Dáil Éireann debate -
Friday, 21 Nov 2003

Vol. 575 No. 2

Hanly Report: Statements (Resumed).

Mr. Killeen:

People on all sides acknowledge that the national task force on medical staffing was made up of eminent medical experts. It is probably at this stage that any agreement dissipates – there is certainly not a lot after that. The point was made in the report that the task force took no account of industrial relations issues or political considerations. This is presented as a positive thing, but anyone who has had the opportunity of considering the report will have come to the conclusion that it is one of the negative aspects.

To be fair, the task force was required to present its report against the background of the European Working Time Directive, the unacceptably long hours worked by non-consultant hospital doctors, considerable publicity around waiting lists and other weaknesses in the health system and the expenditure of €9.3 billion annually, which is more than the full income tax take in the State. It was presented with a difficult job. However, despite the constraints and the difficult background, much of what is contained in the report is positive. Such negatives as there are can be worked through by the project teams. It is true that in the case of one of the pilot regions – the mid-west – it is not at all clear what criteria were used in designating whether hospitals should be general or local. That is a sticking point for Ennis, because on further examination of the report it does seem that Ennis meets the criteria for a general hospital.

I find it extraordinary that so many consultants, GPs and medical personnel are now vehemently opposed to the report, despite the fact that members of their own representative bodies were the very people who drew it up. The task force claims to have consulted widely, but that is not the view of people in the two pilot regions and in Ennis and Nenagh. If the level of consultation I am told about is correct, it was certainly not enough and people are quite right to complain about its quality. The task force people will say they offered the opportunity of consultation and it was not taken up. There is also a dispute about the number of people dealt with in the accident and emergency unit of Ennis General Hospital. The figure provided by the task force was 15,000, while the annual report of the health board says there were more than 22,000. This is a major discrepancy.

The Hanly report says there are two consultant cardiologists in the mid-west, but as far as anybody there is aware, there is only one. Certainly, when one considers the study's modus operandi and the fact that 350,000 is the designated population for a region, it does seem that an area with a population of more than 100,000 ought to qualify for general hospital status. It must also be pointed out that Ennis hospital has a wonderful record. More than 95% of people who present at the accident and emergency unit are dealt with without ever going elsewhere – they are either dealt with on the spot or admitted. The number of acute medical admissions, excluding geriatrics, is running at more than 2,500 per year, or 50 per week, which is a substantial number.

There are grave concerns at Ennis hospital and in the area about the proposals for accident and emergency services, which I share. I raised these concerns on day one with Mr. Hanly when he outlined what was involved in the report. On the other hand, some of those who have spoken on the issue have been extraordinarily alarmist. There is grave concern among hospital staff that the hospital's reputation is being damaged and undermined by some of the comments. This makes it hard for those of us who are serious about having the best level of service to address these difficulties. It is important that we obtain a good outcome from this report and from the Minister, Deputy Martin.

There is unanimous agreement in Clare, in the health board and right across the region that the case for including 24-hour accident and emergency services in both Nenagh and Ennis is well established. I urge the Minister to include the upgrading of accident and emergency services when he announces the development plan for Ennis hospital soon. The arguments about the distance of people from the hospital, the proximity of Shannon Airport, the industrial base in the area, the requirements of the national spatial strategy and the fact that Ennis is one of the fastest growing towns in the country, are all well known and it is quite clear that they were not properly taken account of in the preparation of the task force report.

The lessons of history suggest that the Hanly report could replace the Fitzgerald report as a template for health service development. The latter was completed in 1968 and was formally revisited two or three times in the mid-1970s and again in the mid-1980s. It was never quite adopted but has always hung over the development of services, making it difficult in the areas which were under review. I have taken a look back at various studies. The 1928 Government commission and 1933 hospitals commission were strongly critical of the small county hospitals on the grounds of inefficiency and unsafe practice. However, the people have long since voted with their feet. They have used the services of the local hospitals because they believe them to be top class. More and more, particularly over the last ten years, people have come to the view that the services in Ennis hospital are up there with the best.

For the record, Mr. Fitzgerald did not even propose a regional hospital in Limerick. He proposed two in Dublin, one in Cork and one in Galway. He wanted 12 general hospitals and said that Ennis hospital should have its role changed to that of a community health centre. At least in the Hanly report there is a stronger emphasis on the development of hospital services in Ennis and there is to some degree a template for going forward. However, unless the project team examining this in the mid-west, along with the others involved, reject the proposal for 24-hour accident and emergency services and ensure that the service is provided, this report will not be acceptable. It can be done relatively easily. I have also seen figures which suggest that it can be done much more cheaply than is proposed in the report.

The report sets enormous challenges for the development of health services in areas such as the provision of equipment and personnel for ambulance services and the recruitment of consultants. It goes some way towards addressing costs. Doing nothing is not an option. The deadline for the working time directive is closing in and there is no doubt that changes must be made. Everyone that has looked at this acknowledges that the only prospect of addressing the difficulties within the timescale of the working time directive is to improve services at all hospitals, including Ennis and Nenagh. This can only happen if they are retained as acute hospitals.

Unless a clear outcome is reached quickly on the mid-west and eastern region, the Hanly report will replace the Fitzgerald report and will hang negatively over the health service. We need to establish exactly what can and should be done. We must accept that the experience in accident and emergency departments in large hospitals is extremely negative for everybody using the service.

We need to face up to the implications outlined on page 118 of the task force report on capital costs. The State is not in a position to provide the funding that would be inevitable in capital terms alone were the Hanly report to be proceeded with. The State is certainly not in a position to provide the alternative services proposed within the timescale indicated. It is not in anybody's interest to do this at any stage. The implications of this part of the report, where it is made clear a number of costs are excluded, must be examined carefully by Government.

The project team that is to consider how the report can be implemented will quickly find that the cost of improving services at Ennis and Nenagh is several times cheaper than doing what has been proposed. Everyone realises that if the number of consultants is to be raised from 109 to 305, there must be places to locate them and their patients. Only 10% of this number would provide these services at no capital cost at Nenagh and for €15 million in capital costs in Ennis.

Mr. Hogan:

I wish to share time with Deputy Crawford. I am glad of the opportunity to speak on the Hanly report. I am glad Deputy Killeen made reference to the report in respect of Ennis General Hospital. I remind him that those on this side of the House share his concerns on the report. We are not being alarmist; people are genuinely concerned about the impact it will have on hospitals such as those in Ennis and Nenagh and St. Luke's General Hospital in Kilkenny. I agree with the Deputy's measured comments and suggestions on how these matters can be overcome.

Mr. Killeen:

Most members of the Deputy's party have been constructive.

Mr. Hogan:

Bigger is not always better. Over the years we have concentrated on critical mass issues, especially in the greater Dublin area. The Hanly report will have a negligible impact on Dublin because so many options are available. I am sure the Minister of State's brother, the Taoiseach, would agree and, as he would say, it is down to the demographics and the geographics. He has used this phrase that encompasses much but answers little.

There has been a national health strategy, the Prospectus, Brennan and Hanly reports and we have even had the Government boasting about the €10 billion that is to be spent on the health service, yet it is worse than what he had many years ago. It is an appalling vista for the taxpayer and patients that, while a great deal of money is being invested in the service, nobody knows exactly where it is going and we are not getting value for money. The patient is not being put first.

Mr. N. Ahern:

It proves the point.

Mr. Hogan:

It proves the point that the Government should have reformed the service before it started spending money. Despite the input of additional funds, public services in the country are creaking. Fine Gael strongly advocates reform. There have been enough reports and we want to see action rather than words. The Hanly report is another action away from the Minister for Health and Children taking action. When will we have the Martin report? The national health strategy was supposed to be the greatest ever report. How many more reports will be written on the health services before we see action?

The working time directive, which is to be implemented, will cost an enormous amount of money to implement. The capital investment needed in regional hospitals has not been provided for in the Estimates. What will we do in the meantime? People will be frightened about the prospects for their local services, especially accident and emergency and maternity services.

I am most familiar with St. Luke's General Hospital, as is the Leas-Cheann Comhairle. The hospital has done an excellent job and has reduced its waiting lists. It has increased its activity and 24,500 admissions were made to the accident and emergency department last year. It is a huge throughput. People can go the hospital's medical assessment unit and get a bed. A large number of patients can be dealt with in short periods.

The geographical area identified in Hanly cites a population of 250,000 and this will certainly have an impact on a hospital such as St. Luke's. I want to see the report being well thought out. I do not want to see a hospital lose some of its services because of the notions of a small group of people who did not consult everybody.

I agree with Deputy Killeen, the general practitioners have a major problem in accepting that they were consulted. Despite the presence of the chairman of their organisation on the review group, I do not believe GPs were properly consulted. If certain services in Nenagh, Ennis or other hospitals are closed, what will be the new catchment areas that will form the new and better services according to Hanly?

The Minister for Health and Children needs to take on the power of the professional bodies. Medical guidelines laid down by medical personnel across the professions call into question whether this report is interested in all parts of the country and not just the large population centres. I urge the Minister to think long and hard before undertaking the implementation of this report. He should take into account the concerns voiced by Members on all sides of the House.

Mr. Crawford:

I thank my colleague for sharing time with me. Will the Minister of State inform us if the task force, especially Mr. Hanly, consult local communities on this issue? It seems that it only consulted the staff and consultants and this is a consultant-led report. This is the 148th report we have received. With a €10 billion budget this year, we want action rather than reports.

The national treatment purchase scheme is an area where money can be saved. Under the scheme, people have been sent to Manchester and elsewhere and anyone who receives treatment is naturally delighted to get it. How much economic sense does this make when the same treatment could be carried out in Monaghan General Hospital where the theatre and staff are available? We want value for money rather than money being wasted for political purposes.

Mr. N. Ahern:

Did Monaghan hospital put a pitch in for this?

Mr. Crawford:

Monaghan hospital is not even allowed to be on-call. Before the Minister took the hospital off-call, it gave Northern Ireland based patients the same treatment now being carried out in Manchester. This is how bad this failure has been.

There is no proper debate. How can I make a reasonable comment on the Monaghan General Hospital issue in the five minutes allocated to me? The Dáil took a week's recess some weeks ago. Why was the Hanly report not discussed on those three days? We have only been allowed to make statements. We are not allowed to ask questions and there is no opportunity to vote. I would like to see people that have been vocal on the report in their constituencies voting here in the way they told their constituents they would. Deputy Hoctor will be aware that I do not refer to her, rather to her famous ministerial colleague who tried to shaft her. The Minister said this was the map of the way forward for acute hospital services and would deliver all necessary facilities and that local hospitals would continue to provide the great majority of treatments.

The following case was brought to my notice this morning. A 97 year old lady was brought to Monaghan General Hospital where she was told she had to go to Drogheda to have her finger looked at, but after waiting a considerable time in Drogheda she was told nothing needed to be done. She was lucky in having her family to look after her and guide her through the system, and the staff were extremely helpful in taking account of the trauma she was experiencing. How does this incident tally with the Minister's statement that all minor cases will be dealt with at local hospitals? Things do not work that way. That lady would not even be taken into Cavan hospital and she had to travel the 60 miles to Drogheda.

Drogheda hospital, where I was born, is an extremely good hospital but it is not capable of dealing with the overload being forced on it and on Cavan hospital. Monaghan hospital has been used as the template for the Hanly report and other reports. It has been closed down without preparation and without funding being provided for the other hospitals which are to provide the additional service.

On 21 October last, a man was rushed to Cavan hospital with a severe chest complaint The consultant in Cavan is trying desperately to have him admitted to the Mater Hospital in Dublin and held him in Cavan hospital, at considerable cost, for three and a half weeks in case anything worse would happen to him. The man is now at home and his family are in desperation because they do not know what might happen from one hour to the next. Nevertheless, the Minister tells us how the systems are to be upgraded. Cavan hospital is doing its best, as is Drogheda. If we are to operate a Hanly report structure we must see capital funding for the regional hospitals before general hospitals are wound down.

In January 2002, the Minister for Health and Children stood on a public platform and guaranteed that all the good things he is now promising to other local hospitals would be delivered to Monaghan if we would only have patience. Monaghan hospital was taken off call on 3 July 2003 and is still not on call, although the staff behind the scenes are delivering the best service possible.

We do not need reports. We need common sense action led by the community and not by consultants, who do not give a tuppence and only wish to ensure that they have the best possible time. The Government must confront the consultants before patients die.

Ms Hoctor:

Tá mé buíoch díot, a Cheann Comhairle, as ucht an seans seo a thabhairt dom labhairt faoi thuairisc Hanly. I am grateful for the opportunity to address the House on the Hanly report.

Nenagh hospital, my local hospital, is a pilot site and, together with Ennis hospital, is under the microscope with the mid-west region's proposed participation in the implementation of the Hanly report. From the beginning I have recognised the benefits for Nenagh hospital in the recommendations of the Hanly report. The report set out to put in place upgraded services to improve patient care to treat the patient in the most appropriate setting, based on the recommendations of medical staff, that is, doctors, nurses, consultants and general practitioners. I believe this is the right way to move in identifying the problems, addressing them and working together with the medical staff to reach a solution which would deliver a world class health service to the patient swiftly, efficiently and effectively.

In putting in place the reduced hours and enhanced services at the regional hospitals I call on the Minister to take cognisance of the importance of hospitals like Nenagh hospital, which currently serves not alone the fast growing population of 7,000 in the town of Nenagh, but the greater rural area reaching back to Riverstown on the Offaly border, Lorrha and Redwood on the Galway border and the large towns of Thurles and Templemore and their rural and often remote hinterlands.

Following the public meeting called by the town council in Nenagh, concerns have emerged regarding not so much what is said in the Hanly report as what is not said in it. I share the concerns of general practitioners and the public about the provision of a doctor for 24 hours and day, seven days a week. It is unthinkable and unacceptable that, in the long-term, a doctor would not be on duty at Nenagh hospital between 9 p.m. and 8 a.m. The current provision of an anaesthetist on call overnight for accident and emergency in Nenagh is paramount and must stay. This is proved by specific cases of people who have been stabilised in Nenagh and kept overnight because they would not have survived the journey to Limerick in the initial stages of trauma. General practitioners need the assurance that they may admit a patient at any time of night if they so need.

Mr. Hanly's proposals focus on securing benefits for the centres of excellence in a large urban setting but due regard must be given to the rural population dispersed in the far-reaching countryside. Those in trauma a long distance away need the assurance of an accident and emergency service in Nenagh.

I welcome the concept of emergency medical technicians with advanced training. I call on the Minister to proceed with the training of such teams in co-operation with the unions, putting in place the advanced ambulance service and, at the same time, leaving accident and emergency services in Nenagh. The merit of the emergency medical technicians is not clear to the public or even to some medical staff and nurses. It is not until there is full confidence in the proposed enhanced ambulance service that it will be acknowledged.

We hear on the grapevine in Nenagh that the rabbit will be pulled out of the hat and that the leader of the Labour Party will join our march next Saturday week in defence of Nenagh hospital. The Labour Party in north Tipperary has been known in the past for great talk and pathetic delivery. Mr. Barry Desmond, when Minister for Health, had an ideal opportunity to upgrade Nenagh hospital, as had his colleague, Mr. Brendan Howlin, but no capital investment was made by either of them. They are good to talk but poor on delivery.

I acknowledge the investment already made by the Government in Nenagh hospital, with an additional consultant and a fine extension wing. The €5.5 million invested, and now visible in the comfort of the new extension, is indicative of the Government's commitment to Nenagh hospital. This includes the enhanced intensive care unit facility first introduced to Nenagh by the Minister for Health, Deputy Woods, and upgraded in 1998 when announced by his successor, Deputy Cowen. Provision of the much needed psychiatric unit in the next three years will be welcomed by the local people whose needs are being served in St. Michael's in Clonmel until the unit is finally in place. I welcome the Minister's recent approval of a new community hospital facility at Thurles which will replace the existing Hospital of the Assumption, and I thank the Minister of State, Deputy Callely, who was to the fore in achieving this. Continued investment is needed to upgrade the services at Nenagh and to reduce our dependency on the larger hospital in Limerick.

While I fully acknowledge the need for specialist multidisciplinary teams it has been clearly stated by GPs, nurses and medical staff associated with Nenagh that the hospital is capable of enhanced treatment services with additional staff and equipment in place. The provision of a CT scanner and MRI scanner with the accompanying staff would give greater support to the medical and surgical facilities already in existence in Nenagh. I welcome the recognition given in the Hanly report to the identified need for this equipment and urge the Minister to accept that these are clearly needed at Nenagh hospital.

We are in earnest in holding on to what we have with a view to seeking funding for enhanced services at Nenagh. This would enable us to continue what is already being done in Nenagh with greater ease, swiftness and effectiveness.

We need the retention of the service of a doctor 24 hours a day, seven days a week to assure general practitioners that a patient may be admitted to Nenagh hospital at any time of the day or night. We need to retain our accident and emergency services as we know them and enhance our ambulance service by providing it with upgraded equipment. We want to keep our services in Nenagh. In retaining them we look to the Minister for enhanced services, including the CT scanner, the MRI scanner and cardiologists, so that the service currently in place in Nenagh may continue with greater effectiveness. I look forward to working with the Friends of Nenagh Hospital action committee, the project team and the Minister to solve the difficulties and deliver for greater patient care in north Tipperary and the mid-west region.

Mr. P. Breen:

I wish to share my time with Deputy English.

An Ceann Comhairle:

Is that agreed? Agreed.

Mr. P. Breen:

There is a big difference between the two pilot areas outlined in the national task force report, namely, those of the Mid-Western Health Board and the East Coast Area Health Board. Loughlinstown Hospital is located within six or seven miles, or within half an hour, of St. Vincent's Hospital. The downgrading of Nenagh and Ennis hospitals would have a huge effect. We have all used the words "demographic" and "geographic" over the past week but I believe those who wrote the Hanly report, including Mr. Hanly, did not understand the demographic and geographic considerations.

I am delighted to have the opportunity to speak on the famous Hanly report but I regret very much that the House is only having statements on it. Had there been a vote on the report's recommendations, it would have been interesting to see if Members on the other side of the House would have voted against them. I welcome the statements of Deputies Killeen and Hoctor on the predicaments in which they, as Government Deputies, found themselves. I hope they will continue to lobby the various Ministers concerned to ensure that the 24-hour accident and emergency services are maintained in both Ennis and Nenagh hospitals.

I read in The Irish Times this morning that the Minister for Defence, Deputy Michael Smith, will be given a key role in implementing the health reforms. I hope he will use his influence on the Cabinet sub-committee to reiterate his public criticisms and his expressions of concern, uttered on three occasions, regarding the downgrading of Nenagh Hospital. This is very important. Much has happened in the two weeks since the report was published.

The 215-page Hanly report was commissioned to put in place the framework for the implementation of the EU Working Time Directive in respect of junior doctors. It now appears that Mr. Hanly was given the task of producing the report in the certain knowledge that no extra funding would be put in place for the implementation of the directive. The funding to implement the proposals and create centres of excellence, as provided for in the recently published Estimates, is very paltry. Therefore, I cannot see how the recommendations can be implemented. Mr. Hanly says implementation should take place immediately, but if there is no money available this cannot happen.

Mr. Callely:

Ten billion euro.

Mr. P. Breen:

What will the Minister of State do if he closes down Ennis and Nenagh hospitals and has to make up 300 beds and upgrade the ambulance service? One should remember recent reports on the ambulance service which stated that one in three ambulance response times—

Mr. Callely:

The Deputy should stop talking nonsense.

An Ceann Comhairle:

Allow Deputy Pat Breen, without interruption.

Mr. P. Breen:

—is above the accepted level. The Minister of State, Deputy Callely, should have been in Ennis last Saturday afternoon when 15,000 people turned up to state that they were not accepting the Hanly recommendations. This was the clear message sent to the Government on the day. Even the Fianna Fáil Party was represented at the march.

Mr. Callely:

We are building a first-class service—

An Ceann Comhairle:

I ask the Minister of State to allow Deputy Pat Breen to contribute without interruption.

Mr. P. Breen:

The Hanly report recommendations cannot be implemented. It offers no realistic solutions to the crisis in the health service. The plan is, in essence, a dangerous experiment which, if implemented, will see more people suffer and die.

Paragraph 3.7.5 of the Hanly report states:

The conclusion that the full range of emergency services can only be provided in Major Hospitals may raise concerns about the access of patients to treatment in life-threatening situations. It should be noted, however, that many of the main life-saving measures in emergencies are not affected by the immediate proximity of a hospital. The critical concerns are early resuscitation and early access to skilled diagnostic, medical, surgical and anaesthetic care. This can best be provided in a consultant-staffed Major Hospital . . . .

In other words, it states that proximity does not make a difference in terms of life-saving measures, yet it states that early access is important. This is totally contradictory. The Minister speaks of the services we will get in Ennis General Hospital. We will lose many services, including the acute accident and emergency facility. People are very concerned about this.

An Ceann Comhairle:

The Deputy's five minutes have concluded.

Mr. P. Breen:

I could have spoken for 20 minutes because there is so much to talk about, but there will be another day. The Minister of State should have watched "Prime Time" last week and listened to the consultants talking about many lives which have been saved in Ennis General Hospital. He should read this week's The Clare Champion, which he has probably not yet received, the main headline of which reads, “We are all off to Dublin”.

Mr. Callely:

We are making great progress.

Mr. English:

I am glad the Minister for giving out housing is with us today. This is the Minister of State's new post, based on what I heard last Friday.

Mr. Callely:

I do not understand that at all.

Mr. English:

The Hanly report makes recommendations on the future of the health services for the next 20 years and more. Considering that the Cabinet could not agree on it, it will be very hard for everyone else to accept it as a blueprint for the future. While nobody could question the qualifications of those who produced the report, they have made insufficient reference to instances in which they asked customers or patients for their views. Fine words and rhetoric are coming from the health experts but there is no proof that they consulted any groups or organisations.

One must define clearly whether the projected health service will be for the health care professionals or for the patients who need it. The report states that compliance with the EU Working Time Directive and the move to a consultant-provided service "will require phasing out all non-training NCHD posts . . . and ensuring that additional posts are not created purely to meet service needs." What is the point if it is not to meet service needs? This is the purpose of the health service. I am worried about this.

Local hospitals, such as that in Navan, have over many years and at a cost of millions of euro of taxpayers' money, established a long tradition of caring for the communities they service and from which they derive a large proportion of their staff. Many more voices than that of Mr. Hanly will be required to convince the people of Navan and other areas that the maintenance of their hospitals is not the best approach for them.

It has been stated in public – I am inclined to agree – that because of the Government's record, the Hanly report will be cherry-picked by the Government to achieve what it wants to achieve, i.e. cutbacks in the health service. I assure the House that I, for one, will not tolerate any negative changes under the report until permanent infrastructure has been put in place and until the people are guaranteed a proper, efficient health service where it is needed.

We all strive for a better health service. As the Minister of State said, €10 billion is a lot of money, but we all know we are not getting value for it. In spite of what the Minster for Health might say, he is at fault. He is the boss.

A 4% increase in the number of beds available in recent years represents a complete failure. No matter how much the Hanly report is talked up, it cannot take away from this.

Mr. Callely:

Expenditure increased from €3 billion to €10 billion in the past—

Mr. English:

I am talking about beds and service on the ground. I compliment the Minister of State on the amount of money that has been allocated, but he will agree that we are not getting value for it.

We require root and branch reform of the health service, starting at the top and working down rather than in the other direction. The Hanly report is a challenge and an opportunity for us all, but without an understanding of this challenge or a willingness to accept criticism or genuine objections, health service reform will not stand a chance. I am not saying I fully accept the report but I realise it has some good proposals. My only hope is that it, like so many reports before it, will not end up on the shelf or in a bin because of a lack of political leadership. This would be wrong.

I agree with the concept of health service reform. Hanly 1 is not the full answer. I want to see Hanly 2 and then we will decide if it is right or wrong. There is no point in publishing a report that says future reports will be published which will not focus on Dublin and the bigger regions but on the other hospitals in the country. This is not good enough. We cannot make decisions based solely on the first Hanly report. It has both good and bad recommendations. It has caused much fear because it is not clear or concise. It does not appear to be patient-orientated. We need to get the rest of the information before we start making any major changes or decisions to wind down or downgrade hospitals.

If one were to ask the average person on the street to make a choice between a top class, regionalised health service, which we all agree would provide the best service once one reaches hospital, or local hospitals which currently provide a high quality service, he or she would choose a local service. We all say politics is about location, location, location – the same applies to our hospital services. When the work is being done for the second Hanly report, I will make a strong case for Navan General Hospital because it is in the right location.

Dr. Devins:

I welcome this opportunity to speak on the Hanly report or, to give its full title, the report of the national task force on medical staffing. The task force was established by the Minister because of the requirement in the European working time directive that non-consultant hospital doctors must, from 1 August 2004, work no longer than 58 hours per week on average. It is amazing that in this day and age, junior hospital doctors who are in effect doctors in training, are required to work excessively long hours, with some working in excess of 100 hours per week. No other group of workers would tolerate such conditions. Tiredness, with its potential for a serious mistake, possibly with fatal consequences, is the inevitable result of such long working hours. All Members of the House will welcome the reduction in non-consultant hospital doctors' hours.

In addition to the need to reduce non-consultant hospital doctors' working hours, the need to change the method of delivery of our hospital service from a consultant led to a consultant delivered service has become apparent in recent years. The health care service must provide the best possible care to the patient who is, after all, the most important person in the health care system. The ready availability of a consultant in the specialty required by the patient is a sine qua non if our system is to be the best possible health service. The Hanly report lays down the template for best meeting both the aforementioned requirements and, as such, I warmly welcome it.

In doing so. it is important to clarify exactly what the report states. There has been considerable discussion of the report in the media and a significant amount of negativity has developed. From some of the comments, it is patently obvious that the Hanly report has not been read by the people concerned, or else parts of it have been selectively used. The report explicitly states that a full range of hospital services should be available in each region. This means that patients will not have to travel outside their region for specialised treatment, other than for services provided at national level in accordance with best international practice. Let us compare this with the current position in which patients must travel to Dublin or Cork because the services they require are not available in their region. No neurologist is available in the North-Western Health Board area, which means patients must make a journey of 130 miles from Sligo, or more from Donegal which is even further, to see a neurologist in Dublin.

Let us take the position of patients who suffer from multiple sclerosis. Is it fair to ask such patients to travel long distances to see their consultant? The first Hanly report is concerned only with two regions, the mid-west, that is, counties Clare, Tipperary and Limerick, and the east coast area centred around St. Vincent's Hospital in Dublin. The current position in Limerick is that the county has no rheumatologist. If the Hanly report is implemented, it will have four rheumatologists. As a member of the Committee on Health and Children, I recently heard evidence from patients and consultant rheumatologists concerning the low level of consultant rheumatology posts. All those giving evidence agreed that the provision of even two consultant posts in rheumatology in Limerick would be a significant step forward. When the recommendations of the Hanly report are implemented, the mid-western region will have four rheumatologists.

The role of local hospitals will be enhanced, not diminished, if the Hanly report is acted upon. Instead of having only two or three specialties, an additional range of specialties will be available in each local hospital. Considerable debate has centred on the role of emergency treatment rooms which currently operate in some of our smaller hospitals. If patients are to have the best possible care when they are involved in a serious accident or sustain a major, life-threatening medical injury, the provision of immediate, highly trained care at the site of the emergency offers the best chance of survival. It is an essential requirement of the report that ambulance personnel with advanced training be available all over the country. In this regard, the implementation body the Minister is about to announce must insist that ambulance crew with advanced training and appropriate equipment are in place at the start of the process.

Despite the considerable sums allocated to the hospital services, severe problems remain. This year, approximately €10 billion will be spent on the provision of health care. The time for reports is now over. The Hanly report, in conjunction with the Brennan and Prospectus reports, charts the way forward. While there will be problems along the way and local fears will have to be allayed, I strongly believe that the implementation of the recommendations of this report will result in a much better health service, which is something to which all of us in the House aspire.

Mr. Wall:

I welcome the opportunity to contribute to the debate on the Hanly report. This debate is gaining momentum across the country, which is to be welcomed by all sides of the House. Concerns have been expressed in areas to which the report did not refer and about which it makes no proposals. This is regrettable and is leading to considerable confusion and contradictions in many areas. Following the events in Ennis, it is clear the debate will heat up when the second phase of the report is brought to fruition, and many similar demonstrations by concerned constituents will take place.

Many of the supporters of the report argue that one must look at the overall picture. This is difficult when my concerns and those of the constituents I represent are not, as yet, in the picture. The report states that the task force makes no specific recommendations about the application of its proposed model to the rest of the country, but proposes that the organisation of hospital services should be the subject of a second report to be prepared as quickly as possible. In addition, it states that the proposals in the first report should be used to help inform the development of proposals nationally. This statement has led to a great deal of conjecture on how the greater Dublin area, with which one would align County Kildare, including my constituency, will be affected.

Naas General Hospital has recently experienced drastic changes, all of which have been welcome. One could say a new hospital has been built on the old site. Problems have occurred, however, in obtaining funding to permit the new facilities to be used to their fullest. One cannot but express dismay that this should occur in circumstances in which Tallaght General Hospital, the sister hospital of Naas General Hospital, is experiencing overcrowded conditions and is unable to function properly due to lack of funding from the Departments of Finance and Health and Children. This does not add up.

If one were to use the report's proposals for information purposes for my area, one could only assume that Naas General Hospital, despite all the wonderful work recently completed on it, will not function as an active accident and emergency hospital. This is despite the fact that all the Dublin hospitals are warning the general public practically on a daily basis about overcrowded conditions.

With the second report not yet published, we must obviously discuss this issue in negative terms. As Deputy English stated, Navan General Hospital is in the same position as Naas General Hospital. The question of what will happen to hospitals in the hinterland of Dublin, in which large sums of taxpayers' money have been invested, remains a grey area. We do not know what will happen now.

The Minister was chairman of the South-Western Area Health Board and he knows that Naas and Tallaght hospitals have formed a great relationship. Indeed, he was probably involved in forming it given the movement of consultants between the two hospitals. What will happen to that relationship? Will it continue? Will Naas hospital become part of the greater Dublin area, as Navan should be, to facilitate the growth in population in those areas?

Mr. Callely:

It is in the region.

Mr. Wall:

Yes, but will it be part of the sector? St. Vincent's Hospital will be the central focus. What part will Naas play? Will it be just a daily hospital or will it be a full service hospital working within the sector of St. Vincent's Hospital? That is the concern.

The people in Kildare daily hear about the problems being encountered in St. Vincent's Hospital. It is unable to cater for the current population, let alone with extra numbers from other areas. We must examine what mechanisms can be put in place to provide an infrastructure that will cover areas such as Navan, Naas and Loughlinstown. This is what will generate much of the debate when the second report is produced. Given the population boom in those areas we will have to look at the greater picture rather than just focusing on the centre of the city. The outlying hospitals will have to be part of the function of the main hospital in the sector and not operate as just a daily hospital.

One has to agree with some aspects of the report. Nobody wants to see junior hospital doctors working 140 hours per week. That is not sustainable, as can be seen in other sectors of the public service, for example, in the prisons. There has to be a reduction in the hours. Life has to be more normal for junior hospital doctors. In doing that, however, we must also consider how to provide the number of professionals required to meet the recommendations in the report. How will that happen? They are not available at present. Take the example of nurses. There is a grave shortage of nurses. An assessment and respite unit in the local geriatric hospital in Athy has had to be closed and yesterday I received notification that the day care unit would also be closed due to the lack of nursing staff.

One aspect of the report which is of great importance is in section 2.3. It refers to the setting aside of industrial relations and politics. I listened to David Hanly discuss the report. He had an excellent team and produced a good report. He was most forthcoming in providing information when he visited the parliamentary Labour Party meeting. However, one thing he said sticks in my mind. In reply to a question about industrial relations he said he knew nothing about it and did not want to know anything about it. He said he was asked to produce a way forward based on a greenfield site situation.

It is wonderful to see what is contained in the report but what about the contradictory comments from the different medical associations which we saw in the media last week? Some were for it and some were against it. Industrial relations will be a major problem but providing the necessary professional staff will also be a problem. Each week Members of the House put down parliamentary questions to the various Departments about services such as speech and language therapy for children and adults. There are no therapists available. Nevertheless, this report says these professionals will be in every hospital. Deputy Devins told the House there is no neurologist in Sligo. Why? The Department has not provided one. Are we suddenly going to see all these people fall from the sky to make everything in the garden rosy? That will not happen and this is where the report fails. We do not have the professional personnel to fulfil what it proposes.

I welcome the report. The only thing wrong with it is that it does not deal with the entire country. That is a mistake. As a result, there will be a recurrence of what happened in Ennis and Nenagh and is beginning to occur elsewhere. There are many good things in the report but they will be overlooked. However, we must look at the greater Dublin area and examine how places such as Naas, Loughlinstown and Navan can be interlinked to ensure that the services provided will be appropriate for the population, what can be done to ensure there are sufficient professional staff and, above all, how we will overcome the industrial relations problems this report will create.

Mr. Finneran:

As the Deputy elected by the people of Longford-Roscommon, I have overseen the largest investment in Roscommon County Hospital since it was built in the 1930s. The hospital's facilities are being refurbished and upgraded. The wards are currently being refurbished. There is a new extra department and screening room, upgraded theatres and a new, state-of-the-art accident, emergency and admissions department. There has been a 25% increase in staff and the number of consultants has doubled in recent years. A total capital investment of over €11 million has been made.

The Hanly report has many good points and if resources are made available for the recruitment of extra consultants, the provision of centres of excellence and extra services at all acute hospitals such as Roscommon County Hospital, it will be welcome. However, if the second Hanly report is produced and makes similar proposals which are to be applied to Roscommon County Hospital, this Deputy and the advocates of that report will be on a collision course. I will not accept the removal of any of the services that are being provided at present at that hospital, including the 24-hour accident and emergency service.

The people of Roscommon elected me to develop Roscommon County Hospital and I have discharged my duty in that regard. I will stand with the people of Roscommon and oppose any downgrading of the hospital that will diminish the health service to the people of the county. It should be clearly understood that if the second Hanly report makes similar proposals to those in the first report which attempt to remove existing services from the acute general hospital in Roscommon, I will oppose it and I will oppose anybody in this House who attempts such action.

Mr. Callanan:

The main objectives of the Hanly report were to examine the best way forward for the health service and how to achieve a reduction in the working hours of junior doctors from 75 to 48 hours per week by 2009. The Hanly report suggests doubling the number of consultants, which would provide a better and safer service to patients. The report states that a number of major hospitals should become centres of excellence. This would mean patients from the west would no longer have to travel to Dublin for major operations as University College Hospital Galway would have all the facilities as a centre of excellence.

There would also be general and local hospitals. The report does not recommend the closure or downgrading of hospitals. There is much concern in my home town of Ballinasloe in regard to Portiuncula Hospital. Even though the hospital is not referred to in the report, the threat of the Hanly report is causing concern. I do not see any reduction in services occurring in Portiuncula Hospital, owing to the fact that it is a large hospital serving not just County Galway but a large part of the midlands, including Athlone.

Portiuncula Hospital is nationally known for its excellent maternity services, where up to 2,000 births take place each year. It has a very busy accident and emergency unit where many road accident patients attend due to the fact that Ballinasloe is on the N6. It is an excellent acute hospital with 17 consultants, three of whom are shared with Roscommon. It has a state-of-the-art intensive care and coronary care unit which was opened two years ago.

As a member of the Western Health Board, I promoted the purchase of Portiuncula Hospital by the board. I felt at the time that if the Western Health Board did not purchase the hospital it would be bought by a private concern for private patients only, and public patients around Ballinasloe could not avail of its services. I compliment the Minister, Deputy Martin, on providing more than €10 million to purchase the hospital, which now employs almost 650 staff. The hospital will not be downgraded and I as the local Deputy will promote the development of Portiuncula Hospital in the future.

I thank the nuns in Portiuncula Hospital for the great work they did through the years to develop the hospital to the standard it provides today. They have served Ballinasloe well.

Mr. McHugh:

I wish to share my time with Deputies Gogarty and Crowe. If we were setting up a health service in the country in a scenario where there was no structure, no hospital or any other such health infrastructure in place, the Hanly report would have much relevance and a lot to recommend it. We could then divide the country into equal regional divides and work from there. However we are not living in that Utopian artificial health situation. We are living in the real Ireland where there is a health system of sorts. There are some very good hospitals which provide a high level of health service under difficult circumstances.

The Hanly report missed that reality and, consequently, what could be termed very good rural hospitals are now under threat. The effect of the Hanly report recommendations is that all the investment that has been put into these rural hospitals over the years can now be designated as waste. The report is basically stating that medical practitioners in these rural hospitals are not capable of continuing to provide the high level of service to which the population in these catchment areas has become accustomed. The medical professionals in these hospitals find that insinuation highly insulting.

The Minister stated that the report is not about downgrading hospitals. If that is the Minister's view, he needs to give a solemn undertaking to hospitals that feel under threat that they will not be downgraded. While no model has been developed for the Western Health Board area, the clear indications are that Portiuncula Hospital, Ballinasloe, is in danger of being downgraded. This realisation has caused much anger in the area and, indeed, much worry has been generated among the public in the very big multi-county area Portiuncula serves. Is the Minister in a position to confirm the statement by the Minister of State, Deputy Treacy, that no change will occur to Portiuncula Hospital under the terms of the Hanly report?

As I said initially, if we had a greenfield site scenario countrywide, the Hanly report would be invaluable. While I have been critical of its potential to downgrade hospitals, I believe it has the potential to provide a framework in areas that lack hospital services. I refer specifically to Tuam, the commitment by the Taoiseach and the Minister to provide a hospital in the town, and the subsequent designation of Tuam as a hub under the national spatial strategy. One of the characteristics is that such a hub would have a local hospital. Now is the opportunity for the Minister to put his promises into action, develop a prototype local hospital in Tuam and use it to indicate what a local hospital can be, as envisaged by the Hanly report.

No other study, report or assessment is needed to underpin the case for a hospital in Tuam. The Western Health Board submitted its planning brief for the Tuam hospital to the Department on 8 October 2002, and it has remained there since. No action has been taken and no response has been given. The Western Health Board submission on Tuam hospital, including separate submissions on a primary care unit, ambulance base and services for the elderly in Tuam to cover the catchment area of north Galway, south Mayo and west Roscommon, are all elements of a local hospital. These all point to the need for a local hospital in Tuam. I ask that the go-ahead be given to Tuam hospital. I ask the Minister to honour his commitment, and the commitment of the Taoiseach, to the region. The Hanly report is the vehicle for doing so.

Mr. Gogarty:

My colleague, Deputy Gormley, has already alluded to many aspects of the Hanly report and how it will impact on communities throughout the country. We are aware of the debate in the pilot counties. The Green Party in Ennis has kept us up-to-date on the impact the proposals would have in that county. While the Hanly report is broadly welcome, I was particularly interested in reading it because of issues in my constituency. However, I am not the spokesman on health – Deputy Gormley has the major expertise on the issue.

I was accused some time ago by the Minister of State, Deputy Lenihan, of engaging in parish pump politics because I dared to raise the issue of Peamount Chest Hospital on the Adjournment. In the context of the Hanly report, given that I have just three and a half minutes, I want to use my time to focus on how Peamount could be destroyed and how it is currently being dismantled. There is a five year programme to create certain levels of improvement in some aspects of Peamount Chest Hospital. It appears that due to the intransigence and ideology of Comhairle na nOspidéal, and another person called Martin, the chest hospital option is being phased out. This is a lesson for the country as a whole in regard to the implementation of the Hanly report. Dr. Luke Clancy and others attached to both St. James's Hospital and Peamount Hospital have said patients could wait for up to four hours in an operating theatre, such is the level of work and bureaucracy that takes place.

We have already heard from some of our colleagues in Nenagh about how that hospital can be much more effective. Local hospitals can get work done much faster than hospitals in major centres because there are professional, dedicated staff and there is not the same workload of a general nature.

The same applies to Peamount. The chest hospital treats chronic sufferers of tuberculosis. These are not acute patients who can have high tech treatment and then leave. These are people who do not necessarily take their medication correctly. Some of them suffer from AIDS, are drug addicts or have other long-term disorders which render them unable to integrate properly into the community. It makes sense for such people to be treated in a hospital such as Peamount. This hospital has served people for decades. If it is not broken, why fix it?

In the context of the Hanly report, Peamount Hospital is a shining example of how a local small hospital has built up expertise over the years, and this expertise is in danger of being dispersed. As Deputy Gormley pointed out in the press conference, if chronic sufferers of TB are not treated when their symptoms begin to flare up because of the dismantling of Peamount and the fact that the high tech facility in St. James's Hospital will not cater for chronic sufferers of TB, there is a danger that a nation-wide epidemic will occur. Given that the incidence of tuberculosis is on the increase, there is such a danger. There is a need to focus the expertise where it works and is cost effective. For that reason I reiterate my call to the Minister for Health and Children, Deputy Martin, to do all in his power to ensure the chest hospital is retained at Peamount.

Mr. Crowe:

Earlier this month in Dublin, 120 patients were left on trolleys in the five accident and emergency units across the city. In my constituency, Tallaght Hospital was one of the worst affected with almost 40 patients waiting on trolleys, 19 of whom were in hospital corridors and many had been lying there for days. I visited some of those patients. One man who had a stroke was left there for a number of days. He spoke about the indignity of trying to get to a toilet. While some people say it is not a great discomfort, when one speaks to patients it is an indignity. A lady with whom I spoke was on her fourth heart attack and was left lying there for a number of days.

Tallaght Hospital is supposed to be the flagship hospital but has been starved of funds and has had sections downgraded. Of those on the waiting list for Tallaght Hospital, 35% have been on it for the past two years. The list has increased by 25% since 1997. To many of those families, the Government's solution to the health crisis has been glossy reports and press conferences. We have had the Brennan, Prospectus and Hanly reports and, the greatest solution of all, the Government's health strategy. Those people do not want reports, they want action and firm decisions.

The Minister challenged us to produce an alternative. There are a number of alternatives to what is happening. Sinn Féin seeks the phasing out of the two-tier system to be replaced by a national health service, free at the point of delivery and funded from general taxation. Government policy should be focused on that goal and in the transition period should seek to minimise inequities and inefficiencies in the system.

In Sinn Féin's pre-budget submission, published yesterday, we called for the establishment of a Cabinet committee on health to spearhead the phasing in of an Irish health service. The committee's first tasks would be to plan the transition, assess costs and savings in the short, medium and long-terms and commence multi-annual budgeting on that basis. We called for the acceleration of the renegotiation of the common contract for consultant medical staff.

The Government must ensure a fairer deal for public patients and an end to the exploitation of the two-tier health system. All new consultant posts should be exclusively in the public system. We urge the expansion of the medical card system to all those on or below the minimum age, those under 18 years of age, those in full-time education or those over 65 years of age. There should be a review of the national treatment purchase fund where taxpayers' money goes to the already heavily subsidised private sector for patients on public waiting lists instead of being invested in the public sector. Tax incentives for private public care and for the construction of private medical facilities should be abolished and the savings put into the public system. There is a need to look at how the health service could be improved through greater all-Ireland co-operation.

Mr. Moloney:

I wish to share time with Deputy O'Malley.

An Ceann Comhairle:

Is that agreed? Agreed.

Mr. Moloney:

I welcome the opportunity to contribute to the debate on the Hanly report. I have listened to the debate for the past hour and have noted the concern, and rightly so, for local hospitals and particularly those that have proved successful. At the same time I congratulate the Minister for Health and Children, Deputy Martin. He has shown a commitment to the health service. Members will recall he was the Minister for Health and Children in the outgoing Government and that he expressed an interest to return to the same portfolio. I put that on the record to show he has a clear commitment to reforming the health service. On the afternoon of his press conference he made it clear the Hanly report would be controversial and would cause concerns but at the same time it was an effort to reform the health service. I fully support the Minister. I am aware that when it comes to the time for the Hanly report to take effect in my area I will have concerns too.

Since 1997, each year at budget time, the Government has increased the health spend and yet there are the same difficulties throughout the State. There are concerns about value for money and patient care. Clearly, to continue on the path of increasing funding without getting the necessary return would do no service to the community. In that regard reform is necessary and I support it.

In the past we have tried to introduce certain reforms at regional level and this has caused huge concern. The public is accustomed to and has a love for its local hospitals. In that context it always fears downgrading is on the cards as soon as some reform is mentioned. I do not see it that way. I am fresh from a debate in my constituency where the National Cancer Forum prepared a report. It took four years to bring public opinion around to the view that reform in the shape of a cancer service to a region does not necessarily mean the downgrading of a hospital. For three years I was told that the effect of this major reform would be to reduce my local general hospital to the status of a cottage hospital. The proof has been that the cancer strategy is now operating effectively in the midlands and instead of 1,200 patients travelling each year to Dublin for treatment, 90% can be treated in my region. In the meantime the local general hospital has been upgraded and now has psychiatric and paediatric units.

That the Minister is working to correct the flaws in the health service is welcome. It is important that he goes about his business with a view to improving the standard of service. A key part of this improvement is to be found in the Hanly report. I accept there are controversial parts in that report. Nevertheless the proposals contained in the report are wide-ranging and will make significant changes to the health service. I understand it will take many years to implement the report. It is not as if we can publish a report and expect immediate results. Many Governments have tried to tackle the issue of the delivery of a health service and many have increased the health spend but unfortunately the return has been minimal. I have no doubt that once the report is examined and implemented in a manner that best responds to the needs of the country—

Mr. Broughan:

I am sorry to interrupt the Deputy. He has made some important points.

Mr. Callely:

I hope this will be a meaningful contribution and that the Deputy will be present.

Mr. Broughan:

It is a typically excellent contribution from the Minister of State's colleague and it is important to have a quorum to hear him. I demand a quorum.

Notice taken that 20 Members were not present; House counted and 20 Members being present,

Mr. Moloney:

Although the European working time directive requires us to lower significantly the number of hours that junior doctors work, we should do this anyway. A junior doctor works on average 75 hours per week. In some hospitals doctors work in excess of these hours. In delivering a health service how can junior doctors be expected to provide the best standard of care or complete their training in the best possible manner when they are overworked? The answer is that they cannot. This is why it is important that we move to reduce the workload. I do not hide behind that position to support the Hanly report. The only practical way to do this is by replacing the current approach with a consultant-provided service approach as the Hanly report points out.

When we visited hospitals, especially those of us who have been members of hospital visiting committees, it was always stressed that consultants were required to be at the front line of hospital treatment. The current system whereby consultants work set hours with several junior doctors reporting to them does not provide the best service. This has been acknowledged throughout the service by practitioners and consumers. By increasing the number of consultants and making them work on a rota around the clock, we should see a great leap forward in the standard of treatment.

Patients, regardless of their ailments, want the best qualified staff treating them, and they will receive that through a consultant-provided system. The system could also foster greater team work among hospital staff as consultants will work together rather than on an individual basis as they do now. Similarly, junior doctors will provide a higher standard of service and will make best use of hospital resources in a framework that encourages greater co-operation between health staff.

The Hanly report also recommends that a full range of acute hospital services should be available within each region which is important and why I fully support the report's provisions. It is good news not just for local hospitals but for everyone. The Hanly report also safeguards the future of smaller local hospitals and emphasises, as did the Minister at his press conference, that hospital closures are not on the cards.

We also want to see a large increase in the number of services provided in a given region. In my midland area we often have had to make the case to attract various services and spend and lose time trying to organise, seek support and agree on the location of those services. It is important that patients should not have to travel large distances beyond their region to receive common specialist treatments. They should be able to receive all these standard hospital services and others, such as elective general, ear, nose and throat, elective urology, cardiology and plastic surgery, without venturing outside their region. I could go on about this but there will be debate on the necessity to improve the services in the regions for patients.

Many told me, especially in the debate on the cancer strategy, that people from my region had to rely on public transport to travel to Dublin to secure services and to come home afterwards. That is why it is important that the benefits of the Hanly report can be transferred to providing services in the regions. There will be more regionally-based consultants and people will have to travel only a short distance instead of long distances to obtain local services. A positive aspect of the report is that the range of acute hospital services will be available to patients within their own regions.

There has been much debate about accident and emergency departments in local hospitals which will continue to cater for 85% of the patients who now attend them. Most major trauma cases will not be affected by having to travel a little further to the region's major hospital but should benefit from having the complete range of qualified staff and the relevant equipment under the one roof.

I wish the Minister well and hope that, in the next few weeks and months, we will have debate and see the benefits of the Hanly report. I hope we will always have the courage to realise that if everybody supports reform, there will be benefits and in some cases disadvantages, but it is a far better approach than simply increasing the health budget. I welcome this attempt to reform the health service.

Mr. Perry:

I wish to share time with Deputy Cowley.

An Ceann Comhairle:

Is that agreed? Agreed.

Mr. Perry:

I am concerned about Sligo General Hospital following the publication of the Hanly report which will affect the region. I give credit to the doctors and nurses and all the staff in that hospital for the outstanding work and service they give to a wide catchment area. I am concerned because the Hanly report catchment area is 350,000 people. Any impact of the report to the effect that its area of excellence would be incorporated with a population base of 350,000 would have a bearing on Sligo. I would like clarification on the definition of a region. The North-Western Health Board region is the closest to my constituency of Sligo-Leitrim where the population is 85,000 and that of Donegal is 140,000. On that figure alone we have a population base of 225,000. The population base of Mayo is 140,000 and Roscommon, 55,000.

Sligo General Hospital has surgical and general medical services. It does wonderful work and has many key specialist areas. However, it needs a neurologist immediately. This is critically important and is regardless of any implementation. I call on the Minister not to defer this and to appoint a neurologist for Sligo immediately where one is urgently needed. Given the level of specialty in Sligo General Hospital, it is not certain that the Hanly report will make an impact. I hope not because any general downgrading of the hospital will be fought tooth and nail and any Minister would implement it at his or her peril. The Hanly report proposes a trauma specialist service which would incorporate a full range of services in a regional hospital. It would deal with accident victims, all areas of specialty, regionalisation and the appointment of top specialists. That should not be done at the expense of the region.

Previous speakers have referred to the working time directive and the reduction of hours for medical doctors. We should not lose in Sligo because an EU directive is being implemented which means doctors must work less time. It is not our problem and the people of Sligo should not be penalised because there is a cutback. If that is the case, I call on the Minister to appoint more doctors. It is easy to cut back in any business. If one wants to cut down on overtime, one employs more staff.

My main concern is about the demographics of the region. Sligo-Leitrim is one of the regions with the greatest population base of old people. It would be outrageous if older people had to travel to Galway to receive specialised service. There are two hospitals in the North-Western Health Board region, Sligo General Hospital and Letterkenny Hospital. In the context of the Hanly report, since there is a population base of 225,000 people in the Sligo region, we must have a clear statement that there will be no downgrading of that region.

Mr. C. Lenihan:

That is another self-serving argument.

Mr. Perry:

I am allowed to speak. One must consider the distance older people will have to travel in the north-west and the peripherality of the region. One must remember that the ambulance service is essential. I was amazed at Deputy Lenihan.

Mr. C. Lenihan:

I presume the Deputy is against the downgrading of anything in Sligo.

An Ceann Comhairle:

There is very limited time for this debate and I ask Deputy Lenihan to allow Deputy Perry speak without interruption.

Mr. C. Lenihan:

We heard this before. The Deputy sings a different tune in the Public Accounts Committee.

Mr. Perry:

I am not one bit surprised at Deputy Lenihan.

Mr. C. Lenihan:

If Punchestown was in the Deputy's area he would be giving it plenty of money.

An Ceann Comhairle:

Deputies Lenihan and Perry should address their remarks through the Chair.

Mr. Perry:

If the Deputy mentions Punchestown when it comes to medical services—

Mr. C. Lenihan:

The Deputy is against all downgrading in Sligo. He is for everything and nothing.

Mr. Perry:

I am more than disappointed.

An Ceann Comhairle:

I ask Deputy Lenihan to deduct this time from his contribution.

Mr. Perry:

Deputy Lenihan should not mention Punchestown when it comes to health services. That is what is wrong with this Government.

Mr. C. Lenihan:

Of course it is.

Mr. Perry:

Ambulance services are essential and so is equality of response. I would be very concerned that in light of the Hanly report these would not be guaranteed. Some €15 million has been spent on a state-of-the-art facility in Manorhamilton. The Hanly report will have a huge impact. It is of major concern for Sligo. I would be very concerned that the implementation of Hanly will deplete what is a good service in Sligo.

The level of opposition to Hanly in understandable. I am amazed at the Government's decision on this after 148 reports. The problem with this Government is that nothing is being done. I will fight tooth and nail against any downgrading of Sligo General Hospital.

Dr. Cowley:

I am grateful for the opportunity to speak on this very important matter. I am a GP and I am concerned about people's needs. That is why I became a Deputy, to try to push that cause. I got involved in a campaign for an orthopaedic unit in Mayo General Hospital and the first obstacle was put in front of me by the Irish Orthopaedic Association which said that to have a unit in Galway was sufficient, and that to have one in Mayo was ridiculous, because one would not get a proper service. It was the centralisation agenda, but that battle is now won, and the orthopaedic unit is on the way. If Hanly was implemented we would never get such units.

The Hanly blueprints will be used. There are two blueprints, one for the Mid-Western Health Board and the other for the Eastern Regional Health Authority. The bottom line is that the blueprint will be applied, after the local elections, so that the urology unit sought by Deputy Perry will never come to Sligo unless Sligo is the main hospital. The centralisation agenda goes on all the time but it is not equitable. It is taking services out of areas and thus contributing to greater depopulation. It does not support any type of regional balance.

Hanly will do nothing for people on trolleys. The problem with the health service is not the lack of Hanly proposals but the lack of investment. We have recently put 6.7% of our GNP into our health services. Canada, for example, puts in 9.1%. It is questionable if we are even at the EU average in terms of such input. We are now talking about closing hospitals. We do not have enough hospitals. We have 14 hospitals per million of population compared to the UK, for example, which has 27 hospitals per million of population. We need to be improving hospitals rather than closing them.

The radiotherapy report reflects a similar situation. It is about centralisation but what about the people in the mid-west, the north-west and the south-east? These people need help as well. There are many reports, but reports are not the answer. We need proper investment in our health services.

The Hanly report is downright dangerous, and totally impracticable. It is dangerous because it ignores the most basic rule in emergency medicine, namely, that the most appropriate aid is given within the golden hour. That will not happen in Ennis. I was there recently. It is obvious that people coming from Loop Head will have to travel some 70 miles bypassing Ennis in order to go to Limerick. How long will it take them to travel 70 miles over bad roads to Ennis and then to Limerick? We are talking about at least an hour. Where is the golden hour there? There is no doubt that people are going to die. I have a lot of time for Mr. Hanly and I am sure he is a very good business consultant, but the hospital consultants and GPs are speaking out. One sees their criticisms in The Irish Times every day. They are saying that Hanly will cost lives and I agree with that. We do not have the GP structure in place. We do not have helicopter emergency medical services or proper roads.

I saw Ennis Hospital and it was just like Mayo General Hospital in Castlebar before the investment was made there. What the Ennis area needs is investment. Hanly is a matter of robbing Peter to pay Paul, with Paul being the big hospitals and Peter the small hospitals which are being run down. When beds are closed, where are the patients to go? The 22,000 cases seen in Ennis will go to Limerick, but Limerick cannot even cope at the moment. There is no rationale in that. A person in the Ennis area with a ruptured spleen will die, because no matter how many first responders are there, that person must get the necessary emergency operation in Ennis rather than Limerick, because the person will be dead before arrival in Limerick.

This is impracticable because the consultants' contracts, and those of the people supporting the consultants, will have to be renegotiated. That is not an easy matter. There will be a cutback in the output of the medical schools with the new entry scheme. Even if all this could be sorted out, where are the beds? They are not there. We were promised 3,000 further beds under the health strategy. Their absence proves that the money was never put into the system. Had the money been invested, we would have the beds. We got only 330 beds. To borrow Frankie Byrne's phrase, has Hanly knocked at everyone's door? Remember that.

Ms F. O'Malley:

With the publication of the Hanly report we have crossed a Rubicon on health reform, and there is no turning back. I have just heard Deputy Cowley say that just because it is difficult it should not be taken on. The health system cannot remain as it is. The way in which it is currently constituted is unsustainable. Change is imperative, and the European Working Time Directive requires us to make the necessary changes. We cannot afford not to change.

In discussing Hanly it is important to remember the terms of reference and to remain closely focused on them. The terms of reference include the devising, costing and promoting the implementation of a new model of hospital service delivery based on appropriately trained doctors providing patients with the highest quality service using available resources as equitably, efficiently and effectively as possible.

What we need to remember is that there is not a bottomless pit in terms of the health budget. It currently stands at €10 billion. That is generous by any standards and I have heard many Opposition Members agree. If we look at how much reform we have, the level of improved health care resulting from these enormous increases has been minimal. The good fortune the Minister for Health and Children currently enjoys in dealing with health reform is that he has proven beyond doubt that it is no longer a question of money but of the restructuring needed.

The national task force on medical staffing is by no means a panacea, and David Hanly himself would not seek such accolades for the report he has presented. However, it is a very necessary beginning and the keystone in the construction of an improved health service for all Irish people.

Criticism was made of the fact that political sensitivities, industrial relations issues and vested interests were, quite rightly, set aside in the production of this report. The report's proposals are aimed at delivering improved patient care. In order to produce an honest and objective report with medical and patient concerns to the fore, it is necessary to set aside all the political and industrial relations concerns. Naturally they cannot be ignored when it comes to implementation. Implementation will be a challenge because it is something that is difficult to deliver. However, that is not a sufficient reason to do nothing. I stated in the House on a previous occasion and I repeat it now that it will be the measure of the success of this Government if it rises to the challenge of health reform and it would be a disgrace if we fail to elicit better value for money for the patient.

I attended a ceremony earlier this week where I was reminded of the words of John F. Kennedy when he spoke in 1961 of the four criteria by which the holders of public office would be judged by history. The question would be whether they were truly men of courage, judgment, integrity and dedication. Each one of us honoured with a seat in this House needs to be satisfied that we can answer those questions in the affirmative and none more so than Ministers. Government policy must never be sacrificed on the altar of the parish pump. It is understandable that Members of the House have the interests of their constituents and constituency at heart but Ministers are required to keep the long-term national interest to the fore.

The demands of this report will challenge the resolve of Deputies up and down the country and they will look to the commitment and leadership of Government to support them in dealing with the difficult local concerns they face. This report is a radical departure and people are worried about the local consequences. They need to be reassured that the new infrastructure will be supported by adequate ambulance services and the consolidation of accident and emergency at networks of excellence will provide an improved service throughout the country.

The Hanly report has recommended multi-disciplinary teams in the network hospitals of excellence. At present seriously ill patients have to travel to Dublin but that will no longer be the case. They will be treated in their regional centre by multi-disciplinary teams of consultants who will deal with most of the concerns, the only possible exception being neurosurgery, as I understand it. This reform will deliver a better service but it must go hand in hand with the recommendations of the other reports on the health service and in particular the report on the new GP service. The Hanly report is a brave step forward and I commend it.

Mr. Gilmore:

I am glad Deputy Fiona O'Malley has reminded the House of the terms of reference which were given to the Hanly team. Listening to speakers from the Government side of the House who are now disengaging from the Hanly report, one would think that Mr. Hanly produced this report of his own volition. That is not the case; he did what he was asked to do. The Government asked him to re-mould the hospital services around the fact that from 1 August 2004, the EU working time directive will come into effect for non-consultant hospital doctors. From the very beginning he was given a job of work to do by Government which necessarily involved, as far as his terms of reference were concerned, the reduction in the number of hospitals, the concentration of services in major hospitals and the resultant rationalisation. Mr. Hanly is to be complimented on his work. I am sure he must be feeling a little sore at this stage that, having done the job he was asked to do by Government, he finds so many Deputies from the Government side, including Ministers, literally dropping him in the manure.

I am surprised Deputy Fiona O'Malley did not address the fact that the Hanly report examined two pilot areas in order to reach its conclusions. One of the pilot areas is the area for which Deputy O'Malley and I are representatives, the East Coast Area Health Board. Many Deputies whose areas have not yet been examined might wish to know what has happened in our area. Just one and a half pages of a 211 page report are devoted to the East Coast Area Health Board. That is the total description of the hospital services in that area. There are currently three acute hospitals there, St. Vincent's Hospital, St. Michael's Hospital in Dun Laoghaire and St. Columcille's Hospital in Loughlinstown. The Hanly report proposes that there should one major hospital, St. Vincent's, and two local hospitals, St. Michael's and Loughlinstown. The report states that the full range of emergency services can only be provided at major hospitals. It proposes that in the local hospitals should be what are called "nurse-led minor injury units" for an extended day, that is, 8 a.m. to 8 p.m., depending on the volume of cases. For St. Michael's in Dun Laoghaire and for Loughlinstown hospital, it means in practical terms that the accident and emergency departments of those hospitals will close. There will be no accident and emergency service at all after 8 p.m. and during the day there will be only a "nurse-led minor injury unit", in other words, a glorified Band-Aid station. If the Hanly report is implemented, all the accident and emergency cases such as road accident injuries, accidents in school playgrounds, heart attacks, which give rise to patients being rushed to a hospital, will all be brought to St. Vincent's Hospital.

The constituency which both Deputy Fiona O'Malley and I represent will certainly note Deputy O'Malley's contribution in the House which shows she agrees with the closure of the accident and emergency departments at both St. Michael's and Loughlinstown. In the one and a half pages devoted to the East Coast Area Health Board, there is no analysis given of the accident and emergency cases distributed between the three hospitals. There is no explanation or justification as to why they should be concentrated in St. Vincent's in the first place, either for reasons of geography, medical care or whatever, other than the general statements made in the report. One wonders why this conclusion was reached, given the facts.

I suggest an examination of a typical week such as the third week of October. I understand that the accident and emergency cases presenting to the three hospitals were as follows: 780 in St. Vincent's; 500 in Loughlinstown; 400 in St. Michael's. If there were more accident and emergency cases in St. Michael's in Dun Laoghaire and Loughlinstown together than there were in St. Vincent's, why are the accident and emergency services to be concentrated in St. Vincent's? How can anyone justify that between St. Vincent's in Ballsbridge and Waterford city, there will be no accident and emergency department in any hospital? Not only the entire population of Dun Laoghaire and south Dublin but the entire south-east of the country will have no accident and emergency service. If an accident occurs in Arklow or Gorey, the choice for the ambulance crew is between Waterford city or all the way to St. Vincent's in Dublin.

Mr. C. Lenihan:

The Deputy has forgotten about Tallaght hospital.

An Ceann Comhairle:

Please allow Deputy Gilmore without interruption.

Mr. C. Lenihan:

It is far quicker to go to Tallaght. The Deputy clearly does not know the roads of Ireland.

Mr. Callely:

He prefers to cherry pick.

Mr. Gilmore:

I did not realise geography was such a weak point on Deputy Conor Lenihan's part but if he has not noticed already, Tallaght is on the west of the city. He also has not noticed the distribution of major hospitals in Dublin which are situated largely around the M50 ring road, leaving a situation where the southern end of Dublin with Wicklow and the south-east does not have the service of a major hospital. Apart from the general rationale which is followed in the Hanly report, and which is questionable, the conclusion that bigger is better is not supported by the evidence he sets out himself.

Leaving the general argument aside, we should know what analysis was carried out when Hanly looked at the East Coast Area Health Board. Is there are longer report? Is one and a half pages the entire size of it? Surely there are background documents and reports on the East Coast Area Health Board, a summary of the discussions Hanly undertook with the consultants and management of the hospital services in the East Coast Area Health Board on which the one and a half pages are based. That summary and documentation should be published.

If there is to be just one major hospital serving the East Coast Area Health Board, was the option of locating it other than in St. Vincent's examined? There are constraints in St. Vincent's with the amount of land available and difficulties with traffic and parking. Surely the option of Loughlinstown, which has 20 acres of land available located at what will be the major motorway junction on the southern side of the city, must have been examined? If it was, the considerations should be published. Was the option of distributing the specialties between the three hospitals examined and, if so, why was it dismissed? How did we end up with the conclusion that the hospital with less than half of the total accident and emergency admissions has been selected as the major hospital to serve the East Coast Area Health Board?

Even under Hanly's own terms of reference to rationalise hospital services, the conclusions reached are not based on hospital requirements and the available evidence.

Mr. C. Lenihan:

Having listened to Deputy Cowley, I am surprised that he managed to become a doctor in the first place or how he manages to pretend in this House that he knows anything about health care.

Mr. J. Bruton:

It is just as well the Deputy is speaking in this House. He would need a lawyer if he said that outside.

Mr. C. Lenihan:

I brought my own lawyer along – a senior counsel – just in case. Brothers can be useful when they have a decent qualification, as Deputy John Bruton knows well.

An Ceann Comhairle:

It is not appropriate to make personal comments about any Member of the House.

Mr. J. Bruton:

Will the Deputy's brother defend him?

Mr. C. Lenihan:

Where would the economy have gone without Deputy John Bruton's economist brother in the Cabinet?

I was amazed at Deputy Cowley's outpouring. It reminded me of the populist ravings we see from politicians who appeared in eastern Europe and the former Soviet Union. These people are for everything, more investment, more money for everybody and more money for themselves.

Mr. Durkan:

There are a few like that here.

Mr. C. Lenihan:

There is a whole cacophony of doctors and consultants who are now spreading fear and loathing throughout the population about what is going to happen at their local hospital because of the Hanly report. It is often assumed by the electorate, rather foolishly, that doctors will make good politicians and especially good Ministers or representatives on health issues. The record of this House indicates the opposite is the case. Many of the doctors placed in charge of health care are not up to the task, with the wonderful exception of the Ceann Comhairle.

Aengus Ó Snodaigh:

Name names.

An Ceann Comhairle:

The Ceann Comhairle is totally outside the realm of this political debate.

Mr. J. Bruton:

Obviously Deputy Conor Lenihan does not plan on getting sick in the next 25 years.

Mr. Durkan:

He is delirious.

Mr. C. Lenihan:

When serving his illustrious term as Minister for Health, the Ceann Comhairle was thanked by no one, not least his own profession, the doctors. They excoriated him day in and day out, as did RTE, about health cuts when everyone in this House, including Deputy Dukes and other members of Fine Gael, knew that the Government was doing the right thing at the right time.

That is what the Hanly report does. We cannot continue to pour more money as we have done over the last six years into a health care system that just gobbles up the money and returns nothing in reform, productivity or increased output. That is the bottom line in terms of health reform. There are vested interests and Deputy Cowley clearly represents the doctors and consultants rather than the constituents and patients of Mayo. He is playing out his own personal professional prejudices and pastimes of a lifetime as a doctor who tries to keep the doctors' racket going in this health system. That is all it is and some of the attitudes of these consultants are not dissimilar to the attitudes displayed by some taxi drivers when their monopoly was being threatened by deregulation and reform. It is appalling to see that someone who is allegedly elected to this House to represent the health care issue—

An Ceann Comhairle:

The Chair would prefer if Deputies did not refer to other Deputies in a personal way with regard to the profession. Political allegations are fine but I would prefer Deputies on all sides to observe that rule.

Mr. C. Lenihan:

My allegations are profoundly political. I am talking about someone elected by the people of Mayo allegedly as a health care candidate who is also a doctor. If this had happened in any other area of national life, that person would be accused of a conflict of interest. There is an issue regarding the position of doctors in this House and outside it who deliberately fan the flames of public fear about what is happening in the health sector. I wonder how committed some of these doctors are. I am not referring specifically to Deputy Cowley in this respect, but how seriously do they take their ethical oath, particularly when they enter the political sphere?

Mr. Connolly:

The Deputy should tell it like it is.

Mr. J. Bruton:

In fairness to the Deputy and the other Members to whom Deputy Conor Lenihan is referring, he should withdraw that comment.

Mr. C. Lenihan:

I will not withdraw it since I am referring to the way a doctor comes into this House on a health ticket and represents himself as a public representative.

An Ceann Comhairle:

It is not appropriate to refer to other Members of the House in their other professions. Political charges are acceptable but it is inappropriate for any Member to refer the personal integrity of Members of the House in ways that might reflect on their professional integrity.

Mr. C. Lenihan:

It was not my intention to reflect on his integrity as a professional, I am sure he performs wondrous things on those who attend his clinic as patients. I am commenting purely on his performance as a political operator wearing the doctor's mantle with the health care issue as his presiding and besetting concern. It is important that point is made.

Mr. Gilmore:

The Deputy should stop digging.

An Ceann Comhairle:

The Deputy must move on to another part of his statement. This is becoming repetitive.

Mr. C. Lenihan:

I would not call Deputy Perry doctor because that would be far too pleasing a title to confer on the very grave Chairman of the Public Accounts Committee of the Oireachtas, but it is a great pity the late Jim Mitchell is not still around. We might then have a good committee. Deputy Perry committed himself tooth and nail to fighting the closure or downgrading of Sligo Hospital. All of the contributions made by Deputy Gilmore, Deputy Cowley and, of course, the great magician from Sligo, John Perry, show they are committed to opposing change in their own constituencies.

An Ceann Comhairle:

It is Deputy Perry, please.

Mr. C. Lenihan:

Nothing must change, none of these speakers has ever for a minute looked beyond his own constituency interests.

Mr. Durkan:

On a point of order, the Deputy has a personal affliction with doctors and now with magicians. The Ceann Comhairle should tell him to desist because God knows where he might go next.

An Ceann Comhairle:

That is not a point of order.

Mr. C. Lenihan:

What was ironic about Deputy Perry's contribution is that he was excoriating the Minister for Finance yesterday about Punchestown and what he claims is an alleged beneficial investment grace àthe Exchequer in a racecourse in the Kildare Deputy's constituency. Now he excoriates any suggestion of downgrading of investment in his constituency. I would hate to think what Deputy Perry's attitude would be if Punchestown were located in Sligo.

Mr. Durkan:

The Deputy should get to the point.

Mr. C. Lenihan:

His attitude would change overnight if there was any threat to his back yard. The "not in my back yard" or "not in my constituency" syndrome has entered the House since the publication of the Hanly report. All Deputies' contributions focused on constituency interests.

Deputy Gilmore is amazed that Loughlinstown Hospital is not considered a major hospital, perhaps even a major European teaching hospital. He expected the Hanly report would suddenly transform Loughlinstown Hospital into something far greater than St. Vincent's Hospital. Anybody passing either facility would know the capability does not exist to upgrade Loughlinstown Hospital to the size, magnitude, efficiency and productivity of St. Vincent's Hospital.

Mr. Gilmore:

Why not?

Mr. C. Lenihan:

There has been a serious amount of Exchequer investment in St. Vincent's Hospital. A touch of the old socialist magic wand is what is expected if people suggest that Loughlinstown Hospital can magically be grown overnight into a hospital of greater magnitude than St. Vincent's Hospital. It defies analysis.

Mr. Gilmore:

Where are all the extra patients to go?

Mr. C. Lenihan:

That begs the question whether the Deputy lives beside the hospital or spends all his life there. He appears to have formed a unique attachment to the facility that defies rational analysis. It is clear St. Vincent's Hospital provides a huge diversity of services and specialties. To expect that Loughlinstown Hospital could be changed into something on the scale of St. Vincent's Hospital is off-the-wall.

(Interruptions).

Mr. C. Lenihan:

I cannot believe anyone would suggest that is possible. Members are engaging in a great deal of self-serving rhetoric regarding hospitals in their constituencies.

I do not agree with everything Deputy Fiona O'Malley said, least of all what she had to say about our pay and conditions. At least she did not mention her constituency or the various facilities that will allegedly be downgraded and so on in her contribution. The focus of and point to the Hanly report is that it is not—

Mr. Broughan:

I demand a quorum.

Notice taken that 20 Members were not present; House counted and 20 Members being present,

An Leas-Cheann Comhairle:

The Deputy has 20 seconds left.

Mr. C. Lenihan:

It is a pity I have only 20 seconds remaining. I am reliably informed that Sligo is not referred to in the Hanly report. I was not aware of that when I came into the Chamber. That, again, illustrates that the "not in my back yard" factor is out of control. Deputy Perry is fighting the downgrading of a hospital that has not been referred to in the Hanly report.

Mr. Crawford:

What about Nenagh Hospital?

Mr. C. Lenihan:

This defies logical analysis and illustrates that there is a certain type of Deputy in the House who, in the case of Deputy Cowley, does not look beyond his profession, in Deputy Perry's case does not look beyond Benbulbin and in Deputy Gilmore's case will never in a million years look beyond Loughlinstown.

An Leas-Cheann Comhairle:

I must call the next speaker.

Mr. C. Lenihan:

This is the type of self-serving "not in my constituency" stuff that everybody in the House abhors.

An Leas-Cheann Comhairle:

I call Deputy Connolly.

Mr. C. Lenihan:

However, there are the old hackneyed types who will trot that out at every twist and turn.

An Leas-Cheann Comhairle:

Order, please. Deputy Connolly is in possession.

Mr. Connolly:

I wish to share time with Deputies Boyle and Ó Snodaigh.

Mr. C. Lenihan:

It is a case of "not in my constituency" or "never in my constituency" when they know well it will happen there.

An Leas-Cheann Comhairle:

Deputy Connolly is in possession. Deputy Conor Lenihan should resume his seat.

Mr. C. Lenihan:

Their constituencies will be affected and hospital services will be redeployed—

An Leas-Cheann Comhairle:

Deputy Lenihan is out of order.

Mr. C. Lenihan:

—but this will not be done in a way that will benefit the interests of Deputies in their constituencies or doctors who want to mind their little rackets in their back yard.

An Leas-Cheann Comhairle:

Deputy Lenihan is out of order.

Mr. Crawford:

He should listen to his brother.

Mr. Connolly:

I wish to share time with Deputies Boyle and Ó Snodaigh

An Leas-Cheann Comhairle:

Is that agreed?

Mr. Connolly:

In recent times, the Minister for Health and Children has argued about and denied the closure of hospitals. However, he was arguing with himself and appears to have won the argument.

The nub of the issue relates to hospital downgrading, an issue about which we are all concerned. During the launch of the Hanly report in Government Buildings, the Minister and Mr. Hanly denied on three separate occasions and before anybody read it that the report was about downgrading. We then knew this issue concerned downgrading. One should try to tell a patient suffering a heart attack or a haemorrhage that the lack of an accident and emergency department to treat him or her does not equate to downgrading at their local hospital.

The concept of the golden hour seems to have been set aside. The Hanly report refers in glossy terms to the right treatment in the right place at the right time. I do not see how that can be equated with the right to treatment at the right place and right time. We do not have a Hanly pilot project in Monaghan. What we have is a prototype of the report and we in the north-east have seen the results that has yielded. There have been roadside deaths and roadside births in Monaghan.

One only has to consider the plight of Christina Knox who, at 10 o'clock in the morning, was ten minutes away from her physician and an idle bed in Monaghan General Hospital, was transferred to another hospital and died 40 minutes later. We all remember the Livingstone tragedy.

Mr. B. Lenihan:

We do. The Deputy should be careful.

Mr. Connolly:

There were other tragedies in Dundalk. If the Minister persists with implementation of the Hanly report we will witness such tragedies in Nenagh, Ennis, Monaghan and south Dublin. This report condemns the people of rural Ireland because of their demographic and geographic locations.

Some time ago, the Minister asked for alternatives. The Minister's UK counterpart implemented similar changes in accident and emergency departments throughout Britain and in Northern Ireland. A decision was taken to reverse the downgrading of the hospital in Downpatrick and that hospital is now thriving. If the Minister is serious about examining alternatives he need only look at what happened in Bath in south England and the Mid-Argyll hospital in Scotland. They are now thriving hospitals which are serving their communities particularly well.

The Minister visited New York to see the effect of the smoking ban in that city. I ask him to examine how they deliver accident and emergency services in different states in America. It does not make sense that every broken finger or cut requiring six stitches should be treated in a regional centre of excellence. That is foolish.

Hanly would have us believe that he will provide us with neurologists, rheumatologists and geriatricians. We need those specialties anyway, irrespective of whether Hanly recommends them, but they are being offered as a type of quid pro quo. That is wrong and it is mischievous.

Another issue talked about is that of nurse practitioners. It takes seven years to train a nurse practitioner. We already have five nurse practitioners who have to work under the guise of a consultant. These are issues that are not thrashed out in the Hanly report. This is a half-baked report and it should be withdrawn.

The Minister is playing it cute by putting the Minister for Defence, Deputy Michael Smith, in charge of the downgrading committee. It is a bit like asking him to fall on his own sword. I call on the Minister, Deputy Michael Smith, to resist the temptation. He should not accept the poisoned chalice of the Hanly report and stick to his guns.

Mr. Boyle:

With the publication of the Hanly report, the latest in a long line of reports initiated by the Minister for Health and Children, the time has come for all such reports to carry a health warning. There is a danger of failing eyesight from reading the closely worded print. There is a danger of inducing back pain from carrying two or more of these reports at any time and one gets a constant feeling of nausea reading the recommendations that we know will never be implemented. This Government is causing more health problems than it is solving and if these reports are meant to do anything, it is to create a sense of goodwill and confidence that has long been lacking in the health policies of this Government.

We now have a Taoiseach who says that the implementation of this report and all other reports is a matter of demographics and geographics. They might as well be a matter of hieroglyphics because the reality is that no one can read the signals this Government is sending out. It is sending out two, three or four different messages, depending on which member of the Cabinet is talking and the time of day.

Mr. J. Bruton:

It is a smoke-screen.

Mr. Boyle:

Now we have the farce of the Minister for Defence being put on an implementation committee. What role can the Minister for Defence play here?

Mr. Durkan:

Military take-over.

Mr. Boyle:

Is it that in the event of public unhappiness at any one of these general hospitals closing down, the Army will be called in? That is the farcical level Government policies have now reached. The Government should take stock and not produce another report but finally put resources into health services which have been mythically portrayed as being above the European average.

Mr. B. Lenihan:

There is a total of €10 billion in the Book of Estimates.

Mr. Boyle:

In terms of our social protection expenditure, the resources have not been provided. The reality is that if we want to restore public confidence in the health service we should make it smaller and more local rather than opting for centralisation and rationalisation. The services should be made more attainable to the public. They need to have the confidence to know that if anything goes wrong, it can be dealt with most readily in their local community.

That is not the scope of this report nor the focus of Government health policies. The reality is that we will end up with a health service consisting of one major hospital in each health board area, and possibly just one health board. If the Government thinks that is a strategy for inspiring public confidence in health, it is mistaken. I fear it will get the first indications of the degree of public confidence in its health policy next June and I, for one, will be interested in that result.

Aengus Ó Snodaigh:

The implementation of the European working time directive for junior hospital doctors is long overdue and to the extent that the Hanly report provides for that, it is welcome. The fact that consultant-delivered rather than consultant-led services are provided for in the Hanly report, is also to be welcomed. Both of those changes are essential if we are to improve delivery of health care to patients throughout the State but the Hanly report goes much further. It contains a fatal flaw in that it links both these changes to the downgrading of the services delivered by local hospitals throughout the country. The report does not name the hospitals which will lose services. It does not even name the hospitals in the eastern region which will lose services, even though it will be piloted.

The Minister for Health and Children stated on Question Time in the House on Wednesday that there is nothing new in the emphasis in the Hanly report on the development of so-called centres of excellence. We have to go back to 1966 to find the first report on Dublin which stated that there should be three hospitals on the northside and three on the southside but consider the disaster we have in Dublin because of that. The Minister is right. There is nothing new in that. It is fine in theory to suggest we should have centres of excellence but there is chaos in the centres of excellence we already have in Dublin. There is a lack of facilities in maternity wards which means they are not fully equipped to deal with the number of patients in them. These hospitals are supposed to be centres of excellence and they cannot cope but there are hospitals throughout the country which could cope very well. All that is needed is investment to provide services at local level.

Deputy Conor Lenihan said we should not refer to hospitals in our constituencies and that we should know about all the hospitals in the country. I know about quite a few but the ones I know best are those to which I have brought my wife, my children and my father-in-law recently and every one of them is chaotic. The small cubicle my father-in-law was in in the accident and emergency department in St. James's Hospital contained two trolleys. There is chaos in what is supposed to be a centre of excellence. We are expected to close down more hospitals and send more patients to these centres.

The Pollock report published earlier this year on Our Lady's Hospital for Sick Children in Crumlin highlighted a tenfold increase in patient numbers yet there are now fewer beds than when it first opened. The Coombe Women's Hospital, the National Maternity Hospital in Holles Street, which is not in my constituency, and the Rotunda Hospital are bursting at the seams. They are supposed to be centres of excellence but we have closed maternity units in other hospitals.

The aspect of the Hanly report which concentrates on centres of excellence will not work. It will cause chaos throughout the country. That part of the report should be shelved. We should implement the aspects I mentioned regarding the working time directive, which is overdue, and the principle of consultant-directed services should be introduced forthwith. The Government should live up to the commitments it made to the electorate to eliminate hospital waiting lists and deliver a health service. I would like to see that happen but I do not believe it will. It definitely will not happen if the recommendations in the Hanly report are implemented.

Mr. T. Dempsey:

I dtús báire glacaim leis an seans caint inniu ar rud chomh tábhachtach agus atá cúrsaí leighis agus cúrsaí ospidéil. Nuair a bhí me ar lorg vótaí san olltoghchán, ní raibh aon ábhar a raibh níos mó cainte faoi ná cúrsaí leighis so tá sé tábhachtach go gcuirfimid an bhéim, mar a chuir tuairisc Hanly, ar na cúrsaí sin.

I believe it was the late Tip O'Neill who said that all politics are local. Like most maxims, when they are subjected to closer scrutiny, we find exceptions. Today might be an exception because it is necessary from one time to another to allow the national interest to transcend local interests in order that the locality may be better served.

The culture of a people is often manifest in its language and there is an equally important maxim in Gaelic which applies to the Hanly report. It is a beautiful phrase that urban and rural people in particular who are familiar with the thrashing of long ago will remember, "Ní neart go cur le chéile – without unity we cannot have strength". The old meitheal used to come together to help the farmer on the day he most needed help. It was about the integration of farmers and farm helpers at that time. The Hanly report is about integrating a network of local, general, acute and major hospitals to work for a better patient service in an area.

It is time we congratulated the Minister for Health and Children, Deputy Martin, and his three junior Ministers, Deputies Brian Lenihan, O'Malley and Callely, on having the courage to bring forward this report. Every Government in the past has done its best to provide a hospital service with which the generality of people will be happy – one can never make everybody happy. All Governments, including the one led by Deputy John Bruton, did their best. I was amazed – and still am – to find that the whole income tax take is spent on health. There is not a penny left for education or social welfare – it all goes on health. The health budget next year is €10 billion. It is essential that we as politicians ensure we obtain value for money. That is why it is important for us to consider the area of health care in which the Hanly report may deliver.

I was impressed by the contributions of two Deputies this morning – I am new to this business so I am not sure from listening to the Ceann Comhairle whether one may mention Deputies or not, but I presume one may praise them.

Mr. J. Bruton:

The Deputy may.

Mr. Durkan:

That is always welcome.

Mr. T. Dempsey:

I was mindful that the Ceann Comhairle himself is also a doctúir, so I am not sure where he stands in all of this. However, Deputies Wall and English, from the Labour Party and Fine Gael, both emphasised the good points of the Hanly report. That is what politics needs, an integrated approach among ourselves to obtaining a better health service. I congratulate the Deputies.

There are five important areas. The first is patient care. As some people know, I come from a hurling background, and I have had occasion to require medical services after training sessions that started at 7 p.m. Two years ago a young fellow broke his ankle. He was to sit exams in two days. We were lucky to have an expert orthopaedic service to which he could be brought and that it operated 24 hours a day, seven days a week. In my younger days, when I played myself, that was not the case. There are cases of sportsmen from every background – rugby, soccer – who were unfortunate enough not to have experts available. The Hanly report at least tries to promote the availability of specialists 24 hours a day, seven days a week. If this was all that was achieved the approach of the report would be laudable.

The second area is that of contracts. Contracts that have served consultants and patients in the past may not serve them today. I am not au fait with the nitty-gritty of them but it is time these contracts were revisited, from the point of view of the consultants and of the patients. It is beyond time the appalling hours worked by junior doctors were investigated. This is unbelievable, but it goes unnoticed by many of us. Their working hours, by virtue of EU diktat and the Hanly report, will be reduced to what is fair and proper. I also note from the report that their training will be improved.

Another vital area is investment in ambulance personnel. The availability of ambulance vehicles should be investigated as well as training so that we have medical emergency technicians who are trained to an advanced level to respond when necessary in the best way possible.

The last important area, in deference to the Tip O'Neill philosophy of all politics being local, is development of services in local hospitals. That too will receive an injection of capital, which is important. I will go further and say that non-major hospitals should also be facilitated in developing expertise in their areas. It is vital that the taxpayer obtains value for money, that junior doctors are looked after and that patients and consultants are looked after.

I return to the Tip O'Neill philosophy in saying that I have been asked by many people in my own constituency what will happen to Wexford General Hospital. The answer is that Hanly has not referred to it. We must be careful that we do not enter the area of scaremongering. My colleagues from all parties in Wexford, along with Senator Jim Walsh, meet regularly with the South-Eastern Health Board. We are dealing with major issues in Wexford – 18 new beds and an accident and emergency consultant for our hospital. We are proud of the hospital's dedicated staff. At this point, however, Hanly has not referred to the hospital, and when he does we will have an input. All local interests will be involved in a proper analysis of the needs of Wexford and the surrounding area. That is vital.

The challenge of the Hanly report is that politicians from all parties must insist on a better patient service. It should be about patients rather than politics, especially local politics. I hope the outcome will be good for patients. Deputy Durkan asked a most important question of Deputy Conor Lenihan, with some passion. It is important to realise how emotive the issue is. That is why I congratulate the various Ministers involved. Too often emotion obliterates sense. Deputy Durkan asked Deputy Lenihan to tell us which hospitals are to close. According to Hanly, no hospital will be closed. I am sure when Deputy Durkan goes back to his constituency he will be delighted to be able to say that.

Mr. Durkan:

I will refer my constituents to Deputy Lenihan.

Mr. T. Dempsey:

That will be fine. There is no better Deputy to deal with them.

Mr. J. Bruton:

Most Deputies in this debate have been praising the Hanly report while looking for so many exceptions to it as to render it meaningless. My approach is different – I question the underlying assumptions of the report.

The report does not set out in a convincing way the evidence on which its conclusions are based. The two key arguments in the conclusions of the report are: "There is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team," and "Studies have shown a statistically significant link between "high volume" surgeons in "high volume" hospitals and lower death rates in hospital." In other words, Hanly argues that big hospitals provide the best means of saving lives.

The report does not set out the arguments in favour of this conclusion. It mentions in a tiny footnote research by Batista et al, Chassin et al and Nuffield Institute for Health. Why is this research not set out in more detail in the report? Are the public and the Members of the Dáil not educated enough to read and understand the research referred to in this almost dismissive footnote? Are we supposed to accept it on authority from the doctors that this research is right and its conclusions are proven? This research needs to be summarised in the report and set out before the Dáil, because we are well capable of reading this research and deciding whether it shows that big hospitals save more lives than small ones. Let us have an evidence-based approach.

The report concludes that the European working time directive, which requires a dramatic reduction in working hours, can best be met by "the appointment of more consultants working in teams" and concludes that these teams can only be constituted in a smaller number of big hospitals. Again, I am not yet convinced by Hanly's argument in favour of a consultant-led service.

Hanly rejects using non-consultant, career-grade hospital doctors for reasons of medical education. Reference is made to "various expert reports" in the UK. Again, these reports are not set out for Members to read. It is assumed that we are not smart enough to understand these expert reports which argue on grounds of medical education that only consultants and not career-grade hospital doctors should be the leading providers of services in hospitals. If the evidence if produced, I am prepared – as I am sure many Members would be – to accept even unpalatable conclusions. Although everybody has praised the Hanly report, it only sets out the evidence, not the conclusions.

The report has failed to be realistic in dealing with public transport networks serving hospitals. Hospitals that are inaccessibly located in the middle of traffic-clogged towns are not suitable for dealing with emergencies. For this reason, I am puzzled by the rationale for choosing Limerick Regional Hospital as the major centre for that region. Anyone that knows where the hospital is located will know how difficult it is to get to it at rush hour, even from the centre of Limerick. I would have thought that traffic levels and the configuration of public transport networks would have been a key consideration in the Hanly report, yet it is not referred to, any more than is the national spatial strategy. This puzzles me. We should integrate transport and health policy in a single policy.

Hanly concludes by paraphrasing Mrs. Thatcher's famous "TINA" dictum – there is no alternative – by saying that it had identified no realistic alternative to its proposals that would safeguard patient care. While this may be true, it has not been proven beyond doubt. Having said that, it is now for those who oppose the report to bring forward arguments that contradict the two key assumptions it makes. They must also come forward with an alternative method for complying with the EU Working Time Directive as it cannot be avoided. So far, the opponents of the report have not done this. Deputy Finneran made a strong statement and one would assume that he would disappear from Fianna Fáil if the Hanly approach is applied in Roscommon. However, neither he nor any of the other Deputies making strong statements have suggested an alternative method for dealing with the problems posed by the directive.

Without knowing much about it, I would prefer to see an approach that uses non-consultant hospital doctors rather than a consultant-led service. The consultant-led service approach is being dictated, in part, by the professional interests in consultant grades. There is a sense that no one but them has the qualifications necessary to provide the sort of service that ought to be provided and, flowing from this, services must be centralised in big hospitals. This House should subject such assumptions to acute forensic analysis. Unfortunately, the report has not given us the evidence that would allow us to do this. Hanly has not summarised the academic research that provides the basis for the conclusions of the report. This should be part of the report and part of the debate.

I also question the overall health strategy set out in the Brennan and Prospectus reports. These propose to establish a single semi-State body to run the health service throughout the country. The Government wants to use the CIE model to run the health service at the same time as it is proposing to dismantle CIE. If this comes to pass, the Minister will not answer questions for anything that is a matter for "An Bord Sláinte" and there will be political accountability at this level. Equally, as there will be no regional health boards, there will be no accountability at that level either. It seems to be assumed that politicians are not qualified to question health policy decisions and that only medical people have the appropriate gravity and knowledge to make them. I remind the authors of the Hanly, Brennan and Prospectus reports that we are elected representatives. We take responsibility for raising the resources spent in the health service. While I have no doubt that politicians will only make the right decision when they have first tried every possible wrong decision – that we are not all that courageous is a failing of our profession – at least we are accountable.

I am worried that as a result of this combined approach, we will have a highly centralised and unaccountable health service that will present an annual bill to the Minister for payment by the taxpayer. We will not have genuine accountability. It stems from a sense within the medical profession that others ought not to question the resource decisions they take. This goes back to clinical decisions they make for individual patients. They seem to insist on retaining the freedom to buy the more expensive treatment even when a less expensive one is available. The sense that their professional freedom should not be questioned is also applied in the wider areas such as the location of hospitals, etc.

We need another debate, as this one is inadequate. The academic studies must be produced, either in the House or in the relevant committee, forensically examined and the researchers need to be questioned by Deputies. Perhaps when this is done Members will accept what is best for the national interest. To paraphrase Deputy Tony Dempsey, they will come together. While Members are prepared to come together and do what is right for the country and what is right for our regions as well as for our county or constituency, we need to see the evidence first. We must be convinced of the merits of it and we cannot be taken for granted by professionals who simply cite footnotes referring to expert research from other countries without producing the research.

I hope the Government will take this approach. This is a test for the Government and for political leadership in the country. If the Government fails to deliver on a comprehensive package and is blown off course by sentiments such as those expressed from the backbenches today, it will be a failure for politics and not just for the Government. Politics is being tested in this regard. In its present form, the Hanly report is not sufficiently robust and does not contain sufficiently well argued and demonstrably valid evidence to justify the political price it may be necessary to pay. We should be presented with the evidence before we are asked to pay that price.

Mr. Durkan:

Deputy John Bruton has given us much food for thought with his analysis of the Hanly report. He has been critical in a fundamental and constructive way and the Government will do well to listen to the points he has raised. The points I wish to raise are probably more political, but will have a certain level of fundamentalism attached to them.

My first fear of the Hanly report is that it is one in a series of reports on the health service that has been built up in recent years. When it became obvious that a general election was in the offing we were told about a ten-year plan. Due to the fact that an election was coming the Government said it needed more money. The Government recruited 29,000 additional personnel in the health service. That is a lot of recruitment. It is almost like an employment agency. Were those recruited junior hospital doctors, consultants or nursing and medical personnel?

Mr. B. Lenihan:

Recruitment was right across the board.

Mr. Durkan:

If that is the case I find it hard to understand why we have longer waiting lists than ever. We have waiting lists for all services except maternity services and that is because the people who require those services cannot wait.

The Government continually complains about the extra money it has spent. On which part of the health service was the money spent? Was it strategically spent or was it just thrown at the service and someone told to do what he or she could with it?

The Eastern Health Board was the biggest health board in the country and administered services to one third of the country's population. The Government divided it into three health boards and provided an Eastern Regional Health Authority, so adding another tier. I can offer assistance as to where the money went. That is where it went. The Eastern Health Board had a chief executive officer and three programme managers, who delivered the services. They were all accessible. One could ring them up, even at night, and speak to them. They could respond to emergencies as they arose and they often did. I compliment them on that. A new tier of administration was imposed on the system and five times the number of programme managers were put in place in each of the subordinate health board areas. Now, every time one rings them up one is told they are at a meeting. Meeting and exchanging views with each other on a daily basis is now their full-time occupation. The public no longer have access to the service.

On top of this expenditure the treatment purchase scheme was introduced. We send patients to Northern Ireland, to Britain, whose health service shares many of our own failings, and to France in order to get services for which we have put structures in place in our own country. Given the amount of money we have spent on the health system and the number of reports that have been created over the years, it is paradoxical that we must send patients abroad for treatment.

It is not enough to say we did not know the population was getting bigger or that we did not have time to plan for this situation. In the old days when there were several small hospitals throughout this city it was easier to get service than it is now. I disagree with the notion that big is always better and that establishing big centres is the way to solve our difficulties. We should have learned from our experiences in the years since big hospitals replaced little ones. I appreciate the need for specialist units. However, this does not mean that we should dismiss all the smaller regional hospitals and create two or three major hospitals to deal with all issues in the future.

Deputy John Bruton referred to traffic. At a meeting in my constituency the other night some expert decided it would take 11 minutes to go from Naas to Tallaght. If it were that easy to calculate the time of that journey surely a commuter who travels the route every morning would have come to a conclusion in that regard a long time ago. Unfortunately none of them has done so. This is what I call a desktop examination of an issue. Someone looks at a map and, on the basis of what he sees, decides that a service can be delivered in a specified time.

The Hanly report will cause the downgrading of many of our good county and regional hospitals to the status of local health clinics. I do not criticise health centres. In fact, much good could be done by upgrading local health centres but this issue is not addressed in the Hanly report.

Deputy John Bruton drew the House's attention to references in the Hanly report to various experts in the United Kingdom and in Ireland, who believe they see things correctly. I spent 16 or 17 years on the Eastern Health Board and I hope I learned something about the health service during that time. We were always very busy but there was democracy and a local input. Under the proposed changes there will be no democracy because there will be no accountability to this House or to the public who elect it. Deputies who ask questions about the health service will be told the Minister has no responsibility for that area. If the Hanly report is implemented – and I am not convinced it will be – strict provision should be made for the Minister to be accountable for the health service to the House and obliged to answer questions on the service in the House. If the Minister provides the funding for the health service he should be accountable to the House for the way the funding is spent.

I congratulate the Minister for Defence on his elevation to the pivotal post he has been given in the engineering of health services. I am not certain which position he is likely to take up, whether defending the embattled services at hospital gate level or assisting the people who wish to gain access to the service. However, military intelligence, expertise and hardware will be impressive in that area and I hope the Minister is successful in assisting in doing what has not been done so far, namely, making a health service available to the public as and when they want it.

Certain procedures cannot wait and need to be as close to the community as possible. For several years we have been treated to pie in the sky and told that certain centres of excellence would be in particular locations and that it would be possible to reach them in a certain number of minutes. We knew what we were being told was not true. In the interest of the health service and of the people of the country, I ask all who are involved in the service to see that people get access to it, which they do not get now.

I do not believe it is intended to implement this report until after the next general election. That is my political point and I know the Minister of State is surprised I made it. Money was poured into the health system before the last general election to give the public the impression that the Government had the means to solve problems and was about to do so. The Government failed but nothing more was said until after the general election. Once again a new report has been rolled out which will take ten years to implement. At least two general elections will have been held by that time. I hate to think what is likely to have happened to the poor people of this country by the time two more general elections like that of last year have been visited upon them.

Ms Harkin:

I thank you, a Leas-Cheann Comhairle, for this opportunity to speak on the Hanly report, an issue of great concern to many people wherever they live. We all know that where one lives is a crucial factor in determining access to health services and particularly to accident and emergency cover.

The Taoiseach himself and many Ministers have spoken about demographic and geographic considerations. Despite what Deputy Conor Lenihan said earlier about different Deputies being concerned only with their own constituencies, the people in my constituency elected me and others to represent their views in this House and to put their case. While party politicians and Independents must and do have a national vision—

Dr. Cowley:

Hear, hear.

Ms Harkin:

—the local feeds into the national. This is a two-way street. I am sure Deputy Conor Lenihan has heard the statement that all politics is local.

Dr. Cowley:

He is deaf.

Ms Harkin:

There are 166 Members in the House so the local pieces of the jigsaw will fit into the national picture. What happens if just a few pieces of that jigsaw are missing, such as Nenagh, Ennis, Monaghan or Roscommon? We would not have a complete picture. This is not the type of health service we want. Maybe Deputy Conor Lenihan would be happy with this but I guarantee him that the remaining Members would not.

Deputy Conor Lenihan referred to Sligo General Hospital and stated that the Hanly report presents no threat to it. This is exactly as it should be, and it should remain so. Let us consider the hospital in Manorhamilton, County Leitrim, where I lived for 11 years. I know from experience the value of its accident and emergency service. Two years before the Hanly report was issued, the casualty unit in Manorhamilton closed and we now have a minor injuries unit. However, the ambulance service has not been upgraded to provide the required service for north Leitrim, nor have the roads and infrastructure been improved to facilitate better access to Sligo General Hospital. Therefore, people from Rossinver to Kiltyclogher to west Cavan now face a considerable journey on bad roads because of the failure to provide the necessary upgrading of the ambulance service. Is this to be a template for the future? Is Manorhamilton hospital to be a blueprint for what we can expect? It is no wonder that those from Loop Head, Kilrush and Ennis took to the streets in their thousands to demonstrate. They are afraid they will be left with an inferior service such as that in Leitrim.

I know we need reform in the health service and that the working hours of junior doctors must be reduced. Centres of excellence can and will contribute to a better health service. However, if we are to have them, we must have equality of access across the country to basic hospital services, particularly accident and emergency services. One might ask how this could be achieved. An answer might involve considering the Government's spatial strategy, for example. In County Mayo, Ballina and Castlebar are grouped together in such a way that they can pool their resources, expertise and strength to create a critical mass for development. Could the same not apply to Nenagh, Ennis and Limerick, for example? We are told nine consultants are needed to run a good and proper accident and emergency service. However, all nine do not have to be employed in Limerick on a full-time basis. Their contracts could stipulate that they work two or three days in Ennis or Nenagh. In other words, we should move the consultants and not the patients. Similarly, this might work in the case of Roscommon and Portiuncula or that of Cavan and Monaghan. We need some lateral thinking and should start from the premise that the service is for the patient, whose needs are paramount. Although top-class medical care is critical, so also is access. We need a balance between the two.

The real problem with the Hanly report, which is excellent in many ways, is that it is unbalanced. We are told we cannot accept it in part and that we must accept all or nothing. This makes no sense. We need to take what is best and discard the rest in the interest of patients. The report, like many other reports, is too centralised in its thinking. It is not true to say that bigger is necessarily better, yet this idea permeates the report. It does not strike a proper balance where access is concerned. We need a system that ensures that, whether one lives in Manorhamilton, Ennis, Monaghan or Roscommon, one has equality of access with those in Limerick, Cork and Sligo.

Dr. Cowley:

On a point of order, can the Leas-Cheann Comhairle do anything about these Friday sittings given the calibre of politician that is being let loose? When I left the Chamber to meet my brother, a Deputy made a scurrilous personal attack on me. He resorted to insults when he could not answer the good case I made in the interest of my constituents. When we have Friday sittings, people such as the Deputy concerned are the only ones that can be dragged up to come into the House and they interfere with those trying to do their jobs.

Minister of State at the Department of Health and Children (Mr. B. Lenihan):

I am glad to have the opportunity to discuss the Hanly report and to outline the Government's perspective on it. It is important to realise that the Government has a very definite line of policy on the health service, with two crucial pillars. One is to invest in the services and the other is to bring about significant reform.

We have to recall the investment that has been made in the health service. The past six years have seen a huge increase in additional spending on health care, capital projects, staff, as Deputy Durkan mentioned, and the day-to-day operation of the different services concerned. An increasing number of patients have benefited from these additional services and it is worth recalling that the volume of activity in our hospitals has increased dramatically in recent years. There has been a huge increase in the number of treatments and procedures being carried out and this is the result of a very substantial increase in investment.

Of course the Government, under the Constitution, has to propose and agree the investments, through this House, but ultimately those moneys are voted by all of us to the health service. Deputy Tony Dempsey stated this afternoon that all the income tax receipts of the State are now committed to the Department of Health and Children. This is a matter on which we all have to focus our sense of responsibility. Of course we have had a very far-ranging debate, from the local to the national. As Deputy Tony Dempsey pointed out, all politics is local, a point later echoed by Deputy Harkin. Naturally, Deputies are concerned about the provision and range of services available in their immediate localities. Many of them have direct experience of these services.

Unfortunately, Deputy Connolly opened a particular episode that was investigated in great detail. There were never the facilities in Monaghan Hospital to deal with the type of case about which such public discussion took place last winter.

Mr. Connolly:

We need to save people's lives.

Mr. B. Lenihan:

Deputy Connolly is well aware of this. This is where politics does interfere with the science of the position. This is a regrettable fact but I do not want to discuss it this afternoon.

Mr. Connolly:

We are answerable to the people.

Mr. B. Lenihan:

We are not elected to the House only to echo opinion but also to lead.

Mr. Connolly:

We are here to reflect opinion.

Mr. B. Lenihan:

We are committing more than the entire income tax receipts of the State to this service. We have a duty to focus on the service and ensure the patient gets the best treatment. This is absolutely fundamental, and I believe all Deputies share this view. We have to have these discussions but we also have to have conclusions.

I very much welcome the fact that Deputy John Bruton, in his contribution, called for an evidence-based approach. One of the difficulties we have in debating health issues in the House is that the health service, historically, was not run on the basis of incentivisation but on the basis of block allocations of money by the Department of Health and Children to certain agencies. In other words, it is run they way the economy of the old Soviet Union was run. Deputies of all parties fall into the trap of thinking we can manage the service following political instincts, and I would not single out any Deputy of any party, from any era, for doing so. We have invested very substantial—

Dr. Cowley:

Why are we closing hospitals?

An Leas-Cheann Comhairle:

Please allow the Minister of State to reply.

Mr. B. Lenihan:

I would like to address the issue of the hospitals.

An Leas-Cheann Comhairle:

The Minister's time is very limited.

Mr. B. Lenihan:

We have invested very substantial sums in the health service and we all have a responsibility to ensure they produce the best possible results.

Dr. Cowley:

We have a responsibility to keep hospitals open.

Mr. B. Lenihan:

This is what the Hanly report, as part of a mosaic of reform proposals, including the Prospectus and Brennan reports, is about. It is about reforming the system to ensure that the patient comes first.

Dr. Cowley:

It is about closing hospitals.

Mr. B. Lenihan:

There has been a great deal of discussion about local hospitals in this debate. It is very important to notice that the Hanly report recommends investment in local hospitals to provide more services for patients—

Dr. Cowley:

Not at night.

Mr. B. Lenihan:

—including more elective medical and surgical procedures, out-patient services, pre-natal and post-natal maternity services and better access to diagnostic facilities.

Dr. Cowley:

Not after 8 p.m.

Mr. B. Lenihan:

The report proposes that 70% of the patients who currently attend accident and emergency departments should continue to do so in the local hospitals. It does say—

Mr. Connolly:

That 70% of—

Mr. B. Lenihan:

In the moment I have left I would like to make my point. We did not commission the report. It was produced by experts in the medical field and represents a consensus of medial opinion.

Mr. Connolly:

They are self-interested bodies.

Mr. B. Lenihan:

The report states that it is in the best interests of this group of patients to be treated elsewhere.

Mr. Connolly:

The people involved are from the large colleges in central areas.

Mr. B. Lenihan:

Either we represent a local industry or we put patients first. That is the issue and Deputy Connolly will have to face up to his responsibilities.

I do not take issue with one point Deputy Cowley has made consistently since being elected to the House, namely, that an improved ambulance service is needed. I agree that the Hanly report option is contingent on that type of exercise being mounted.

As legislators, we have a duty to examine this issue. Three or four decades ago, when we had a poor record of industrial development—

Mr. Connolly:

We had hospitals three decades ago.

Mr. B. Lenihan:

—we came together and agreed upon a strategy. If we do not collectively agree on the health service, we will not improve it. This is not just a matter for the Government or its successor. Recently, when asked what problems face the health service, Professor Brendan Walsh of University College Dublin pointed out that the greatest ones are political. We must recognise that in the House because this goes to the heart of the debate on the Hanly report.

The Government must also address the issues arising from the working time directive.

Mr. Connolly:

Will the Government ever learn?

Mr. B. Lenihan:

I agree we have to learn, but we must base our conclusions on the evidence. We must take an evidence-based approach to developing the health services. We cannot just pick and choose.

Mr. Connolly:

Children are being born and people are dying on roadsides.

An Leas-Cheann Comhairle:

The Minister of State should conclude.

Mr. B. Lenihan:

I am obliged to the Leas-Cheann Comhairle for reminding me to observe Standing Orders. I will conclude on that note.

The Dáil adjourned at 4 p.m. until 2.30 p.m. on Tuesday, 25 November 2003.