quality of working life for our health service staff; developing performance management; promoting improved industrial relations in the health sector; and developing the partnership approach further. Work on the action plan is already under way and is being undertaken in the context of partnership and consultation. This amendment to the Medical Practitioners Act represents yet another measure to improve the working arrangements for non-consultant hospital doctors.

An intensive series of negotiations held in 2000 under the auspices of the Labour Relations Commission concluded with agreement on all of the major concerns of non-consultant hospital doctors. The proposals for settlement included a very significant improvement in the overtime rates paid to non-consultant hospital doctors. In addition a senior manager has been appointed in each major hospital with specific responsibility to manage non-consultant hospital doctor hours. A concerted effort has been made to improve working conditions and to reduce non-consultant hospital doctor working hours with particular attention to long periods of continuous duty.

Significant increases in overtime rates have been implemented. A substantial training programme has been put in place. New procedures have been introduced to deal with NCHD grievances at local level. Relocation expenses are also being paid to NCHDs who have to move residence as part of formal rotation schemes. A programme of refurbishment of medical residences is well advanced. These enhanced terms and conditions are summarised in the Non-Consultant Hospital Doctors Agreement, 2000, and will cost in excess of €100 million in the current year.

In relation to non-consultant hospital doctors staffing, health service employers and the Health Service Employers Agency are continuing to monitor the filling of NCHD posts. Current occupancy levels are in excess of 98% and initiatives are ongoing to ensure that vacancies are kept to a minimum. Hospitals are exploring different options in an effort to ensure that all medical posts are filled. With the full co-operation of all concerned and a commitment to making the best use of available resources, occupancy levels will be optimised.

On a broader front, the issues relating to the medical staffing of hospitals were addressed by the medical manpower forum. With particular regard to non-consultant hospital doctors, the forum sought to redress the imbalance between career posts and training posts, the need to improve postgraduate medical training to keep more Irish medical graduates in the country and the need to look at the position of women in medicine in Ireland with a view to reducing the number who leave medicine.

Some of the issues which affect NCHDs' working conditions cannot be resolved immediately. Among these are the twin issues of working hours and the restructuring of the medical career hierarchy. The working hours of NCHDs have been the subject of negotiations at European level in the context of the proposed extension of the 1993 EU Directive on Working Time to doctors in training. In this context and to provide for a smooth transition and the least possible impact on service delivery, I am glad to note that EU agreement was reached on a formula that provided for a nine year transition period to apply the directive to junior doctors. The directive requires each member state to reduce the working hours of doctors in training to more acceptable, and safer, levels within a specified, legally binding timeframe. Subsequently a major study of NCHD working hours was conducted with the Irish Medical Organisation at eight hospitals by PA Management Consultants, called the Hanley report.

Furthermore, the national task force on medical staffing was established by the Minister for Health and Children, Deputy Martin, to prepare and cost an implementation plan for a new approach to hospital services, based on appropriately trained doctors providing patients with the highest quality service. The task force will prepare detailed implementation programmes based on the two key reports already mentioned and published last year: the Hanley report on the phased reduction of the working hours of non-consultant hospital doctors and the report of the medical manpower forum. The implementation programme will be addressed in the context of the new health strategy, Quality and Fairness – A Health System for You, which was published last November. The key work of the task force will be to oversee the implementation of detailed strategies for reducing the working hours of NCHDs, so that a 48 hour working week is achieved by 2009; to address the associated medical staffing needs of the Irish hospital system; to analyse the practicalities and estimate the costs that would arise if a consultant-provided – rather than consultant-led – system was in place; and to consider the medical education and training requirements arising from any changes to the current model of delivering services.

The inaugural meeting of the task force took place on 21 February and the steering group met again on 14 March. The Minister for Health and Children has asked the task force to devise and cost a suitable model of delivery within nine months. I am confident that, with the full co-operation of the profession and with other measures such as the Medical Practitioners (Amendment) Bill, 2002, we can achieve these objectives.

Every analysis to date comes back to the same key point – we are over dependent on junior doctors who, while still in training, are required to provide 24-hour, seven day medical care, formally under the supervision of individual consultants. A number of factors affect consultants' ability to be present on site at weekends, evenings and during the night. Patients in turn may have limited access to appropriate levels of senior clinical decision making, with implications for safety of diagnosis and treatment, on the one hand, and efficiency and cost-effectiveness, on the other. As an independent entity, the task force is in a good position to develop a suitable cost-effective model which best meets patient safety and quality concerns, as well as contributing centrally to the two fundamental principles reflected in the title of the new health strategy, Quality and Fairness – A Health System for You. It also addresses some of the key national goals of the strategy, which relate to responsive and appropriate care and high performance.

Public health systems, demographics and lifestyles, technology and expectations are exhibiting an international pattern of unprecedented change and challenge, which urgently demand new methods. In preparing the new strategy, it was necessary to look critically and constructively at service issues such as the length of the working day and how we provide cover over this longer period; the redrawing of professional boundaries; organising care and service delivery around the patient rather than vice versa; and a much more dynamic and committed approach to managing quality. The health service will continue to make the case for additional investment, provided we can work collaboratively in making the necessary reforms to yield improved results.

The message from the medical profession expressing its willingness to be more flexible, while maintaining admirably high standards under pressure, is very much welcomed by the Government. Where there is a clear willingness to jointly reassess in a fundamental way some of the assumptions attached to the inadequate status quo, the Government's response can also be flexible. By adopting an open approach together to face change and modernisation, implementation of the strategy will ensure the best use of resources, the sharing of best practice across all disciplines and the provision of significant additional funding.

Industrial relations within the health sector has been a matter of concern and much comment. Both health service unions and management can draw many valuable lessons from the comprehensive audit carried out by the Labour Relations Commission into the industrial relations situation within the Irish health service. It provides a unique opportunity for a new departure in relation to how we conduct our business and highlights the need for better communication, more transparency and partnership among all stakeholders. The renewed emphasis on a people-centered approach must be as applicable to staff working within the health services as it is to the ever-growing number of people accessing these services, towards the delivery of high quality health care for all. This approach will be strongly reflected in the forthcoming action plan for people management to which I referred earlier.

In addition to the steps already outlined, the Department of Health and Children has been in contact with the Departments of Enterprise, Trade and Employment, Justice, Equality and Law Reform and Foreign Affairs. The purpose of these contacts is to explore ways in which the processing of visas and work permits can be streamlined to assist health service employers with their recruiting drives. In this regard, the possibility of extending the working visa-work authorisation scheme, which already applies to nurses, to other health service staff is being examined by the departmental group. The scheme would provide a more flexible mechanism for regulating the entry of non-EU and non-EEA citizens into Ireland for the purpose of working in the health service. It is hoped to progress this initiative in the very short-term.

Both health service providers and members of the public would like to have the best quality and range of services available. This is a worthy aspiration, since service demands are triggered largely by issues such as demographic change – an increasing population that is living for longer – and the continuous and rapid developments in health technology. It is part of the role of the Minister for Health and Children to measure the real need for additional services, taking account of public expectations as well as the expert view. A second and subsequent demand of that role is to bridge the gap between current provision and what is needed, as speedily and efficiently as possible.

There has been a dramatic and well-documented increase in the provision of funding to the health service over the life of this Government. Gross non-capital expenditure has risen by 129% from 1997 to 2002. This Government is committed to maintaining sufficient support to empower professionals to continually improve the services in our hospitals and in the community in general. On the capital side the high level of investment by the Government will continue over the period of the national development plan, demonstrating a considerable increase in capital investment relative, historically, to any previous period. Again, examining the level of capital funding provided over the life of this Government, 2002 boasts a capital funding allocation to the health sector that equals a 260% increase on the 1997 figure.

The commitment this Government has given to provide the funding required to implement the health strategy has been crucial. There is little point in producing health strategy documents which map out the path to quality health services if we are not committed to following through with the investment, reform and modernisation to make this a reality over a reasonable period of time. I believe that the public demand and deserve the best health services that our economy can now afford and sustain, and initiatives such as this legislative amendment to advance recruitment and retention of requisite staff are among the significant measures to achieve this. Through collaborative work effort and effective change management, the health strategy will ensure the best use of resources in delivering a health service based on quality and fairness for all this country's citizens and its health service staff.

As I have said, I am seeking the co-operation of this House in amending the Medical Practitioners Act, 1978, to allow for further revised registration arrangements for doctors. Whether originating from Ireland, Europe or beyond, there is no doubt that medical personnel are a major and key resource to the Irish health services, deserving of acknowledgement and support. This amending Bill, in conjunction with the main Bill later this year, will be key factors in ensuring that in five years' time, there should no longer be shortages in those crucial disciplines which are currently holding back the development of much needed services.

I hereby commend the Medical Practitioners (Amendment) Bill, 2002, to the House.

Deputy McManus and I facilitated taking this Bill at the request of the Minister because he indicated its urgency as a technical matter in relation to registrations that would run out in July. I do not agree with taking Bills in this manner. To some extent, we are taking in good faith the contents of the Bill and the assurances we have received regarding the technical nature of the Bill and that there are no substantial changes to which the Oireachtas should give detailed consideration. Having facilitated the Minister, I am disappointed that he has not paid us the courtesy of coming into the House but that is not to take from the Minister of State, Deputy Hanafin, who has already explained to us why he is not here today even though Deputy McManus and I made ourselves available.

I will return to some of the contents of the Bill and the Minister of State's speech in a moment but I will first make a few points on the Bill. To some extent, a golden opportunity in relation to steps that could be taken to radically change the supply side of Irish medicine is constantly being missed. Irish consumers are not, in the main, complaining about the cost of health care but about inefficiencies and lack of services. These problems arise not only because insufficient resources are being put into the health services but because the health services are controlled by a series of monopolies which are highly inefficient.

In Europe, we share with the United Kingdom the major problem of waiting lists, lack of services and no measure of output or outcomes. The most important step which the Minister can take in resolving the log jam is probably to relinquish control over the supply of doctors. The number of Irish students allowed in medical schools is ridiculously small. Foreign students with fewer qualifications are allowed in because they are a source of funds for the colleges. Comhairle na n-Ospidéal has a restrictive role, as does the Minister, in the supply of consultants. What is a consultant? Professional qualifications as a doctor, time served and experience are what should determine who is qualified to take a position as a consultant.

Why are we restricting numbers so tightly? Even the Irish Hospital Consultants Association agrees that we need more consultants. The IMO agrees we need more GPs. Why should hospitals not recruit directly? Once the standard is set, qualified persons should be allowed to apply just like accountants and others. There are many qualified Irish candidates living here and abroad who could be encouraged to apply. There are many non-Irish candidates well qualified professional people who could be recruited. Certification of standards should be the measure and not where someone lives or where they got their qualifications once the qualifications are certified. There are many countries in which there are many highly qualified unemployed doctors. We should open Irish medicine to them. We need more doctors, and they are available.

The United Kingdom has actively gone out recruiting these doctors to deal with its supply problem, and we should do the same. I would like to read an extract from The Guardian Weekly of 7 to 13 March 2002 headed “German doctors to ‘aid' NHS” by John Carvel. It states:

A radical plan to use German doctors to eliminate the huge National Health Service waiting list for day-case surgery before the next election is to be presented to Tony Blair this week by the former Labour minister, Frank Field.

He will tell the Prime Minister that hundreds of freelance German medical teams – including consultant surgeons, anaesthetists and theatre nurses – can be made available at short notice to treat more than 500,000 patients waiting for quick operations that do not require an overnight hospital stay.

The patients would not have to travel abroad. Mr. Field, Labour MP for Birkenhead, will present a business strategy from German Medicine Net, a healthcare company based in Schleswig-Holstein, which is offering to set up prefabricated surgery units across England to treat all these patients at an approximate cost to the NHS of £725m.

"We can transform the NHS debate by dealing with the entire waiting list for straightforward operations such as cataracts, hernias and varicose veins," Mr. Field said.

The German company will present costings that will show how the NHS outpatient waiting list could be eliminated using foreign doctors on temporary assignment in Britain.

Its managing director, Hans Finck, said the latest figures showed that more than 1.8 million people were waiting for a first outpatient appointment in England, including nearly 400,000 who had been waiting for more than 13 weeks. This work could be handled by 261 German consultants working flat out for a year at an approximate cost of £155m, he said.

The reason I read that out is that I am not too sure we need to replicate exactly what Mr. Field has in mind for the NHS but the British Minister for Health is out there looking to recruit German and other doctors, and we are not. The biggest problem we have – I will come to the Spanish example in a moment – in the health services is not so much the beds, which are needed but which will take time to come on stream, but qualified staff. Where there are qualified staff and competition, throughput will increase and a quality service will be provided. We have a series of monopolies and the Minister has allowed this to go on unchallenged.

There is a surplus of doctors in Spain, Germany and the eastern bloc. Why are we not recruiting them? Our medical schools are turning out insufficient numbers of doctors even to replace those who are retiring or moving on. This cannot be allowed to continue. What is even a greater scandal is that our medical schools are taking in thousands of paying students from abroad who would not have reached the standard of many of our own leaving certificate students. This problem must be addressed. Even if it was addressed in the short term, it would take many years for the supply of doctors to come into equilibrium with demand and consumer requirements and preferences.

The experience elsewhere – I have in mind Spain, in particular – is that once control over the supply of doctors and consultants, other than fitness to practice in the chosen speciality, is relinquished, then market forces take over and have a dramatic impact. What happened in Spain was that after Franco, the state relinquished control over the supply of doctors and throughput and quality improved as the numbers of doctors increased, especially in public hospitals.

In my research, I found that a visit to a consultant in Spain can cost €10, one tenth of what it costs here. I am not advocating these rates but it shows what the market will bear in another EU state compared to what we are paying through the nose in this State. The waiting times in Spain in the public system for major items are shorter than those in the private system in Ireland, yet the percentage of GNP spent on health in Spain compares well to Ireland. According to the World Health Organisation Report 2000, Health Systems: Improving Performance, the per capita health spend in US dollars was Ireland $25, Spain $24. That is a comparable level of expenditure. The economic cost of an overnight stay for some of the private hospitals in Spain is lower than the charges for semi-private beds in public hospitals in Ireland at around €100 per night. The advent of the euro has made this much more transparent.

The cost of CAT scans and MRIs, which are paid for by insurers in Spain, are a fraction of the charges levied in Ireland. However, I note that the two insurers in Ireland have begun to compete in terms of tendering for MRI services and this is to be welcomed. Again in Spain, the public contracts for consultant services cost about half what they do in Ireland and the consultants are within the public hospitals for the first seven hours of the day.

The changes the Spanish have succeeded in making to its system have been driven mainly by supply reforms. We see no sign of such a move here. The patient's needs come fifth after the Minister's political needs and the bureaucratic, providers and practitioners needs. When are we going to put the patient first? It is our job as legislators to do that but we are not doing it. The death rate in Ireland is above the EU average, and the EU average is greater than that in Canada. Not putting patients first means that people will die sooner. We must take steps to end these monopolies.

The major reform in Spain was the relinquishing of the control over the supply of doctors. Doctors in Spain now compete on grounds of quality, customer service and price. This has had the impact of driving efficiencies within hospitals and reducing the need for expected increases in bed capacity. Do we really need 3,000 more beds? We certainly need more beds. I do not have a team of economists, accountants or productivity specialists available to me to determine how many additional beds we need. If this House was to ask the Comptroller and Auditor General if the problem is one of the supply of doctors or a bed shortage of 3,000, I would be surprised if he did not tell us we need only 2,000 beds because an increase in the supply of doctors would create the necessary competition and throughput to deliver a reduction in patient numbers. Of course that would be too much to do as it would upset the apple cart for some very powerful people.

Hospitals in Spain also compete on quality and price. This is good for the patient. The fundamental question for the control and processes for the supply of doctors and consultants must be immediately overhauled. I know the Minister has said she will return to this in another Bill later in the year. We do not know who will be Minister later in the year. It may be Deputy McManus or me. We must return to this issue. Perhaps it is being left until after the election because the issue is going to be addressed.

There are many anecdotes about approved consultant posts that have remained unfilled for years. Even if some of these posts were filled, the lack of doctors would merely shift the problem elsewhere. We know the Spanish health system is regarded as being in the top six in the world. It is on a par with the health systems in France and Germany. This country has a modern image but in terms of its health system it is rated 19th and is not improving. Pushing more money into a flawed system would merely use up more of our national resources. Reform of supply is the key issue in delivering a world class health service to the people.

The Bill before us appears to be technical amending legislation seeking to regularise the position of foreign doctors in Ireland. I have not tabled any amendments. Foreign doctors provide a valuable and worthwhile service to the Irish hospital system. I welcome this Bill in so far as it will enable us to overcome problems which have arisen regarding their position and length of service in the Irish system. However, we must be honest and admit that the reason we need foreign doctors in such numbers is young Irish doctors are unwilling to remain within our system. We need to examine the circumstances in Irish hospitals and address the fundamental problems which are discouraging Irish doctors and require us to bring in foreign doctors, to whom we should give a more permanent status.

We must address the shortage of consultants. Junior doctors do not get the quality of training they deserve because they often have to carry the burden in hospitals rather than spend their time in learning. The shortage of consultant posts means the prospects for advancement for junior doctors is not what it should be. Junior doctors see their colleagues go abroad to get better experience and improve their skills. In many cases they see them return for promotion to one of the limited senior posts. We have talked for long enough about a consultant-delivered service. When will it become a reality? I know the introduction of such a system requires hard negotiations with consultants about the nature of the new service. These discussions cannot be allowed to drag on indefinitely just because the Departments of Finance and Health and Children do not want to fund such a system. Irish patients, their families and those working in our hospitals deserve better.

There is a great need to encourage and develop the amount of clinical research carried out in Ireland. This could increase the number of Irish doctors who remain in the Irish hospital system while also improving the quality of patient care. I know the health research strategy is committed to increasing funding for research but more needs to be done if we are to see an increase in clinical research. Clinical research helps to improve the skills of doctors and promotes the use of new and effective procedures to the benefit of Irish patients. However, I am sure the Minister is aware that there are serious indemnity issues which currently prevent the scale of research we would like. The Department of Health and Children needs to become actively involved in seeking the solutions to these indemnity issues if we want to retain our best young doctors and provide patients with the best possible treatment.

I am disgusted that no journalist or newspaper has taken up the issue of the recently extended apartheid in primary care. We know there has been apartheid in secondary care for some time. Last year, on the eve of a by-election, the Minister wilfully and deliberately extended apartheid into the area of primary care. The average medical card payment was £50. Some payments were as low as £30 while others were more than £70. There is an existing agreement with the IMO that up to 40% of the population can be covered for medical cards. Last year, the Minister got the IMO to ignore its campaign of extending medical card cover to poor people. Some people who live alone receive only €128 per week but no longer qualify for a medical card. The Minister persuaded the IMO to extend medical cards to those aged 70 and over. The Government offered £245 per head, plus a deal on secretaries. There was no further mention of the poor.

I have no difficulty with 70 year olds having medical cards. Fine Gael policy calls for the doubling of income limits for medical cards. It also calls for the extension of a free GP service to everyone up to the age of 18 and beyond that for those in full-time education, to the lowest paid 60% of the population and to everyone over 65. The Minister said that the extension of the medical card to 39,000 people aged 70 and over would cost the Exchequer £14.95 million. The poor would have to wait.

I do not see how this impacts on the Medical Practitioners (Amendment) Bill, 2002.

I am about to tell the House how it does. It impacts on accident and emergency wards and the need for doctors in them.

But it does not impact on the contents of this Bill.

We are on Second Stage and I am entitled to say what should be included in the Bill, as well as referring to elements of it with which I do not agree. It was expected that 39,000 people would apply but more than 70,000 did and the cost this year will not be £14.9 million but £30 million, or about €40 million. This means the number of people covered by medical cards has fallen from 37% when the rainbow coalition was in Government to 29% because the Department of Finance refuses to pay for medical cards. Deputy Martin did the deal with the IMO and is being left to solve the problem. Sick poor people are left at home on €128 a week—

I remind the Deputy that that is not relevant to the content of the Bill.

These people, therefore, present themselves at the accident and emergency wards. The ESRI says that for males aged 55 and over the death rate is 11 per 1,000 for the well off, who got medical cards, 22 per 1,000 for those on middle income and approximately 32 per 1,000 for those on the lowest income, who die earlier and harder. They are discriminated against, clog up accident and emergency wards, and are ignored because they live in areas where older people vote and the turn-out at elections is 30%. Apartheid such as that went down well in the American Deep South where there were two waiting rooms, one for the blacks and one for the whites. That is happening here and no bishop's encyclical or sermon from the pulpit, no newspaper editorial or journalist's investigative article mentions it. Perhaps apartheid in primary care is not sexy enough to sell newspapers, but it is the greatest scandal in the health services in my time in this House that people are deliberately discriminated against in this way without a murmur from the so-called pillars of society.

I ask the Deputy to return to the content of the Bill.

The Minister of State said that "nowadays more and more Irish students have decided to study medicine abroad within the EU. Many of these students would wish to return to Ireland for the purpose of completing their internship in an Irish hospital." I made that point already myself, but ask the Minister to explain to the House why so many Irish students decide to study medicine abroad when we allow students, who do not have the required same, or equivalent, leaving certificate results to study here. It is a question of money as they pay £15,000 per year in fees. When we need doctors here, why are we forcing our students to go abroad to do medicine and return to do their internship here?

She also stated that "hospitals are exploring different options in an effort to ensure that all medical posts are filled. With the full co-operation of all concerned, and a commitment to making the best use of available resources, occupancy levels will be optimised." Will they? I do not agree. That will not happen until we increase the supply side, as the Department of Health and Children must know.

I must now correct the record as I used it to accuse the Minister of having more fora, committees, inquiries, tribunals and standing groups than there are varieties of Heinz products. I estimated it at about 65, but was shocked to find out in reply to a parliamentary question that there are 107 such bodies. All the vested interests are represented except the patient's, which is why the supply side is not being addressed. The Minister of State also said in her speech that "the possibility of extending the working visa and work authorisation scheme, which already applies to nurses, to other health service staff is being examined by the departmental group." We have had a health crisis for all of the Government's term of office, but it is only being examined now. Meanwhile, the British minister is recruiting staff from here. We have 107 different committees examining, but when we will get decisions? What do Minister's get paid for? She talks of examining while poor people wait in pain for treatment.

She also spoke of "rapid developments in health technology," but the teaching hospitals have cardiac scanning machines, which are vital to their work, for which they did not receive any money, last year or this year, for essential repairs or restoration. It will have a catastrophic effect when these machines break down and what happened recently in the accident and emergency wards will be minor in comparison, as this equipment is the difference between life and death. This is how we treat the health services at a time of abundance. We will not pay for the machines we have now, but the Minister of State talks of future developments. I am assured by reliable sources that people will die.

The Minister of State also stated, "On the capital side the high level of investment by the Government will continue over the period of the national development plan, demonstrating a considerable increase in capital investment relative, historically, to any previous period." What a claim. We have had a time of unprecedented growth in wealth and resources yet we keep our spending relative to historical previous periods when we were a poor country. There is no greater indictment than the Minister's own words. We are about to enter the fourth month of the year and still there is no budget for any of Dublin's major teaching hospitals. Their chairmen and chief executive officers recently met the EHRA and the Department because they cannot run these multi-million euro hospitals without knowing what their budgets are. They have no budgets because the Minister does not want anyone to know the true situation until the election is over. Will the Minister for Health and Children tell us why this is so? Why has St. John of God's in Islandbridge no budget agreed? We cannot run a health service like this.

In concluding, the Minister of State said: "This amending Bill, in conjunction with the main Bill later this year, will be key factors in ensuring that in five years' time there should no longer be shortages in those crucial disciplines which are currently holding back the development of much needed services." These shortages were there five years ago but what has the Government done? If there are no shortages in five years' time, it will be because Deputy McManus, myself and others will be in Government taking the decisions we are paid to take. Why has this Government allowed this situation to continue for five years? The operation of the health services is appalling and what passes for good ministerial action is Ministers spending their time holding the hands of journalists, leaking information to curry favour with them, and setting up forums and committees to keep people in the hospital services happy but not taking into account the needs of the patients, especially poor patients.

I hope the Minister will reply to some of the points I raised and in particular to the question of the supply side and why the Government wilfully extended apartheid to the primary care services.

It is appropriate that the last debate in the House for this term, and possibly for this Dáil, is on a health issue. Clearly, health is the most important issue as far as the electorate is concerned, and all the research shows that. Health is also the most deficient area as far as Government policy is concerned.

It is fair to say that in the past five years, Fianna Fáil and the Progressive Democrats have little to show for themselves in the area of health care, leaving aside the various crises that have occurred, the most recent of which was in the accident and emergency departments, a dispute which is still unresolved and may lead to further industrial action by nurses; the ongoing staff shortages in nursing; the growing shortage of doctors; the plummeting morale in our hospitals which, sadly, is being experienced by many people trying to deliver a good quality service; and the ongoing shortage in hospital and rehabilitation beds which has not been alleviated even though the Government has been in power longer than most previous Governments.

It is worth examining what this Government set out to achieve when it was formed. The programme for Government made clear commitments in the area of health. It promised to tackle the crisis surrounding hospital waiting lists, to review medical card eligibility for large families, to introduce value for money initiatives in the health service and to create a customer focused health care service. It is clear now, almost five years on, that none of these commitments has been delivered on. Approximately 26,000 public patients are still on hospital waiting lists, with many more thousands waiting to see a specialist. That figure has more than likely increased because of the industrial action which prevented elective procedures being carried out when the accident and emergency departments were affected by the nurses' industrial action. Families on low incomes, whether large or small, have had no alleviation in terms of the cost of attending a doctor. Medical card eligibility was not extended to poor families but rather to the most well off of the over 70s.

A recently published Deloitte & Touche report highlighted that the Department of Health and Children, and the health boards, are poorly organised, resourced and managed. The Minister for Finance decried the inefficiencies in the health service and pointed out that he put more money into the health service, even though he was a little aggrieved about it. There is now growing public dissatisfaction with the service, which is experiencing major problems. The Deloitte & Touche report indicated clearly the limitations of the Department of Health and Children in terms of strategic planning and economic management. The report states:

We are concerned that the remit of the Department is too broad, spanning a range of health and social service issues. The Department has been continually asked to do more; this arises in an environment where 20% of the positions within the Department are currently vacant.

Furthermore there are a whole range of skill sets where the Department is either under-resourced or has no resource at all, for example financial, statistical, social analysts, strategic planning, QS, health economics, personnel with direct experience of working in the health services.

When a Department is so restricted in terms of what it can do, but managed in such a hierarchical way, fundamental structural reform must be delivered on. We have not seen that. There is a saying that in politics, perception is reality. The Minister for Health and Children has created the perception that he is being effective but the experience of patients on a daily basis is different, whether in trying to get the money to go to their general practitioners or waiting for long periods in an accident and emergency department, some times in conditions that are substandard or even dirty, sleeping on trolleys, sitting in wheelchairs or standing trying to access care. That is the reality as opposed to a perception that has been carefully spun by the Minister for Health and Children.

In 1997, the Government's legislative programme promised a new medical practitioners Bill and a health and social care professionals regulatory Bill. We were also promised a nurses' Bill. That legislation would assist in modernising the law on the registration of health professionals and provide an appropriate supportive framework within which vital and increasingly scarce health professionals can operate, but we are still waiting for it to be brought forward. This Government is going out of office but none of these three important legislative measures has been published – not even the heads of the Bills. They have been promised for some time this year, and in that regard I am reminded of the song "What's Another Year". The programme is renewed every Dáil session and the same commitment is given, only the year changes.

This Bill, the purpose of which is to resolve a problem of registration, mainly for medical practitioners, cannot be considered controversial. I am sure everybody will support its passing because most of us are familiar with doctors caught up in excessive bureaucracy and with the blockage that threatens their professional futures here beyond 1 July if the problem is not addressed. The Bill deals with a problem that essentially is not new. Our over-dependence on foreign doctors to man our hospitals is long-standing and the least we owe them is a better registration system. For many years, the majority of our 2,500 junior hospital doctors came from non-European Union countries without whom our hospital service would have ground to a halt. At times doctors applied to fill a range of posts but were unable to do so because of restrictions here.

Statements were made by one Government Deputy in particular, which were essentially racist in nature, but it is important that we acknowledge the debt we owe to thousands of people who came here from Asia, India and Pakistan to work in our hospitals and care for our loved ones, sometimes in conditions that were less than favourable to them. Some of these issues are still not resolved but the conditions in which these young doctors lived and worked were not good, particularly when one takes into account that most of them were far away from home and did not have family support. We took advantage of them. It was a form of exploitation and we must acknowledge that.

The Bill arises out of a medical manpower crisis which goes far beyond the issue of non-EU doctors. It is a manpower crisis that is real and growing. If we are to encourage more Irish doctors to commit themselves to our health service and increase specialist and general prac titioner numbers, a sea change must take place. Currently more than half the places in our medical schools, in effect, are reserved for non-nationals. Non-nationals bring in money. That is the reality of why this is occurring and why we do not produce enough Irish doctors. Even among the doctors who graduate from our schools, 20% of them do not engage in medical practice. We know why we are catering for foreign doctors, but we need to ask why we are losing so many precious medical graduates. If one were to ask any general practitioner about the future and health status of general practice, he or she would inevitably give a view that is, at worse, negative, and at best, mixed. There are concerns about the pressures of work but also about the difficulty in attracting young doctors into general practice. There is a famine in terms of young doctors coming into areas of disadvantage, particularly in urban areas but also in rural areas.

Part of the reason areas of disadvantage are experiencing difficulty in attracting young doctors or any doctors relates to the decision by the Government to favour doctors who treat wealthier patients under the medical card scheme. Deputy Mitchell was right in saying that apartheid has been introduced into primary care. This has a knock – on effect in terms of difficulty in attracting GPs to certain areas. The proportion of GPs to patients is very different in the poorer areas of our towns and cities than on, what some people refer to as, the gold coast, the east coast, where doctors are awarded and given incentives to care for private patients over the age of 70 who are better off. There is an active disincentive to care for poor families under the GMS. That must change.

Whoever will be Minister, following the forthcoming election, will have to create a grant system, an incentive driven system, to encourage doctors to practise in areas where there is greatest need. We all know that poverty is an indicator of poor health, yet the Government's record ensures that reality of low health status connected to poverty is exacerbated by a policy that rewards care for the better off and negates the chance of developing better care for the poor.

There is also a manpower problem in our acute hospital service, the low number of specialists compared to the high number of NCHDs. This imbalance was highlighted recently by the Post Graduate Medical and Dental Board in its latest statement on the problem. This is not a new problem. We have all been aware of it for some time. It is interesting to note what the Post Graduate Medical and Dental Board say about it. The board states that based on current training career requirements, there should be only 850 NCHDs above intern level as opposed to nearly 3,000 junior doctors in place at present. Its report stresses the need for radical reform in career structures if an equitable balance is to be struck between those in training and the ultimate numbers of career opportunities available.

This imbalance is impacting on the care of pub lic patients. It is not the experience of private patients that their care is being delivered by doctors in training. They have a consultant provided health service. Public patients, however, have a consultant led health service that depends greatly on NCHDs, who often work in stressful and difficult conditions. Essentially, they are doctors in training and should not be expected to carry such a burden, even though that burden has been there historically for many years. There should have been a significant shift in the imbalance over the past five years because the Government had the resources to make decisions to address the changes that were evident in our acute hospitals, but that change has not occurred and the imbalance continues.

The medical manpower forum trundled on for years and now a task force is in place, but there has been no real change on the ground. That is worrying in terms of how the Minister is operating and how the Department of Health and Children, which has such power in terms of the nature of its position with regard to the hospital sector, does not recognise the changes required. Unless these manpower issues are addressed, no strategy will work and the service will continue to creak on trying to meet increased demand without being able to manage its manpower in a way that more effectively meets the needs of patients.

It is worrying that the Minister thinks it is an achievement that 98% of vacancies in our hospital service are filled. How can he think that? We can only say it is an achievement when 100% of the posts are filled and can guarantee, as a matter of course, that all the posts will be filled and there would be competition for them rather than the current position of struggling to achieve the filling of 98% of posts. A new manpower drive is needed. Attention needs to be given the fact that more graduates now are women. We all know that women doctors, like women in any other sphere, will set different characteristics for their profession. They have other priorities. They are not like the traditional male doctor who seemed to be willing to work 24 hours a day and allow his spouse to carry the attendant burden of child rearing. Women doctors are bringing a difference into the profession, but the profession is not shifting and changing in accordance with what is happening on the ground.

I talked to a medical student recently who spoke of his internship here compared to a friend of his, who, having trained here, will return to Norway to a similar internship programme and there was no comparison. Interns' pay is substantially higher in Norway, their conditions are substantially better, their choices are wider and their training is much more comprehensive. More and more young doctors who want to be in training will leave Ireland because they will be attracted elsewhere and meanwhile we have a difficulty in filling our posts. It takes around ten years to produce a doctor, even a GP. Where is the planning and change in policy? Leaving aside all the consultation and the myriad number of commit tees and working groups that have been established, where is the hard concrete evidence that we will be able to produce sufficient medical practitioners to meet the needs of our population? This is not a big country, it is small one, yet it is one of the wealthiest in the world. How have we so little to show at the end of a five year period in office when the Government presided over such prosperity?

Even in its own terms, the Bill is disappointing because it should have been part of a bigger Bill, a new medical practitioners Bill to amend the Act of 1978, which has outlived its usefulness. By now we should have enacted a Bill that would have dealt with the issues outlined in reply to a parliamentary question, as far back as 27 May 1999, by Deputy Cowen as Minister for Health. He stated:

During previous discussions with the council and other interested bodies a number of proposed changes emerged, many of which will be non-controversial and will easily be incorporated in a new [Medical Practitioners] Bill. A number of areas which need to be changed are as follows: registration, fitness to practice, establishment of a health committee, membership of the council, and the role of the Minister. The council has also brought forward discussion documents in relation to the following items: reform of the intern year, health procedures and competence assurance standards.

The Minister stated that it was his intention to circulate draft heads of a Bill in 1999. He said he would need to prioritise these proposals in line with the relative priority of a new Nurses Act. Neither of these proposed Bills have been published in any form at all. All we have is an amendment to the current Bill which deals with a very specific and immediate problem.

Several issues that should be in the Bill were listed by the Minister. It has happened on occasion that British doctors have been practising here who may not have been fully qualified or were operating in a way that was undesirable. It was clear that the overseeing role of the council and the health boards was not sufficient to protect patients from danger. For example, a report was issued about a doctor, Dr. James Ellwood, who worked as a locum consultant in various hospitals, quite a number of whose diagnoses had to be reviewed subsequently as a result of concerns about his practice. People who come to practice in Ireland are very welcome but a system of checks is needed so that the Medical Council, which is charged with this duty, can ensure good quality care for all our patients.

Speaking to anybody who has gone to the Medical Council to make a complaint one learns very quickly that it is a very difficult and rather unfriendly process. I have talked to the women, for example, who were involved in a case about their experiences in Our Lady of Lourdes Hospital in Drogheda which was discovered to have had a very high level of caesarean hyster ectomies over a period of 20 years. Some of these women were very young when they had hysterectomies, without due consultation or, it would appear, any real need for one. Some of these cases are extremely distressing. However, when one talks to the women about their experiences at Medical Council hearings it seems that the process can be unnecessarily harsh and confrontational. This is something that needs to be reformed if we genuinely want a patient-focused health service and if we are to accept the idea that patients have rights and that there is such a thing as empowerment of patients. Otherwise it is simply a case of being fortunate enough to afford care or being grateful for access to care without payment.

The lack of legislation coming from the Department of Health and Children may be explained by the fact that its officials' energies and concentration have been diverted into the production of the health strategy. The latter has just been published, within months of the Government's leaving office, yet it is already fraying at the edges. I suspect that the lack of legislation may also be explained by the referendum on abortion which divided the country and was fortunately defeated by the common sense of the people. All this has been diverting energy from the real work of any Department, which is the production of legislation. We have long been waiting for a proper and appropriate Medical Practitioners Bill which has been talked about all through the lifetime of this Government. As yet we have had neither sight nor sound of it.

This is a Bill about which I have no complaints. Like Deputy Mitchell, I must take this Bill on faith. My faith in the parliamentary drafting system has been damaged by the experience of the Public Health (Tobacco) Bill, 2001, during the course of which so many errors came up that the Minister was obliged to produce amendments constantly. The Opposition had its own amendments but the Minister certainly outflanked us. This was due to mistakes in drafting. I must accept, because I have no choice, that technically this Bill is sufficient for its purpose and is not flawed. We are debating Second, Committee and Report Stages now and the Minister for Health is not even here to deal with any issues that arise on Committee Stage. I hope this Bill will sort out problems with non-EU doctors and Irish doctors training abroad. Time will tell whether it has done so.

Looking to the future, we need a proper Medical Practitioners Bill and a decent, effective medical manpower policy. We have seen neither. We have seen rows between the Minister for Health and Children and the Minister for Finance about funding – even the funding of the health strategy has been an issue. We have also seen a row about medical manpower in the exchange of letters that was published in The Irish Times. Some of the points made by the Minister for Finance are valid but once again it is reinforced that the Govern ment does not appear to have a clear direction even though it has had five years to figure out what is wrong with our health service and how to fix it. We have no commitments on funding for the future. The Minister for Finance says it is unsustainable to continue the current rate of growth in funding.

At our recent conference the Labour Party made very clear how we would, over the next five years, provide an additional €1 billion in capital funding. We have explained where we will find the money to meet these capital needs. However, we are still waiting for Fianna Fáil and the Progressive Democrats to explain where they stand and how they see the future. The record has been one of failure. Rather than making decisions we set up a committee, a task force or a working group. Rather than having a strategic approach from day one we invent a strategy at the eleventh hour. That is not the way to develop a health service, particularly one which is under stress because of a growing population, limited resources and staff numbers – lack of beds, nursing shortages and so on. Ultimately the relationship between the patient and the doctor is the most important thing and if there are not enough doctors or if they are not at the right level and do not have the proper training, we will experience problems. We can see these problems all too clearly in the health service at the moment.

I thank the Deputies for their consideration of this Bill and for agreeing to take all Stages today. I reassure them that it is a necessary technical amendment and it was important that it was taken today. I appreciate the willingness of Deputies to do that.

A number of issues have been raised, some specific and others general. In the general context, the implementation of the national health strategy will bring a sense of quality and fairness to our health service, ensuring that everybody can benefit from the improved service which is backed up by investment and legislation. This minor amendment is just one of those elements of legislation. However, more major legislation is in the pipeline, including the amendment to the main Act, the Medical Practitioners Act, 1978, which will be introduced in the autumn. Other legislation which is currently being prepared will provide for the regulation of the nursing profession and the health and social care professions. All that will add to the legislative basis of the national health strategy.

There was criticism today of the lack of investment in the health strategy. However, there has been a huge increase in investment in our health service, including in the level of capital investment. By any standard, an increase of 260% since 1997 is significant. In planning for our future and the health service, we as a party do not believe raiding the pension fund is the way to raise the money. We acknowledge that the success of our future health service and strategy requires more investment.

Where will the Minister get the money?

It also requires flexibility in the service so that it can respond not just to the needs of those working in the service, but particularly the needs of the patients and those who access it.

A key feature in the context of what we are talking about today is the important role of non-consultant hospital doctors. I reiterate our acknowledgement and appreciation of the contribution of doctors from within the EU, and particularly doctors from outside the EU, who continue to work here and who make a major contribution. These are the people we are specifically dealing with here in terms of the amendment being put forward. It obviously would be nice if we trained all our Irish doctors at home. However, perhaps all our Irish students do not want to be trained at home. A number of people now go to other colleges by choice. This Bill will facilitate them returning from colleges abroad to do their internship here and then perhaps keeping them within the system. That is one of the values of this Bill and the number of places for students in our medical colleges is being examined by the medical education and training projects group of the national task force, in consultation with the Department of Education and Science. That group is also looking at the quality of the education and training and I agree with comments to the effect that this must be of the highest calibre.

Our recruitment of doctors from abroad is very extensive. The Department and the health service employers' agencies have undertaken a range of recruitment initiatives, some of them in consultation with FÁS in Germany. We have also recruited in Australia and New Zealand and doctors from these countries are already working here. Deputy Mitchell mentioned Spain. A number of initiatives, particularly in relation to nurses, have been finalised there. Again, the facilities that this Bill allows will attract other people to come to work here. It will then be up to the Medical Council to lay down rules and regulations governing that.

The supply of consultants is one of the issues that was raised. We recognise that a significant number of new consultants are needed. The precise numbers needed, facilities, time frame and costs are being looked at by the national task force on medical staffing. It is not just a case of putting in the money and recruiting all the staff now. In return for the benefits to our health system to patients, we want greater flexibility, greater management involvement and new approaches being adopted to ensure that not only is there value for money, but value for the service.

The question of the consultant ratio was raised. At the moment the ratio between non-consultant hospital doctors and consultants is two to one. We are working towards a ratio of one to one which would improve the situation for everybody involved. Again, there are differences across the system and people are needed in all parts of it. However, if we are comparing Ireland to other countries, we should compare like with like. Deputy McManus talked about Norway which has a completely different GDP and a different system. Its standard of living, for example, is different. It is therefore important that we should compare like with like.

They do not have a system where Ministers take decisions. It is completely different.

Decisions in relation to health, health strategies and health systems should be based on evidence and on the advice of working groups and people in the system, not on a political perspective. Deputies criticised the legislation on the basis that it did not involve consultation with the various parties involved. Now they are saying we should go ahead with investment and legislation without consulting the various groups. There are so many stakeholders in the health system that it is important they are all kept on board. That is how the health strategy was devised, bringing those people on board and bringing together a system that can be implemented. That is why there are so many different working groups. They are the people who will have to implement the strategy in the end. It is not just a political decision, but it will be backed up by political commitment. To attract other doctors, a working visa scheme is being examined. I understand that the Minister is hopeful of having positive news in this regard in the near future. This is something that has been worked on for the past couple of years.

Other issues were raised in relation to the common contract. Negotiations have recently commenced in the context of the recommendations of the national task force. This legislation is just one element of a legislative programme to back up our national health strategy. It will make a real difference to people who are currently coming to the end of their temporary registration. It will make a real difference to the health service by ensuring that we will be able to keep the services of professional people. It will also ensure that their experience can be taken into account. It will reduce the period of temporary registration for them and it will also ensure that doctors who might have had to leave the country can now remain here and apply for permanent registration.

Issues about doctors have been raised. One with which I particularly sympathise relates to women doctors, not so much the numbers entering the profession but the numbers leaving. What that shows above all else is the need for flexible working arrangements. That is something that must and will be worked out in order to ensure that we keep the calibre of women who come into the profession. The system must be such that it enables them to carry out their work. This Bill will result in continuity of staffing and maintenance of service delivery. It will tackle the inequities that exist in relation to permanent registration. As the Taoiseach said this morning, the Bill, in many ways, is a first step which had to be taken immediately to enable the Medical Council to make rules regarding applications for permanent registration in which relevant validated experience would be taken into account. It is an element of our legislative programme and of our health strategy. It is also proof of the Government's commitment to making whatever changes and investing whatever moneys are necessary to make sure that we end up with a system from which inequalities have been removed and that can give important and necessary care to patients. All of us recognise the need to develop, reform and modernise but, in doing so, we are dependent on those who provide the service. We need to ensure the structures are put in place at all levels to facilitate those people and they, in turn, will provide the flexibility that is needed to deliver the service.

Ba mhaith liom buíochas a ghabháil leis na Teachtaí as ucht na gcabhrach a thug siad inniu chun dul ar aghaidh leis an mBille seo. It is an important Bill and the Minister appreciates the willingness of Members to take it today.

Question put and agreed to.
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