Dáil Éireann debate -
Wednesday, 7 May 2003

Vol. 566 No. 1

Private Members' Business. - Severe Acute Respiratory Syndrome: Motion.

Ms O. Mitchell

I move:

That Dáil Éireann believing that there has been a further serious erosion of confidence in the public health service arising from:

– the mishandling of the SARS threat by the Minister for Health and Children,

– the issuing of inadequate, confusing and contradictory communications,

– the lack of a speedy and comprehensive public information campaign, and

– the Minister's failure to resolve the dispute with public health doctors at a time when the need for their expertise is greatest;

notes that these failures are symptomatic of a more general failure by this Government and its predecessor to effectively and efficiently manage the health service at a time of unprecedented spending; and

calls on the Minister for Health and Children to address this crisis of confidence and provide the leadership and clarity of purpose which his office demands by:

– immediately resolving the public health doctors dispute to provide 24 hour, seven day public health cover,

– ensuring that when threats to public health arise, a clear, co-ordinated and effective public health communications strategy is implemented without delay, and

– publishing as a matter of urgency his proposals for the reform of the health services, including clear and transparent definition of functions, responsibilities and accountability of those charged with the development of policy and the delivery of services.

I ask that, in the same spirit of generosity shown when we agreed to a ten minute extension to the previous item, ten minutes be added on to Private Members' Business.

Acting Chairman

The Deputy has 40 minutes.

Ms O. Mitchell

I wish to share my time with Deputies Neville and Naughten.

Acting Chairman

Is that agreed? Agreed.

Ms O. Mitchell

I heard the Minister for Health and Children tell the people this morning on radio that there is no health crisis. That will be a relief to the thousands of people on waiting lists who, by the same logic, must only imagine they are ill. The other thing which came vividly to mind was the story of the emperor with the new clothes. The Minister must feel unlucky when he reflects on the events of recent weeks. He must feel that the gods who shone on him in the past have turned their backs on him as he faces disaster in every direction he turns. I am sure he felt unlucky that a new and dangerous disease emerged on his watch, that public health doctors were on strike when it emerged, that it happened just as the Special Olympics was about to be hosted in Ireland, that the system appeared hopelessly unable to cope with the SARS threat and that the public reaction to this apparent ineptitude was only short of outright panic. He must have felt unlucky that communication within the health service and between the health service and the public was so confused and contradictory it would have been laughable if it had not been so frightening. To outside observers, the handling of this crisis reached the realms of high farce.

If this was a new Government and the Minister was newly appointed, we could put it down to sheer bad luck. If this was a fledgling Government struggling to find its feet, we would give it the benefit of the doubt and say it was a victim of circumstances. However, the Minister is not newly appointed and it is not a new Government. I will not go back over the past 16 years of almost unbroken Fianna Fáil Government because the last six are enough. We have had six years of unprecedented wealth and spending. We have had six long years of opportunities foregone. The Minister had all the money in the world with which to make his own luck, but he did not use it. He and his Cabinet colleagues must be held accountable for that. That is why the motion is before the House. The flaws in the health service, which we saw glaringly in the past few weeks and which we will see again next week, are flaws of the Minister's making. The responsibility for every decision not taken in the health service, every investment not made and every reform postponed, rests with the Minister. Those failures cannot be put down to bad luck. They are the inevitable result of a failure of decisive political leadership and all the spin doctors in the world cannot disguise that fact.

There is a crisis of confidence in the health service. This is caused not just by the grossly inadequate, confused and confusing handling of the SARS threat, but by the daily, unremitting onslaught of media stories about more frightening and heartbreaking failures of the health service. The failure to manage the SARS crisis is seen as symptomatic of the more general failure of the Minister, the Government and its predecessor to provide us with a reliable functioning health system, despite all the money spent. There have been structural, management, administrative and communications failures in recent weeks. These failures are common in the health service and are unequivocally the result of the failure of political leadership.

It is not that we do not have good doctors and nurses or that health personnel, including the much maligned administrative personnel, are deficient and unmoved by the crisis over which they are forced to preside. It is a failure at the top to undertake the fundamental reforms required of the complex mesh of health services and of how they are provided and procured. This is not news to the Minister. He lectures us regularly about the need for reform. He knows the deficiencies in the health service and the financial, legal and public health problems associated with those deficiencies. While the Minister continuously makes worthy speeches about the need for reform, he seems to want to ride out his time in health without making a hard decision.

We have heard about the reports which have been published. Almost every area of policy was reviewed by consultants. Some, who made the mistake of reporting too soon, were asked to review the review, while other reports gather dust on shelves. Others which require difficult decisions are not allowed to report, but seem to be condemned to be endlessly rewritten until they are so diluted they will not upset anyone and a passing approximation to reform has long since disappeared.

One of the earliest reports commissioned by the Minister, the value for money report, spelled out clearly that his Department does not have the skills or the structures to implement the health strategy. Month after month we are told in reply to parliamentary questions about the number of action plans to implement the health strategy. However, the relationship between what we are told and what is happening is tenuous.

Reform must start at the top. It must start with openness, transparency and the taking of responsibility. It must start by telling people unpalatable truths rather than hiding behind spin and shifting the blame. Leadership is about taking responsibility, not about playing blame games. How can reform begin when the Minister cultivates a health service which sets region against region, specialty against specialty, nurses against doctors and hospitals against health boards? The system forces medical specialists into public relations campaigns against each other to compete for funding. Everyone in the system is to blame, except the Minister. The Minister tried again this morning to set one region against another. He tried to set the good little boys in the hospitals outside Dublin against the bad little boys in the hospitals in Dublin. However, the health cutbacks will affect the entire country, not just the Dublin teaching hospitals.

Every week during Question Time the Minister is unable to accept responsibility. We are always told the responsibility lies somewhere else, such as with the health boards, the GMS or the Health Service Employers' Agency. If we are not told that, we are told about the health strategy as if that bore some relation to reality. The Department is more interested in public relations policies than in health policies.

On 20 November last, during the Estimates debate, the Minister said that the increase of €694 million represents a 9% increase in year-on-year current spending. He further stated, "This demonstrates more than anything else the Government's commitment to the health services and our determination to protect them and resource them adequately, even in an economically tougher year than we have become used to." We should examine that. The Eastern Regional Health Authority received a determination for 2003 of €2.92 billion. That was sold as a 7.1% increase on the spending for 2002. However, it was a 2.7% increase on the outturn for 2002. The ERHA needed €285 million to stand still, without developing new services. However, it received €81 million.

I heard the Minister's interview in Brussels last night. He said he had heard such announcements about cutbacks before and that they were not serious. He said cutbacks had not occurred and that is was scaremongering. It is not scaremongering. In the debate last November when the Minister announced the Estimates for this year, I predicted savage cutbacks in the acute hospitals because I knew that the 9% increase was not an honest reflection of what was happening. Basing budgets on what was supposed to happen in the health service last year rather than on what actually happened, is a farce. I heard the Minister trying to defend it today. The teaching hospitals in Dublin required €87 million to stand still, but they received only €200,000. It should not come as a surprise to the Minister that there are cutbacks. It is hard to believe that the Minister continues to deny it. Are things so bad that the Minister does not know what is happening?

I asked six weeks ago for details of the hospital budgets for 2003 compared with 2002. The Minister's response in a parliamentary question was that he did not have that information. How can that be possible? How can the House accept that the Minister for Health and Children does not know the hospital budgets? Again, the Minister tried to blame the Dublin hospitals as if they were deficient in some way. The reality is that these cutbacks will affect the entire country. The South Eastern Health Board region needed an extra €23 million just to stand still in terms of the services it was providing; it got €6 million. If you live in the West there is also bad news despite what the Minister said; that health board received €5 million less this year than last year.

What these hospitals planned to spend last year is irrelevant. We can only judge by what they actually spent. Unfortunately, people cannot regulate their health to suit the Minister for Finance. During the Estimates debate the Minister said: "It is the first time in 20 years that we have had any kind of concerted increase in hospital beds in the public sector." The Minister continued to indulge in that flight of fancy this afternoon. When I disagreed and predicted bed closures he said he could not accept those predictions. As for the Minister's increase in beds, last year the ERHA region opened 265 beds, as the Minister proclaimed proudly some months ago, but forecasts suggest yesterday's budget cuts will close 250 beds. That means that in reality 15 beds were opened. Of course the Minister ringfenced new beds, but he ringfenced them from the budget for the old beds. Where is the sense in this budgeting, which makes neither sense nor savings?

We did not quite appreciate the Minister's irony during the Estimates debate in November 2003 when he said: "The year 2003 will be a significant year in terms of structural change." The structure is falling apart.

The public saw the handling of SARS as symptomatic of the deeper malaise in the health service. If so, the handling of the public health doctors dispute was a manifestation of a very deep malaise in the health sector. On the one hand, the Minister professes to place great importance on disease prevention and health promotion. He knows that unless that shift in emphasis takes place that the demands on the health service will rapidly become unsustainable, if they have not become so already. He knows too that public health doctors are crucial to prevention and that not only is prevention far preferable to cure from the public's point of view, but these doctors are the only group of doctors in the entire health system who can save him money. The reason for the existence of public health doctors is to prevent disease and, consequently, reduce the need for treatment, saving the Minister money.

The Minister is spending €9 billion annually and is desperate for savings, but he allows a problem to fester for nine years with the one group which could help him. When the issue came to a head against a background of a new emerging disease and the Special Olympics, he came to the Dáil to insult the members of that group and, in case they did not hear him, he went to their conference and insulted them again.

I hope we have learned that disease knows no timetable and that disease control can no longer knock off at 5 p.m. on a Friday evening. I ask the Minister to take the public health doctors' dispute seriously and to show them the courtesy of expressing concern about the issue. He should inform the Labour Relations Commission that he is serious, that he is willing to go there to solve the dispute and that proposals will be put forward for discussion. What has been going on so far is a disgrace, with officials turning up who do not know what the issues are. This involves people, largely women, who do not deserve the disdain with which they are being treated. We need them.

Members of the public depend on the Government to protect them; that is why they elect it. Specifically, they depend on the Minister for Health to protect their health, but they have lost confidence in the Minister's ability to do so. As a result the Special Olympics, instead of the joyous event it should be, has become a focus of great concern for participants and host towns. Thousands of people around the world and in Ireland have put enormous energy, time and hope into the games. It would be a travesty and a tragedy if anything were to happen to jeopardise an event into which so many have invested so much. The Minister must demonstrate beyond all doubt that he can and will protect our health and the health of 40,000 visitors coming for the games, the vast majority of whom come from countries not affected by SARS.

In this, as in all aspects of the health service, perception is very important. Restoring public confidence is essential and to do so, the public must believe that someone is in charge, someone who knows what he is doing, someone who is competent, someone who will look out for their best interests and someone who is capable of protecting them. The current perception is that the Minister cannot do so.

Mr. Neville

I refer to the Department of Health and Children's website statement on what is being done to prevent SARS from entering Ireland: "An action plan for dealing with the SARS issue has been in place since mid-March."

An article in The Irish Times of 26 April, almost six weeks later, stated:

In the early hours of last Wednesday morning outside the GPO in Dublin's O'Connell Street . . . a car, which had been slowly cruising the streets of the capital for a number of hours, screeched to a halt. Three masked women jumped out and pursued two Chinese women, who moved away anxiously. After a few minutes, the visibly frightened Chinese women agreed to put on face masks and accompany the Irish women back to their car. All five drove off in the direction of Cherry Orchard Hospital. The three women cruising the streets of Dublin were senior public health doctors from the National Disease Surveillance Centre and the Eastern Regional Health Authority. Although on strike for 10 days, they had decided to try to find a Chinese woman who had gone missing from SARS quarantine late on Tuesday night. They eventually found the Chinese national and her sister in front of the GPO.

Welcome to communicable disease management, Irish-style. Such Keystone Cops-type antics won't be found in the World Health Organisation manual of best practice for dealing with emergencies. However . . . [it] is likely to find its way into future training notes as an extreme example of how not to manage a potential infectious disease epidemic.

In February 2003, severe acute respiratory syndrome was recognised as a threat to public health by the World Health Organisation. On 12 March the same organisation issued a global alert about cases of atypical pneumonia occurring in some far eastern countries. As of yesterday, there were 6,727 cases worldwide and 478 deaths from the disease.

The SARS outbreak has had a cataclysmic effect in areas of high infection. It has affected individuals, economies and travel and has ended lives. Dr. Mike Ryan of the World Health Organisation stated on the "Six O'Clock News" that 14% to 15% of those infected die, and 45% to 55% of those infected over 60 die. SARS has separated families and put a strain on health facilities and health professionals. It has had a cataclysmic effect in this country also, though not because the disease is widespread – we had one probable case, now thankfully recovered – but because the management and handling of the possibility of an outbreak of SARS has exposed yet again the irresponsibility, incompetence, mismanagement, ineptitude and dishonesty which are the hallmarks of this Minister and Government.

The whole SARS episode to date is an ongoing catalogue of disaster. From the date of first alert by the WHO in March of this year, the director of the NDSC alerted health professionals and the Department of Health and Children of the possible risk. This action continued over the following weekend. The public health doctors, whose expertise in the area of infectious disease is a prerequisite for success, carried out their mandate with impeccable correctness. On 11 April, in the midst of the global epidemic, in a dispute which has dragged on for more than nine years, the Minister for Health and Children forced public health doctors on to the streets. He deprived himself and the public of their skills, knowledge and expertise. To ensure they would not return to work, he insulted them in the Dáil and, as Deputy Olivia Mitchell said, then went to Tralee to add insult to injury. It was all down hill from then on.

If the Minister wanted to solve the industrial dispute, attacking the officials was the worst way to go. I was involved in frontline industrial relations for 15 years and was on the Employment Appeals Tribunal for nine years. If one wants to bring a strike to a head and is prepared to close down the shop, one takes on those on strike head-on. If one wishes to sort out the problem and to get back on the road as quickly as possible one works in the background to resolve the matter. The Minister was prepared to close down the shop in any interpretation of industrial relations practice.

Concern was expressed here about SARS. People were interested and a little worried and needed reassurance that somebody was taking care of things, but they were to be disappointed. In times of concern or threat, people will listen to authority figures if they are convinced a plan is being followed. The best example of this was the behaviour of people during the foot and mouth outbreak. What rapidly became clear at that time was that there was a plan and that somebody was in charge. People responded positively to that plan. It is clear that in this case there is no plan despite the Minister's website statement. The Minister was more interested in public relations than public health, more spin than care. The gaping black hole of Government ineptitude opened beneath our feet. What followed was panic and the "what if" syndrome which characterises situations where there is no leadership. What fuelled the fire was the worst-case scenario imagery in the headlines of our newspapers, in contributions to chat shows, in pubs and workplaces. What started out as media and public concern ended up as consternation.

From one day to the next, we had no idea what the Government was doing. We know expert groups were set up and that they met – we had press releases from the Department of Health and Children telling us so. We had media interviews with the Minister, full of concern, but with no idea, no plan and no action. There was confusion about the treatment of a suspect case of SARS. There was further confusion about whether the case had become probable or suspect. The Minister told us that the patient had been given the all clear. There was relief all round. Then it became clear, or at least less unclear, that the patient was not out of the woods. The Minister's anxiety to be associated with good news was misguided. The situation worsened when on 24 April, ten days after the public health doctors began their strike, the chief medical officer and the Eastern Regional Health Authority flatly contradicted each other about disease categorisation. As the ERHA and the CMO are supposed to be arms of the same organisation, the health service, such dysfunctional miscommunication became as serious in the public eye as a misdiagnosis of the disease. The chaos was exposed. The Minister did not know one part of his anatomy from the other. This was bad publicity and the publicity fightback began.

To read the Department of Health and Children website is a treat in itself. There is a banner headline on SARS with the date of update emblazoned across it and there is a link to information. The first line states that an action plan has been in place since mid-March. If that is so, where is it? There has been no plan, and certainly no action, for weeks. Had there been evidence of a plan in airports, ferry ports hospitals and GP surgeries, there would have been less panic and less concern. Now, we are bombarded with information, all backdated. Revisionism is a blessing for the Government. It has become a way of life for it.

I will refer now to the Special Olympics World Games and in particular a statement made at approximately 6.26 p.m. this evening by Dr. Mike Ryan of the World Health Authority.

Mr. Martin

The Deputy has not referred to one particular aspect of Mr. Ryan's comments.

Mr. Neville

Perhaps the Minister will allow me to finish.

Mr. Martin

The comments I refer to are those made by Dr. Ryan in relation to the excellent manner in which the Irish Government handled the case.

Ms O. Mitchell

We are wondering which cumann he belongs to.

Mr. Martin

The Deputy is now making his third quotation from those comments.

Mr. Neville

I did not hear such comments and I listened carefully to what was said. The Minister listened only to what he wanted to hear.

Ms O. Mitchell

Was he by any chance outside the GPO?

Mr. Neville

Dr. Ryan said his people were working closely with the committee. He was confident of a safe and enjoyable Olympics. On people not travelling to the games, he said that other measures under discussion were equally as effective as banning people from travelling. I wish to put that on the record.

What happened in China today is deeply worrying. The disease has spread to a rural area which has no health services.

Mr. Naughten

I welcome the opportunity to speak on this debate and to thank Deputy Olivia Mitchell for tabling this motion. Some 270 public health doctors, the majority of them women, are earning a fraction of the salaries earned by their peers. There are currently no negotiations taking place between the Department of Health and Children and public health doctors. The IMO and the HSEA went to the Labour Relations Commission but there was no move from the HSEA or the Department of Health and Children. The Minister said "No".

This dispute dates back to 1994 following a review. That review, which took nine years, was completed last year. Last October, public health doctors were informed by the Department of Health and Children that proposals would be on the table within six weeks. To date, they have not seen any proposals. The Minister now claims the report is out of date. So much for value for money. We hear ad nauseam about value for money. The Minister pays lip service to it but we see no action. There is nothing on prevention which, as Deputy Olivia Mitchell said earlier, saves money. That is one way of saving money within the health service.

The public health doctors dispute is a symptom of the extent to which our health system under-values prevention and the breakdown within the health system. The work of public health doctors ranges from controlling the spread of infectious diseases such as SARS, meningitis and salmonella to the prevention through vaccination of tuberculosis and measles, mumps and rubella. The vaccination programme operated by the Department of Health and Children is a disaster. There is no public confidence in it. The uptake of the MMR vaccine is almost 25% below the targets set.

The Minister of State, Deputy Brian Lenihan, expressed concern at the low uptake and urged parents to have their children immunised. What action has been taken in that regard? In 2000, a measles outbreak cost the lives of three children. This is evidence of what happens when there is a fall-off in immunisation rates. There is great fear in relation to the MMR vaccination and autism. Parents are not provided with adequate information in that regard. Public health doctors are crucially important in providing basic information allowing parents to make a conscious decision to have their children vaccinated. The cost of infectious diseases is astronomical. Bacterial meningitis is an extremely serious disease and can be successfully treated with antibiotics if detected early. There were 515 cases and 30 deaths from bacterial meningitis in 2000. Some 15% of those who survived are left with disabilities such as blindness, deafness, limb amputations and behavioural problems. That costs at least €75 million per annum, which is approximately the cost of 300 acute beds – that is the crisis in the Dublin teaching hospitals. Where the investment is put in and where the supports are being provided by the public health doctors, there is a rebate to the State and the funds are coming back to it.

In 2002, the winter vomiting bug had significant cost implications for many of the health boards, with staff accounting for one third of those who became infected. It cost the Western Health Board €1 million. The outbreak resulted in a serious disruption of some hospitals, which had to cancel elective surgery. So much for addressing waiting lists in two years. The public health doctors are at the coalface of prevention measures and ensuring that diseases do not spread, yet the Minister is not prepared to negotiate with them and has put no proposals on the table to date.

Public health doctors are responsible for the planning and implementation of prevention and awareness programmes such as those for heart disease and diabetes. Type two diabetes costs €461.8 million per annum, or 6% of the total health care budget. That is the cost of approximately 1,850 acute hospital beds. Any saving would be beneficial to the health service. Hospitalisation accounts for nearly 50% of that spending. Early diagnosis and the appropriate management of type two diabetes will prevent or delay the onset of serious complications such as a heart attack or stroke, and eye and kidney complaints. One in every two people with diabetes do not even know they have it. Public health doctors have a responsibility to make the public aware of this and in making people who have diabetes aware they are sufferers, yet we see the Minister in dispute with them and no proposals on the table.

These, and many other diseases, cost taxpayers and the economy millions of euro every year, and put significant pressures on the health services. The Minister for Health and Children is turning his back on prevention and controls. However, lives are saved by public health work. This is real life-saving, and more are saved in this way than in operating theatres.

The Government's health strategy places major emphasis on preventing death and suffering and promoting positive health. That health strategy is now gone out the window, even though the ink is hardly dry on it. The Minister used the health strategy at the general election to pull the wool over the eyes of the electorate and for spin and PR, but it has now gone into the bin.

As my colleague, Deputy Neville, stated, there is no contingency plan in place to deal with SARS. It reminds me of the iodine tablet fiasco the year before last. The reason for the problem in Clonmel is there is a fear of SARS among the public and the information has not been provided. It will damage the Special Olympics, the only positive tourism development which will happen in Ireland this year.

No one appreciates the work of public health doctors until something goes wrong – until there is an infectious disease outbreak. Modern medicine relies heavily on up-to-date advice provided through networks of health doctors about cases of measles and meningitis which break out locally to ensure that vaccination takes place. New infectious diseases with high mortality rates need to be monitored by the experts and, in turn, that information needs to be provided to GPs in a swift and prompt manner. Public health doctors are essential to the investigation and control of infectious diseases and the Government's lack of commitment to put in place an out of hours system for surveillance and control of infectious diseases is making a sham of the system.

There are approximately 40 infectious diseases notifiable by law. These include SARS, meningitis and hepatitis, but there is no out of hours service in place at present and this is a serious concern for everyone. For example, e.coli 0157, one of the more serious food borne illnesses, is dangerous if a child, an elderly person or someone who is immune-suppressed becomes infected. The majority of major infections occur at weekend functions such as weddings and all the serious outbreaks have taken place over weekends. However, there are no back-up services in place.

In 2001, there were 5,923 infectious disease cases reported. There is not even an out of hours telephone number to contact public health doctors and the other individuals involved in providing back-up services. That basic element is not even in place. Our out of hours service is a sham, our infectious diseases policy is a sham and there is no one to cover infectious diseases at the weekend. It is by the grace of God that we have not had a catastrophe in this country, and the Minister is turning his back on this and is not prepared to put any proposal on the table to address this issue.

One of the other roles of public health doctors is the co-ordination of services for older people and people with physical and sensory disabilities. This is an important service. Without it, there will be significant problems within the health service. The Minister has talked about the number of elderly people in acute hospital beds who should not be there. They need to be released into the community or into other hospitals, but they are putting pressure on acute and geriatric services because the structures and supports have not been put in place. They have not been put in place because public health doctors have not been given the resources and they are not being put in place at present. The hospitals, therefore, are delaying the release of those patients and that is putting pressure on acute hospital services.

The Minister talks of reform. Public health doctors are crucially important and are key to any reform of the health service. As Deputy Olivia Mitchell said, prevention is better than cure. However, the Minister has taken no action or decisions on reform and we are still waiting to see what proposals, if any, he will put on the table in the industrial dispute with public health doctors.

If a health care worker in a maternity hospital had an infection such as hepatitis or HIV, public health doctors would have to go and trace that worker. A patient treated by such a care worker would like to know about it as swiftly as possible, but the resources are not being put in place and the Minister is not prepared to put an out of hours service in place.

It is about time the Minister resolved this dispute. Nine years is long enough for it to go on. It is about time it was resolved and that an adequate 24-hour, seven day a week service was put in place. The fact that the industrial action is taking place and the difficulties with SARS exposes what has been bubbling under the surface for years. As I said, we are blessed that we have not had a catastrophe to date.

I want to focus on something Deputy Olivia Mitchell spoke about earlier, namely, the cutbacks in the Western Health Board where €5 million less has been provided in 2003. There is the ludicrous situation in the Western Health Board where we will pay staff and will maintain our hospital beds, but we cannot afford to put patients into these beds. The only way we can put patients into them is to tender for the treatment purchase fund. We must go back to the Department tendering for the treatment purchase fund so that we can put patients into the beds, even though the staff will be paid and the hospital beds have to be maintained.

Ms O. Mitchell

We are going to pay them twice.

Mr. Naughten

This is a crazy system. We cannot treat our own patients, but we could be treating patients from Waterford and Limerick, for example, while our own patients remain on the waiting lists for elective procedures. That situation has not been addressed. That is the sham in the public health service. It is a crazy system where we are paying doctors and staff, yet we must keep beds closed because we cannot afford to put patients into them.

Our accident and emergency units in small hospitals are under threat. There is a question mark over them. Only last year the Department of Health and Children invested in a new accident and emergency facility in my county hospital in Roscommon, which is under construction at present and which is costing nearly €10 million. I welcome that investment, but we have not received a commitment regarding the long-term future of that accident and emergency unit. That is a crazy system of planning and it is typical of what is going on.

The accident and emergency unit in Portiuncula Hospital in Ballinasloe has a massive catchment area. We do not even have a 24-hour ambulance service covering a large geographic area. That is the type of system in place. It is breaking down on a day-to-day basis. It is about time the Minister took action.

Minister for Health and Children (Mr. Martin)

I move amendment No. 1:

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

– endorses the speedy and comprehensive response by the Minister for Health and Children to the threat of SARS which is fully in accordance with World Health Organisation guidelines and endorsed by them, including in particular:

– the prompt and ongoing public information campaign alerting members of the public to the signs and symptoms, causes and transmission modes of SARS and travel advisories in relation to travel to and from affected areas;

– the detailed guidance provided to health professionals in relation to the diagnosis, clinical management, surveillance and contact tracing for suspect and probable SARS cases and to airline crew and cleaning staff in relation to the possible in-flight care and follow-up procedures for a suspect case of SARS;

– the comprehensive operational framework established to provide an integrated public service wide response, comprising:

– an expert committee

– an interdepartmental planning group

– a health service implementation group, and

– a communications group;

– acknowledges the Minister's efforts to resolve the public health doctors dispute within the framework of public sector pay policy, in particular the social partnership agreement, Sustaining Progress, and calls on the Irish Medical Organisation to continue talks with a view to resolving the dispute having regard to the serious threat posed by infectious diseases, including SARS;

and

– notes the intention of the Minister for Health and Children to bring proposals to Government shortly for the reform of the health services.

I welcome this opportunity to address the House on the issue of severe acute respiratory syndrome, SARS, which has been the subject of much commentary and analysis in both the general and specialist health media in recent times. I intend to confine myself to the subject matter of the motion tabled by Deputy Olivia Mitchell and her colleagues. If Deputies wanted to discuss other issues, they should have been encompassed specifically in the motion before us.

I am somewhat disappointed by the tone and tenor of the content of the debate so far. In their contributions, members of the Opposition have demonstrated a level of political opportunity that represents a new low in cynicism and delusion.

Mr. Neville

That is rich coming from Fianna Fáil.

Mr. Naughten

The Minister should tell that to the people on the street.

Mr. Martin

There has been considerable hypocrisy and hype. It is important to keep some sense of perspective in this debate.

Ms O. Mitchell

Just like the Minister did in opposition.

Mr. Martin

It is nonsense to hear Deputy Naughten talk about vaccination programmes being a disaster. Let us remember that successive Governments historically have dealt with infectious diseases in this country with dramatic impact and effect. I invite anybody to look at the mortality reports of the 1930s, 1940s, 1950s and the 1960s and how we have eradicated most of the infectious diseases by vaccination programmes. The most recent illustration of that—

Mr. Naughten

What about the out-of-date polio vaccines? How many of them have been traced?

Mr. Martin

The most recent illustration of that was the meningitis C vaccination programme, a well organised, well resourced and well managed vaccination programme which in two years has recorded an extraordinary reduction in the incidence of meningitis C.

Mr. Naughten

What about the trace-back procedures?

Mr. Martin

We have to be careful about the language we use in terms of describing certain programmes within the health service, because that also lacks credibility. I respectfully suggest to Deputy Naughten, for whom I have considerable respect, that the type of language used in describing the vaccination programmes has no credibility when one looks at the facts and the outcomes of the most recent vaccination programmes.

Mr. Naughten

Let us look at the facts. What about the trace-back?

Mr. Martin

People can quote from various articles published in The Irish Times. There was an earlier editorial in that newspaper on SARS, which Deputy Neville did not quote, that praises the early production of guidelines and protocols by the NDAC and the Government at that time.

Mr. Neville

Guidelines and plans are no good without action.

Mr. Martin

Deputies do not quote that and do not have such long recall. They did not have a particular issue with SARS at the time the congratulatory editorial was written.

Ms O. Mitchell

It is a long time since The Irish Times congratulated the Minister.

Mr. Martin

Prior to Holy Thursday, the House did not over-exercise itself in relation to SARS or anything else. I would like to present a brief overview of SARS and why it has become such a topic of worldwide public concern.

Severe acute respiratory syndrome is an acute respiratory illness of unknown origin, which was first recognised in south-east Asia in February 2003. Owing to the serious nature of the infection, its high mortality and its spread to a number of different countries, it was declared a threat to international health by the director general of the World Health Organisation in March 2003. As part of its worldwide surveillance of the syndrome, the World Health Organisation has requested member states to provide information on their experience. As of 5 May 2003, a cumulative total of 6,583 "probable" SARS cases with 461 deaths have been reported from 29 countries to the World Health Organisation. To date, Ireland, in accordance with World Health Organisation guidelines, has confirmed to that organisation that it has one "probable" case, reported many weeks ago. One probable case does not justify the invective and hyperbole that we have heard this evening.

Ms O. Mitchell

In the case of the iodine tablets, we had no nuclear accident.

Mr. Martin

The 15 EU countries between them have 32 "probable" cases with no deaths. Our nearest neighbour, the UK, has six "probable" cases. Areas of Asia account for the vast majority of cases and deaths. Outside this area, Canada has been most affected. The World Health Organisation has been quite assertive on this issue, saying that its fundamental advice, which we took on board at a very early stage, has been the principal factor for the curtailment of the spread of SARS in areas outside Asia. Those are not my words. That is the consistent position of the World Health Organisation as expressed personally to me by its officials and yesterday to the European Union Council of Health Ministers by the director general of the WHO.

The symptoms of SARS include high temperature and dry cough and-or shortness of breath and-or difficulty breathing. This is relevant only to people who have been in the affected areas and-or have had, during the ten days prior to onset of symptoms, close contact with a person who is a suspect or probable case of SARS.

As the WHO itself recognises, the case definitions, which it has provided to member states to assist in global surveillance, are subject to limitations due to the evolving nature of the illness. They are based on current understanding of the clinical features of the disease and the available epidemiological data, and may be revised. It also makes allowance for the fact that countries may need to adapt the definitions to their own disease situation.

To understand this issue, it is worthwhile for me to set out clearly on record the case definitions for SARS. A suspect case is a person presenting after 1 November 2002 with history of high fever and cough or breathing difficulty and one or more of the following exposures during the ten days prior to onset of symptoms: close contact with a person who is a suspect or probable case of SARS; history of travel to an affected area; and residing in an affected area. A suspect case may also be a person with an unexplained acute respiratory illness resulting in death after 1 November 2002 but on whom no autopsy has been performed and one or more of the following exposures during the ten days prior to the onset of symptoms: close contact with a person who is a suspect or probable case of SARS; history of travel to an affected area; and residing in an affected area.

A probable case is a suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome, RDS, on chest X-ray or a suspect case with autopsy findings consistent with the pathology of respiratory distress syndrome without an identifiable cause.

While there was considerable media coverage in relation to the change in status between a "suspect" and "probable" case, the World Health Organisation's guidelines indicate that because there is no diagnostic test for the virus, SARS is currently a diagnosis of exclusion and that the status of a reported case may change over time. In its documentation, it describes a number of scenarios in which this process could occur.

Examples given include: a suspect case who, after investigation, fulfils the probable case definition, should be reclassified as "probable" and a case initially classified as suspect or probable for whom an alternative diagnosis can fully explain the illness should be discarded. That happened prior to the incident mentioned by Deputy Neville but nobody took a blind bit of notice at the time. Even when we reported our first probable case, nobody took any great notice even though we issued public statements to that effect. It was reported in the media, but everybody was interested in the war in Iraq at the time.

The existence of SARS was first brought to the attention of the Irish authorities during the week ending 16 March 2003. The early advice from the World Health Organisation was merely to provide information about the new condition to the relevant authorities. When the existence and possible implications of this condition were first identified internationally in March 2003 the National Disease Surveillance Centre, NDSC, following consultation with my Department, issued an alert to all directors of public health on 14 March 2003, which represented a very quick response at the time.

Contrary to reports, my Department moved immediately to respond to the threat of SARS to Ireland. Medical staff from my Department in collaboration with the NDSC spent St. Patrick's weekend making the appropriate international contacts and literature searches to fully assess these factors and, having done so, put in place the initial comprehensive public information and the key issue of professional guidance which has been the basis for our approach to this issue since. This approach has been effective in curtailing the spread of SARS.

I wish to pay tribute to our people in the medical division of the Department under our chief medical officer who gave up their St. Patrick's weekend with the director of the NDSC and its staff to work up these guidelines days after the alert from the World Health Organisation. It is not good enough to hear such terms as "ineptitude", "shambolic" and the kind of invective we have heard this evening from the Opposition when the evidence is there that people in my Department and in the medical division in my Department from very early on worked quickly to develop comprehensive, professional guidelines for the professionals over the St. Patrick's bank holiday weekend. I wish to put this on the record of the House. I pay a warm tribute to those officials who gave good service to the public in the discharge of their duties.

On receipt of the initial report of the situation following St. Patrick's Day – over seven weeks ago – I established an expert group under the chairmanship of Dr. Darina O'Flanagan to advise me on the issue and to make recommendations as to what actions would be appropriate to prevent the establishment and spread of SARS in Ireland. The group monitors the situation as it develops and provides advice regarding the measures required to deal with the syndrome. The group includes representatives of my Department, the health boards and the various clinical disciplines appropriate to the task. This group, which is currently chaired by Dr. Jim Kiely, chief medical officer of my Department, has met 14 times to date and continues to meet twice weekly.

Mr. Neville

Why the change of chair?

Mr. Martin

The Deputy knows that. He was given an answer at the Joint Committee on Health and Children which he attended. The answer is quite simple and straightforward; there is a public health doctors strike as we speak.

Mr. Neville

Did the Minister do anything about it?

Mr. Martin

The deliberations and recommendations of the group are based on a number of sound, well-tried infectious disease surveillance, control and prevention principles which are internationally accepted and are exemplified in the guidance on this issue published by the WHO, the Centre for Disease Control and Prevention in the USA and a number of other reputable international public health institutes including the NDSC. These include: accurate, well-informed and easily readable public information; sound practical preventative measures including such basic measures as good hand washing; early identification of cases; effective clinical care including good hospital infection control; effective follow-up and management of contacts; rational travel advice for people travelling to and from areas which are affected by SARS; and legal effect to recommended measures including the designation of SARS as a notifiable disease.

Experts from the WHO have fully endorsed the measures which we have put in place to prevent the establishment and spread of SARS in Ireland. Yesterday on the BBC World Service – to which I know not everybody might be listening – Ireland and the UK were singled out for having managed the situation well by a different spokesperson from the World Health Organisation.

Mr. Naughten

GIS is working overtime.

Ms O. Mitchell

The machine is working well in the Department.

Mr. Martin

When one is in Brussels one gets a lot more information on what is going on worldwide. That is actually how we are perceived and the kind of comments people are making internationally—

Mr. Neville

Has the Minister read The Irish Times?

Mr. Martin

—is at great variance with the political commentary we are receiving here which has more to do with political issues than with the reality of the situation. On the basis of advice from the expert group, the following information and guidance, which is then disseminated through the system for use by health professionals and management staff, has been developed: protocols and guidance for hospitals and health professionals which describe the syndrome and provide advice on how cases should be clinically diagnosed and managed have been developed and widely disseminated; guidance for laboratory and infection control staff is now in use, as is information and guidance for aircraft cabin and aircraft cleaning staff; and travel advisories have been given regarding travel to and from affected areas. Essentially the advice is not to travel to an affected area and persons travelling from an affected area are advised to monitor their health for ten days following their return. If they develop any of the symptoms they should seek medical advice urgently and advise the relevant medical practitioner that they have recently been in an affected area. Advertisements to this effect have been prominently displayed in the national newspapers on a number of occasions since the end of March last. Specific travel advice has also been developed for health care workers.

Since the incubation period of SARS can be up to ten days, general registration or health controls, that is, screening at ports of arrival in Ireland, are of little value. On the contrary, they may give the public a false sense of security. This is in line with expert advice received from the World Health Organisation and the European Union communicable diseases committee which I can make available to Deputies. Instead, the WHO recommends that persons departing an affected area should be interviewed by a health worker to assess whether they have any of the symptoms of SARS or have had any contact with a probable or suspect case. That issue about the incubation period is important in terms of screening when people present. It was interesting to hear yesterday at the Council of Health Ministers that the vast majority of the exported cases into Europe would have been well on both departure from the area where the infection was acquired and on arrival at their destination. However, there was much hysteria about two weeks ago in regard to the lack of screening at our airports and a lot of ill-informed comment. There are issues around that which we can debate in a balanced and sensible way but these are the facts.

Recommendations have been made as to the nature of the public information which should be made available. Arrangements have been put in place to give effect to this and early in the process, information was made available by way of notices in airports to alert travellers to the issue. This effort was expanded recently and, with effect from Monday, 28 April 2003, arrangements were made to hand out information leaflets on all incoming flights to Ireland and at other points of entry – ports and the Enterprise train line. It is estimated that some 100,000 leaflets per day will be distributed through these channels. Public announcements are also being made on incoming flights and ferries. SARS information desks have been set up at arrival terminals in all airports and ferry ports. A national free phone line, 1800 45 45 00, has been set up with effect from 28 April. Full information is available on my Department's website which is updated daily. Consideration is also being given by the expert group to the issue of the public health implications of participation by a number of countries in the Special Olympics. It is anticipated that a decision will be taken by mid-May and I await the advice from the expert group in that regard.

My Department has produced a detailed frequently asked questions document which, in addition to being available on my Department's website, has been circulated to other health agencies and organisations, including trade unions, educational institutions, professional bodies, etc., for circulation and display on their websites.

Mr. Neville

The most frequently asked question is: "Who is in charge?"

Mr. Martin

In addition, I have ensured that an organisational framework with clear lines of responsibility and whose function is to ensure that the recommendations of the expert group are implemented in their entirety has now been developed within my Department and includes the following: an interdepartmental planning group which is responsible for co-ordinating the measures needed in other areas of public policy or public services to support the protection of public health; feeding back on the ongoing effectiveness of measures taken; and considering, in light of SARS development nationally and internationally, any further measures required.

In addition, there is now a health service implementation group which consists of senior management of my Department and the chief executive officers of the health boards which is responsible for ensuring a full response by all aspects of the health system to the SARS threat including: arrangements for treatment of SARS cases, both in hospital and the community, including appropriate surveillance; an adequate public information and advisory service locally; adequate protection of health service staff; staffing of information points at airports and relevant ports; a system for notification of potential cases and prompt follow-up of contacts; arrangements for isolation and quarantine where necessary; and prompt information flow to the incident room in my Department.

Furthermore, a communications group, which is led by the press office of my Department in liaison with the Government Information Service, GIS, and communication officers of each health board, is responsible for co-ordinating all communications relating to SARS, including information to the public, statements to media and daily press briefings.

We must recognise that SARS is a new and unpredictable condition. While the spread of the disease has been facilitated by rapid international travel, the actions of the WHO have allowed a remarkably rapid identification of the features of the syndrome, its causative organism, rapid progress towards the elaboration of a reliable diagnostic test and the implementation of a series of public health measures which have allowed for the control of the outbreak in a number of countries in which it was established and prevention of its wider spread. However, the continuation of the outbreak in the most populous country on earth gives serious cause for concern. It emphasises the need for continuous vigilance and for the effective implementation of the public health measures which have so far allowed countries in the European Union, including Ireland, to control the outbreak. We are determined to continue to draw upon the most up-to-date international and national information and expertise to inform our approach to this disease, to collaborate with our EU and WHO partner member states in the fight against SARS and to maintain a state of readiness to deal with the illness as it evolves.

Of course the public health doctors dispute has hampered our response to the SARS threat. I have been consistent about that from the word go. In response to this, the Department, together with the Eastern Regional Health Authority and each health board, have put emergency contingency plans in place to enable them to provide an emergency response to infectious disease outbreaks, including SARS, during the course of the strike. These plans include: the establishment of a national network of senior co-ordinators at health board level – the co-ordinators monitor the contingency plans and report on suspect cases throughout the country; the establishment of an incident room with a dedicated national call number in the Department of Health and Children – staff are available at all times to deal with issues that may arise in health boards and reports on queries that may arise are issued twice daily from health boards to the incident room; and ensuring that the country's experts in virology, respiratory infections and infectious diseases are available to advise and assist in the diagnosis and treatment of suspected SARS cases. Although less than optimal, I am satisfied the contingency plans have enabled an adequate response to the diagnosis and treatment of suspect SARS cases.

I now turn to the strike by public health doctors, who are members of the Irish Medical Organisation. A national strike by any group of health care workers will always have implications for our health service. I value the important contribution made by public health doctors to the health services, particularly in relation to population health and preventative medicine. I have worked very well with public health doctors since I became Minister for Health and Children on a wide range of campaigns and issues. However, I wish to state again, on my own behalf and that of the Government, our serious concern at the national strike action by public health doctors in pursuit of a 30% pay claim.

Groups of staff at every level right across the health system enter claims about a variety of issues related to their terms and conditions of employment. If my job as Minister for Health and Children, or my Department's role, was to simply say "Yes" to each of these claims and demands, not only the health system but the entire country would be bankrupt in no time. There are general frameworks – for example, the various pay agreements – within which any such claims have to be examined and considered. There is also the formal industrial relations machinery through which valid claims must be processed. It is simply not within my power or that of my Department or the HSEA or any other agent of management to simply concede major pay claims just because they have been demanded. That would be the easiest thing in the world to do and that is what the Opposition seems to be suggesting we should do.

Ms O. Mitchell

The Minister knows we are simply asking him to talk to the people concerned.

An Leas-Cheann Comhairle

Order, please. The Deputy will have an opportunity to reply.

Mr. Martin

The Deputy's contribution tonight was as good as that of the IMO in terms of presentation of its case. Opposition parties should not parrot the unions all the time, in all situations.

Ms McManus

Is the Minister not parroting the employers?

Mr. Martin

As a general rule, I do not parrot. Such a scenario as I have just outlined does not apply to any group in the health system or the wider public services. We just cannot say "Yes" to every demand which comes forward. That is simply common sense. This claim has been lodged in relation to the current duties and responsibilities of these doctors and is separate to any pay increase the Irish Medical Organisation has indicated it will demand for the implementation of changed working practices that may be required in the future. It is important to clarify again the background to the current dispute, especially in view of the ongoing variety of selective historical accounts being circulated, some of which we have heard again this evening.

I remind the House of the offer that has been made to the public health doctors and rejected by them. This substantial pay increase would be on top of the increases which fall to be paid under the report of the public service benchmarking body and before the payment of moneys which will arise from the new national wage agreement, Sustaining Progress. The regional public health function was established in 1994, comprising the grades of director of public health, specialist in public health, senior area medical officers and area medical officers. Much coverage has been given to the suggestion that nine years or more have elapsed without the issues at the heart of this dispute being addressed. This suggestion is factually incorrect. Under the original 1994 agreement in relation to the establishment of new departments of public health, it was agreed that a review would be undertaken within two years of the departments getting up and running. This process took longer than expected, which in turn delayed the establishment of the primary health review group until 1999.

The report of the public health review group, the Brennan report, which, through no fault of the parties involved, took longer to complete than anticipated, was published in April 2002. Discussions, both formal and informal, have taken place with the IMO in the interim, though as yet without agreement. In relation to the full review of the public health function, which commenced in 1999, the IMO was an equal partner and co-owner of this review process. The HSEA, the Department of Health and Children and the health boards accept the recommendations contained in the Brennan report. The report, however, reflects the diverging views between the parties on the issue of consultant status for public health doctors. The chairman's comments on the status of directors and specialists were no more than a personal view and, as such, had not the status of a recommendation. The only recommendations contained in the report were on those issues on which the parties were in agreement.

It is important to note that the Brennan report acknowledged there might be a need to revisit its recommendations following the implementation of proposed changes recommended by the health strategy and the primary care strategy. Both of these strategies and the forthcoming report on the audit of structures in the health service and the report of the commission on financial management and control in the health services, will have significant implications for the future role of public health doctors and, as such, must be taken fully into account in any negotiations process.

I have already mentioned the payments which fall due to public health doctors, arising from the benchmarking body and I now wish to refer to this matter in more detail. In 2002, following extensive consideration of a detailed submission by the IMO, the public service benchmarking body recommended increases for public health doctors, ranging from 2.5% for specialists in public health medicine to 14.2% for directors of public health medicine. In making these recommendations, the benchmarking body was determining the rate of pay which should apply to the various public health posts, based on their duties and responsibilities as of 30 June 2002. It is also important to note that these duties and responsibilities have not changed in the interim. The benchmarking body acknowledged that it was not in a position to take account of the issues raised by the public health review group. In this regard, the health strategy envisages a population health division being established in each health board, incorporating such areas as public health and health promotion units. These developments will obviously be influenced by the outcome of the restructuring proposals which are currently being finalised and must be central to any consideration of the future role and responsibilities of public health doctors.

Once again, it is necessary to clarify and reiterate the pay increases that have been offered to public health doctors, based on their current role and responsibilities, to resolve the key issues at the heart of this industrial relations dispute. On 14 March at informal talks in the Labour Relations Commission, management made an offer of 10.5%, excluding benchmarking, through the independent chair. This offer was confirmed in writing by the HSEA on 18 March. Taking into account the increases awarded to public health doctors under benchmarking and the Sustaining Progress national agreement, the application of this increase would result in the following increases for public health doctors between now and 2005, when the Sustaining Progress agreement ends. Directors of public health would receive an increase of €29,000, or 35.39%, bringing them to €111,000 per annum. Public health specialists would receive an increase of €17,000, or 21.52%, bringing them to €95,000 per annum. Senior area medical officers would receive an increase of between €17,000 and €19,000, or 30.41%, bringing them to between €71,000 and €81,000 per annum. Area medical officers would receive an increase between €11,000 and €13,000, or 22%, bringing them to between €59,000 and €69,000 per annum.

The HSEA also requested the IMO to agree to have all outstanding issues referred to the Labour Court. Unfortunately, the IMO did not agree to this request and the strike started on 14 April. On 17 April, I wrote to the IMO requesting that it return to the negotiating table. On 22 April, I again wrote to the IMO confirming the availability of the HSEA and my Department to re-enter discussions with the IMO on the four specific issues identified as being in dispute. On 23 April I invited a delegation from the IMO to meet me. Although it was not possible for the IMO to accept this invitation, I had a telephone discussion with the IMO president on that day. On 24 April, the national implementation body urged the IMO to suspend its strike and avail of the industrial relations mechanisms, in accordance with the conditions of the Sustaining Progress national programme. That was rejected, almost summarily, by the IMO. On 25 April, I had an informal discussion with the president and chief executive of the IMO at their annual conference in Killarney, following my address to that conference.

I have given those details to demonstrate to the House that it is untrue to claim that nothing has been done or that we have not made every possible effort to bring this dispute to a resolution. The IMO agreed on 30 April to enter into exploratory talks in the Labour Relations Commission with the HSEA and my Department. Those talks took place on 1 May and management indicated its willingness to discuss the implementation of the recommendations of the report of the public health review group, including the development of a structured out-of-hours system. In addition, the increase of 10.5% to which I have referred was again offered. During these talks, management stressed that the issue of granting consultant status to directors and specialists was not the subject of a recommendation by the group, but merely the expression of the chairman's viewpoint.

I have already acknowledged on a number of occasions that the professional input made by public health doctors to the management of infectious diseases and other public health threats is significant. I have also made clear my belief that the response of the health system is significantly hampered by the absence of that input. I and my Department have done and are doing all in our power to facilitate the resumption of negotiations on outstanding issues. I again take the opportunity to appeal to the IMO to call off its industrial action and, in accordance with the terms of Sustaining Progress, participate meaningfully in negotiations under the recognised industrial relations machinery with a view to having outstanding issues resolved as speedily as possible.

I now turn to the reform of the health system. The health strategy identified the issues which needed to be addressed in reforming the health system, namely, the complex structure of decision-making, roles and responsibilities within the health system, the many layers and intersecting roles, and the lack of consistency in the development of systems and the application of schemes. It concluded that while the system has served us well in many respects, there remained a need for stronger co-ordination and integration of functions and services, greater consistency in access to services and delivery of services throughout the country and greater clarity around levels of decision-making in the full range of organisations and the requirement for "whole system" effectiveness.

There are three reports currently pending which will inform me and the Government in relation to the formulation of a comprehensive reform programme for the health system. These are the audit of structures and functions in the health system, the report of the national task force on medical staffing and the report of the commission on financial management and control systems in the health service being undertaken on behalf of my colleague, the Minister for Finance. These reports are at different stages of finalisation. My colleague, the Minister for Finance, has recently received the report of the commission on financial management and controls in the health service and is now considering its contents. The work of the national task force on medical staffing is at an advanced stage but has not yet been finalised. A final draft of the audit of structures and functions in the health system has been received by the steering group overseeing the project. I anticipate that this report will be submitted to me very shortly. In consultation with my colleague, Deputy McCreevy, it is my intention to propose, in due course, an integrated reform programme to the Government based on the findings and recommendations of these reports. That integrated reform programme is based on considerable consultation and detailed work. Decisions will obviously flow from that reform programme and it will be interesting to observe the Opposition's response to those when they emerge.

Ms McManus

I wish to share my time with Deputy Burton.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Ms McManus

I welcome this debate which affords us a timely and important opportunity to focus on the crisis in our health service. At a time when strong political leadership and clear vision are required, we have a lame-duck Minister who, despite all the evidence to the contrary, keeps saying that there is no crisis, while all around him hospital wards are closing, procedures are being cancelled and patients are suffering. The Minister's claims that there is no crisis in our health service have about as much credibility as the claims made by "Comical Ali" that Iraq was winning the war.

It is time for the Minister for Health and Children, Deputy Martin, to go. A fresh start is needed and a new Minister would be a good first step. However, the Government as a whole has to accept the blame for the failure to tackle the issues surrounding the good, fair and efficient provision of health care to those who need it. Ultimately the Taoiseach is responsible for Government policy and his lack of interest and the absence of his leadership to deliver the reforms needed in the health service have meant that the real issues have been left to fester.

Had he shown the same commitment to improving the health service as he has shown to promoting the Abbotstown project there would have been a sea change in health. Had he shown the same determination that was shown in dealing with the foot and mouth disease outbreak we would see a very different picture concerning SARS.

The Taoiseach said today that the Minister, Deputy Martin, is doing his best but that is exactly what is worrying people. The Minister's best is simply not good enough and the evidence is all around us. The question the Taoiseach still has to answer is what is he going to do about it.

The motion refers to a serious erosion in public confidence arising from the Minister's mishandling of the public health doctors' dispute and from his Department's shambolic approach to the SARS threat, but it is about much more. It is about the current deplorable state of our health service and a Minister who promised to make things better, yet has only succeeded in making things worse.

The response by the Minister to the crisis in our major hospitals is both deficient and disingenuous but, looking back over his record, should we be that surprised? Inequality has deepened during his term of office. Inefficiency has grown rather than lessened under his stewardship.

The health strategy entitled, if anybody remembers, Quality and Fairness, which he initiated, drove and spent a fortune on hyping to the public, is in need of serious resuscitation. Commitments the Minister made on hospital waiting lists, fairness and efficiency are reduced to meaningless rhetoric. The health strategy included commitments to improve public health infrastructure but look where we are now.

The one significant change the Minister introduced at the Taoiseach's behest, in the deal struck with the doctors, was the costly and inequitable provision of medical cards to better off over-70s. The promise made to 200,000 poorer people to give them medical cards was abandoned. It is no coincidence that there is a 90% turnout at elections among the over-70s. Inequality has deepened during the Minister's term of office and inefficiency has grown rather than lessened under his stewardship. These are the hallmarks of his tenure. It is not coincidental that the health strategy, which the Minister produced as his triumph, was published just before the general election. It was not so much a health strategy, more one about winning votes and ensuring that Fianna Fáil got elected. Over and above the health needs of our sick and suffering population, this was a strategy about winning, no matter what fraud was perpetrated or untruths and distortions disseminated.

The Minister, Deputy Martin, was up there with the best of them spinning yarns about how there would be no cutbacks in health and, ultimately, no hospital waiting lists. No sooner was the election over, however, than the Minister rolled out his real agenda – immediately increasing hospital charges and community drugs charges, as well as sanctioning VHI increases. Even then he persisted in telling the public that current service levels in our hospitals would be maintained despite what were euphemistically called "adjustments" in our public finances.

There is no way the Minister can stand over the comments he made, either then or now. The outcome of Government cutbacks on hospital services is inevitable and he should have owned up, instead of hiding behind statistics that were designed to bewilder. A 10% budget increase to the ERHA does not translate into sufficient funds for the hospital service. The major hospitals have, in effect, suffered a 10% reduction in funding as a direct result of Government policy.

The move taken by the five Dublin academic teaching hospitals to make a joint public statement yesterday on the effects of Government cutbacks, is unprecedented. It is also providing clarity on the ongoing deterioration in essential services that is now impacting directly on patient care and patient access. That could have implications if at any point there is an outbreak of SARS in this country. While we all hope that will not happen, we have to prepare for the worst. The impossibility of coping with such an outbreak is clear. As the Minister for Agriculture and Food said so elegantly, the Minister for Health and Children does not have the luxury of a culling policy. He will have to care for patients who will be in a serious condition if SARS is brought into this country by any means.

When we talk about cutbacks we are talking about patients who are already seriously ill from cancer and heart disease. They will now have their treatment delayed or even denied. The statement by the Dublin academic teaching hospitals pointed out that the reduced availability of beds will directly impact on such critical areas such as accident and emergency, where waiting times for admission are already unacceptable. High acuity scheduled admissions – the majority of which are urgent and which are already being curtailed – will also be adversely affected, with direct medical and surgical procedures. This will inevitably mean potential delays in diagnosis of medical conditions, in the performance of necessary operations, such as cancer surgery and cardio-vascular treatments, and in the treatment of the sick with consequent unnecessary morbidity because they cannot get into hospital, including disability, deformity and pain, with reduced quality of life. It further pointed out that as the hosptials embark on major reductions in their bed capacity forced on them by the funding situation, they are concerned that they are taking actions that will undermine the fabric of their services.

I do not ever recall hearing senior hospital personnel, including doctors, making such a statement. It is chilling news for anyone who is suffering from a life-threatening disease and who cannot afford the comfort zone that private health insurance provides. Some 250 hospital beds – all public beds, of course – are to close over and above the 350 beds occupied by long-stay patients who are inappropriately placed. That adds up to 20% of available bed stock in Dublin hospitals and already our bed capacity is too low. The Minister committed himself to providing an additional 3,000 new beds yet this year we will see a reduction of 20% in all, if one allows for bed blocking.

Some 14,000 procedures and operations will not be proceeded with. There are to be cuts in drugs, replacement equipment and staff hours, as well as a deferral of recruitment and delays in the treatment of seriously-ill cancer and heart disease patients. Rheumotology patients may be affected and even in the Children's hospital in Crumlin there are plans to close Our Lady's ward.

Mr. Connaughton

That is terrible.

Ms McManus

Sick children will suffer, yet the Minister reassures us that he can manage any SARS outbreak. Given the crisis in the Dublin hospitals, it is interesting that the Minister is saying his officials met today with the ERHA to discuss the situation. Big deal, Minister, but why did the meeting only take place when the hospitals went public on the effects of the cutbacks? Why did the Minister not ensure that the budgets for hospitals would be safeguarded and ring-fenced so that patients could be looked after? That is his job and his responsibility. We have to ask why the Minister did not ensure that the measures I have mentioned were taken. Is he happy to hide behind the ERHA as long as he can avoid the flak? Is it a question of ministerial incompetence?

We are debating these issues as the public health doctors' strike drags into weeks and the SARS threat becomes more menacing and frightening. An infectious disease that was thought to have a 4% death rate is now estimated to have a 20% death rate. The sequence of events that surrounded a suspected case of SARS when a person presented at a hospital in Dublin reflected an alarming degree of uncertainty and confusion. There has been no clear strategy and no real attempt to sort out the public health doctors' strike. As a result, the public health infrastructure desperately needed in the face of a new and unfamiliar disease epidemic is not in place. The absence of expertise also affects our ability to combat familiar infectious diseases such as meningitis, measles, STDs, the winter vomiting bug and legionnaire's disease. These infectious conditions require good public health measures, but such measures are not being put in place because of the ongoing strike. The public needs to know that the two parties are talking, but all we know is that they are not.

The Minister used the unfortunate phrase "parroting", but that is exactly what he is doing. The same material is being presented to us yet again in relation to the strike. We all know that the strike will have to end and that the problems will have to be resolved at some point. There was a tremendous line-up at last week's meeting of the Joint Committee on Health and Children. The Secretary General and the chief medical officer of the Department of Health and Children spoke to us about how well they are doing in combating SARS. The distinct impression that was received by the members of the committee was summed up by the Secretary General, who said it is not a question of whether out-of-hours cover will be provided in future, but how it will be done. Most members of the committee took this as a signal implying that there would be some shift. When the parties met at the LRC, however, it seems that nothing happened and that the idea of progress was a chimera.

We are experiencing the legacy of six years of a Fianna Fáil-Progressive Democrats coalition Government. Nobody would argue with the Minister that investment has significantly increased, but it has happened without the vital reforms that should have gone hand in hand with capacity building. There has been a very poor return for the Government's investment. Policy in this regard is like putting oil into a clapped-out car engine – the oil pours through the system, but the engine does not run. Having failed to reform the health service to make it more fair and more efficient, the Minister for Health and Children has little to show for his term of office other than a range of new capital projects, many of which cannot be used because staff have not been allocated. Many existing facilities have been closed down because money is not available to run them. Although there is a trail of broken promises, the Minister for Health and Children is telling us that we should not be worried by how he is dealing with the SARS outbreak.

We should remember that the Taoiseach promised that he would deliver major improvements in services throughout the country. The Minister, Deputy Martin, promised that waiting times would be reduced to below 12 months for adults and six months for children by the end of 2002, but 6,273 adults and 1,201 children were waiting for more than that period of time at the end of last year. We were told that no adult would wait longer than six months and no child longer than three months by the end of 2003. Last May, the Minister went further and promised that all hospital waiting lists would be eliminated in 2004. We do not know how serious the problem is at present because the Department refuses to publish the hospital waiting list figures, which are normally published in March. It is almost mid-May and we have yet to see the figures. We do not know what is going on. It is interesting that this information is being concealed.

We need to see significant and continued investment in our health service. Improvements cannot be brought about on the cheap. We need to ensure that the money follows the patient and to incentivise the system to care for patients, rather than have a system where hospitals are penalised for looking after public patients, as they are now. We need to see more autonomy in our hospitals, as well as health board reform. If the Minister comes back with a decent plan, he will receive support from the Opposition benches. Any new health board system needs to be accountable, preferably by direct election. Any new hospital agency should also be accountable, as people who need to access the health service will be disempowered further if it is not. Lack of accountability will lead to greater deficiencies. Accountability and patient empowerment are the keys to providing a decent health service, but we have very little of either at present.

Some political vision, bringing together all the different parts of the health service to work together, is needed if we are to overcome the fragmentation and territorial in-fighting that is endemic in the health service as it stands. We need political leadership, with the drive and commitment that any Government can deliver if it puts its mind to it. One does not have to be Superman to be Minister for Health and Children. We are encountering a failure of political leadership, however.

As a resident of Bray, I welcome the Chinese delegation before the Special Olympics. I look forward to such an event. How can the Minister assure us that the dangers presented by SARS are totally under control? If he attempts to give us some reassurance, how can we believe him, bearing in mind his track record?

Ms Burton

I had the slightly surreal experience this morning of walking through a €100 million unit in the James Connolly Memorial Hospital in Blanchardstown. It is a beautiful building and the beds are made and the pillows plumped up in some of the wards. The door into the unit is locked, however, because the Minister for Health and Children, his Department, the Eastern Regional Health Authority and the Northern Area Health Board have been unable to make arrangements for the opening of this desperately needed facility. The hospital is located in Dublin 15, which is one of the fastest growing areas in Europe. There is a population of over 75,000 in Castleknock and Blanchardstown. The hospital has a huge catchment area in Counties Meath and Kildare. The project I saw today was initiated when I was Minister of State.

Mr. Martin

Come off the stage.

Ms Burton

Half of the hospital lands were sold and the rainbow Government agreed to match the funds that were received – £75 million – pound for pound. The current Government provided some additional funding to bring the total to about €96 million. Not only has the James Connolly Memorial Hospital not been opened, at a huge cost to the Exchequer, but the hospital's key rheumatology Department and its medical section were informed last Thursday that they were to lose up to 40 beds and up to 20 full-time staff on a contract basis. This is gross incompetence. The hospital is located in an area of Dublin which, thankfully and hopefully, will host the aquatic events during the Special Olympics. What incompetence leads the Government to fail to open a significant hospital structure, the funding for which was bequeathed to it by the previous Government – it added to it, quite correctly – at the height of the Celtic tiger?

I wish to speak about rheumatology. Like the Taoiseach, I have worked as an accountant in many hospitals in Dublin. I will give the Minister a small piece of advice, for which he will not have to pay a fortune in consultancy fees. The rheumatology department treats many people on a day bed basis. This means that young people afflicted by various rheumatic diseases can carry on with their family and working lives at no additional cost to the State or themselves. However, the Department and the Northern Area Health Board propose to merge that department with the medical section so that those people will be put on an acute waiting list while, at the same time, this beautiful, newly equipped hospital will have millions of euro worth of equipment lying in cellophane wrappers in its corridors.

I invite the Minister and the Fine Gael spokesperson on health to next week visit the hospital in Blanchardstown. It was named after James Connolly, the anniversary of whose execution is next week, on 12 May – he was executed in 1916. It was named the James Connolly Memorial Hospital by Dr. Noel Browne when he was involved in helping to create it as a sanatorium for TB treatment in the 1950s. The Minister's party, my party and other parties in this House share a common reverence for what James Connolly did. While the Minister aspires to follow in the republican tradition of Fianna Fáil, the mess that his Department and the health board have left in regard to the James Connolly Memorial Hospital is a disgrace. On next week's anniversary, I suggest that the Minister revisits the legacy of James Connolly and that he takes time out of his busy schedule to visit the hospital to see it lying empty and idle at a time of crisis in the health services.

Debate adjourned.