Dáil Éireann debate -
Tuesday, 2 Mar 2004

Vol. 581 No. 2

Health Care: Motion.

Caoimhghín Ó Caoláin

I move:

That Dáil Éireann,

— recalling:

— the promise by the Fianna Fáil Party prior to the 2002 general election to eliminate hospital waiting lists within two years;

— its promise to extend medical card entitlement to a further 200,000 people;

— that action 89 of the Government's health strategy promised greater equity for public patients in acute hospital services in a revised contract for hospital consultants to be delivered by the end of 2002;

— the promised delivery in the health strategy of a new model of primary care throughout the State;

— noting that:

— according to most recent figures there are 27,212 people on hospital waiting lists;

— while 36% of the population was entitled to a medical card a decade ago less than 30% are so entitled today;

— the consultants' contract has not been renegotiated nor revised;

— there has been minimal progress on primary care since 2001;

— views with concern the continuing drive towards over-centralisation of hospital services including the closure of maternity, accident and emergency and other acute services at hospitals around the State and calls for the restoration of said services at those hospitals affected;

— deplores the continuing failure to reform and resource mental health services resulting in continuing hardship for people with mental illness and the failure of the State to meet international human rights standards in this regard;

— urges a reconsideration of the planned configuration of radiation oncology units in Dublin, Galway and Cork only and calls for the acceleration of plans for the overall improvement in cancer treatment services;

— deplores the mismanagement of our health services at central Government and health board level as shown by the number of investigations into serious incidents, including fatalities, in a number of health board areas, and the delayed and unsatisfactory nature of those investigations;

— considers that reform of health administration structures as proposed by Government will create a democratic deficit;

— affirms that the two-tier, public-private system is inherently inequitable and inefficient and, after decades of underfunding of our health services, the two-tier structure is now causing increased resources to be used in an ineffective manner;

— supports an all-Ireland approach to health care delivery to harmonise and maximise resources on an island-wide basis and urges greater priority for this approach by Government;

— asserts the basic right of equal access to the best health services for all regardless of ability to pay and seeks the phasing out of the current two-tier public-private system which subsidises the private health care business at the expense of the public system, to be replaced by a truly reformed health service with care free at the point of delivery and funded from general taxation;

— calls for the establishment of a Cabinet committee on health chaired by the Taoiseach to spearhead the phasing in of a reformed health service; and

— demands the resignation of the Minister for Health and Children.

I will share my time with Deputy Crowe and Deputy Ferris.

I regret the Minister for Health and Children is not yet in the Chamber for this important debate. This motion is comprehensive but the two most important words in it are "basic right". Only a rights based approach can address the complex problems which beset public health in general and the health services in particular in Ireland today. The absence of such an approach has allowed inequality to abound in the delivery of health services and because of inequality we are making the least effective use of the increased resources now being spent on health.

The constitution of the World Health Organisation sets out the fundamental principles which should inform health policy. It states: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." The reality in Ireland today is that the enjoyment of the highest attainable standard of health is subject to distinction based on social and economic condition. The actual structure of our health services sustains that inequality.

Who now denies that there is a two-tier system in our health services? The Government's health strategy in 2001 admitted that "there are significant inequalities in the system at present" and many of the proposed measures also represent such an admission. However, a decade previously the then Fianna Fáil Minister for Health, Deputy O'Hanlon, not only admitted that we have a two-tier system but defended it. He said in this House: "That has been the position since the foundation of the State and this system, with its integrated mix of public and private care, has served the nation well." Despite the glaring inequalities which have been exposed in the debate on health in recent years, the unequal model defended by the then Minister, Deputy O'Hanlon, in 1991 and his predecessors and successors has been maintained.

This is the Government's preferred model for health care delivery in the 21st century. The core of the motion before the House is the rejection of that model, the identification of many of the inefficiencies and inequities that flow from it and the presentation of a radical alternative. The Government will argue that it has devoted unprecedented resources to health. It has, but this has come after decades of underfunding, and because of the Government's refusal to challenge the two-tier system vast amounts of public money continue to subsidise the private health care business. Meanwhile public patients suffer.

In 2002, Fianna Fáil made a commitment to the people to "permanently end waiting lists in our hospitals within two years". That promise becomes due on 17 May next but there are more than 27,000 people on hospital waiting lists. As the Minister stated in reply to my parliamentary question last week, this is a decrease of only 7% since 2002. That is 93% short of what the people were promised. If that rate of decrease were maintained, it would take more than 14 years to end waiting lists.

The lack of coherence in Government policy is shown by the treatment purchase fund. This was supposed to be a temporary measure but the Government now relies on it as its primary means of addressing waiting lists. It is a perfect illustration of the inefficiency that this Government is funding. While beds in public hospitals remain closed due to lack of resources in the public system, treatment is being purchased in the private system. It is a short-term fix while the need to increase bed numbers and staffing levels in the public system is neglected. It is the patients of the future who will suffer as our public health infrastructure is allowed to wither.

The National Economic and Social Forum report, Equity of Access to Hospital Care, states that structural change is necessary to address the two-tier public-private system in hospital care and, most significantly, it states that this system is left unchanged in the Government's health strategy. However, the Government's amendment to this motion states that the Government relies on that strategy to deliver equity of access. The Government is totally exposed.

The failure to renegotiate the consultants' contract and to require all new consultants to work exclusively in the public system is in many ways the key to all the other failures of the Government in the health sector. It is, above all, a failure of political will to challenge vested interests and to put the public patient first. I am not advocating a policy of confrontation, but fairness and equity must be at the heart of the system. The privileged position of consultants, their undue power in determining policy and their lack of accountability for work in the public system while profiting from private practice are all inherently unfair and inequitable.

The Minister has described consultants as "kings in their own domain". He has been thwarted by them on many occasions, for example, in the disgraceful delay in proceeding with the investigation of difficulties among consultants in Cavan hospital. More seriously, the victims of malpractice in the obstetrics and gynaecology unit at Our Lady of Lourdes Hospital, Drogheda, have been disgracefully treated as a result of the lack of accountability of the professional bodies. The Minister has done precious little to challenge this.

The Minister's party also promised "to extend medical card eligibility to over 200,000 extra people, with a clear priority being given to families with children". In their 2002 programme for Government, Fianna Fáil and the Progressive Democrats promised to "extend medical card eligibility in line with the recommendations of the National Health Strategy". The strategy promises to increase medical card income guidelines. Once again, there has been zero delivery and low income families with children who do not qualify for the medical card are now worse off than they were two years ago.

The failure to extend medical card qualification and the failure to develop primary care as promised makes the closure of services in local hospitals even more grievous. Look at how communities have united in defence of these hospitals. Listen to their voices. The Government has failed to listen to them heretofore. The Hanly report is a recipe for the closure of more services and, possibly, hospitals in a number of locations. Our party welcomed the long overdue reduction of working hours for junior hospital doctors recommended in the Hanly report but we deplore the use of that issue as a trojan horse to close services in local hospitals throughout the State.

Monaghan and Dundalk were the guinea pigs. Monaghan Hospital has had its maternity, paediatric and accident and emergency services taken from it. Primarily, it is women and children who are worst affected by these cuts. This will continue throughout this State if the Hanly plans are implemented. Sinn Féin, in conjunction with local communities and all who wish to see justice and equity in health care delivery, will continue to defend our hospital services and we demand the restoration of those services that have been axed from the hospitals I have mentioned.

This motion is not just about identifying the undoubted failures and broken promises of this Government. It is also about setting out an alternative and urging real public debate. We make no bones about it. The model of health care delivery we advocate will mean that the wealthy in our society will be required to contribute more in taxation than they do at present. All taxpayers, irrespective of income, should be guaranteed that the best use is being made of their money. That is not the case at present. In that context people would not challenge taxation. Instead they would demand a rejection of funding inequity and its twin, inefficiency.

It must be acknowledged that progress has been made in recent years. Tribute should be paid to all those people throughout the health services who have contributed to progress. For a transformed health service we need to harness their talents and their dedication. However, they need leadership with vision and a strategy based on equality. This Government has given them neither and has broken its commitments to the people.

There can be no confidence in a Minister and a Government with such a record, not only since 2002 but since 1997. That is at the core of this motion and what we seek to address. We want to see the mandate on which the people returned this Government honoured, respected and implemented. That has not happened, nor does the Government intend to do it. Accordingly, we say to the Minister for Health and Children, Deputy Martin, that it is time for him to go.

Mr. Crowe

The less well-off in Ireland are dying because they lack access to health care. That was the conclusion of Dr. Jane Wilde of the Institute of Public Health who estimated last May that almost 6,000 people die prematurely each year simply because they are poor.

These figures should shock anyone in civic or political society, no matter what their political beliefs or background. They form one of the most damning, least reported and hidden statistics characterising our health service. Death rates for all diseases among the poorest and most vulnerable section of our society are two to three times higher than for the richest. Unskilled male manual workers are twice as likely to die prematurely than higher professional men.

The two-tier health service is not a soundbite or a slogan but a reality. People suffering from poverty are, in many cases, unable to rear a family on a healthy diet. This is a recurrent theme in health research and is widely known to be associated with a number of easily preventable diseases. Research shows that free school meals are one of the most important nutritional sources for children from low-income families. However, the Government is not prepared to invest adequately in the school meal scheme. People from the lowest socio-economic class are also most likely to suffer from fuel poverty and the medical effects that result from it. Of these, one in four are unemployed and one in five are lone parents.

People living in poverty often feel shut out of the health service. One man told a Combat Poverty researcher that he was due to go into hospital for a bypass. He had already had three heart attacks and was waiting six years. He pointed out that if he had a cheque book he would have been looked after straight away. As cynical as this attitude is, it is accurate.

In many cases we are talking about people who have no savings, no bank accounts and no stock portfolios. They often put their health at risk because they cannot afford to go to a doctor. This is particularly the case with mothers. Money that should be spent on health must be used to pay the rent, pay for heating or to buy food. For these people, good health care insurance is a luxury they can ill-afford.

According to the national anti-poverty strategy, the Government's target is to reduce the gap in premature mortality between the lowest and highest socio-economic groups by at least 10%. It seems that very little progress has been achieved towards this goal.

The most obvious example of the gap between rich and poor in our health service can be seen in our accident and emergency wards, particularly in Dublin. Last May a 79 year old woman from my constituency died after spending five days on a trolley in Tallaght Hospital's accident and emergency unit. Earlier in the same month the hospital, along with other teaching hospitals, had been forced to close 250 beds. Have matters improved since last May? I do not think so. These cuts put tonight's Government amendment which proposes to provide 568 extra beds in its proper context.

The Irish Nurses' Organisation pointed out last week that 155 patients were on trolleys in Dublin accident and emergency departments last Thursday. The Eastern Regional Health Authority reports little progress in opening the 192 beds closed last year due to ongoing funding difficulties. Accident and emergency units and their corridors are places of fear to many patients. They are associated with indignities and extra stress for patients and their loved ones.

Many Deputies could tell horror stories of patients being harassed by drunks or unable to sleep in noisy corridors. This is unacceptable. No Deputy from the Government or the Opposition wants to see anyone belonging to him or her in that situation. While this situation continues in accident and emergency wards, long-stay patients, who literally have nowhere else to go, occupy between 15% and 20% of hospital beds. This blockage in the system highlights the lack of joined-up Government in the health area. Rather than financially equipping and supporting residential homes or carers through the provision of supports enabling families to take their loved ones home, the State prefers to take the easy option and keep patients in hospital beds.

These are the conditions in which we expect our overworked and undervalued health service to operate. I take this opportunity to pay tribute to the work and commitment of the staff of the health service.

I welcome a positive initiative announced in the newspapers at the weekend. The decision to only fund generic medicines, where the option is available, is welcome. This is something Sinn Féin has long advocated in pre-budget submissions. Generic drugs can cost approximately 30% less than brand name drugs. Up to now, the percentage of generic items prescribed under the general medical services scheme has been consistently lower than in Britain or other European countries. The suggestion that the Government is trying to take more vigorous action in this area is positive and I appeal to the Minister to implement this policy with all possible speed.

When the World Health Organisation met in Jakarta in 1997 it declared that above all, poverty is the greatest threat to health. During the lifetime of this Government we have seen economic policies which have led to a massive and sustained increase in poverty and inequality. Responsibility for this does not rest just with the Minister for Health and Children. However, he is a member of a Cabinet which has widened the gap between rich and poor.

Mr. Ferris

One of the most striking features of our hospital system is the level at which consultants use the facilities paid for by taxpayers to give preference to their private patients. I cannot imagine that this would be acceptable in any other branch of the public service. A recent report by the health boards revealed that in some instances over half of those being cared for were receiving private treatment. At St. Nessan's regional orthopaedic hospital in Limerick, 68% of day care patients were private, while in St. John's, 57% of elective admissions were private. Those statistics make a mockery of the guidelines which stipulate there should be a ratio of 80% public to 20% private. The Department is said to be concerned about this and to be reviewing how best to deal with the problem. Surely, it would not be difficult to ensure that consultants adhere to the terms of their contracts in the same manner as any other public employee. They should ensure that public patients attending public facilities receive the treatment for which they are entitled.

I am aware that the majority of private patients only find themselves in such positions because of the inadequacies of the health service. Most private patients have been forced to opt for private care due to the length of waiting lists and other shortcomings in the public system. However, the real issue is that consultants contracted to health boards are abusing that position to boost their own practices. This would not be tolerated in any other branch of the public service and it should not be tolerated in the health service.

One of the reasons for the tolerance of the current level of private practice is the power of consultants. Like members of any other professional body, they are entitled to fight their corner. However, they cannot be allowed to promote those interests at the expense of the public health service to which they are primarily contracted.

People may recall that it was vested interests in the medical profession which obstructed the constitution of the public health care system when it was first proposed in the 1940s. It was this sector more than the bishops which sabotaged Dr. Noel Browne's scheme. They had to be faced down by the then Minister for Health in a Fianna Fáil Government, Dr. Jim Ryan.

A move towards centralisation is apparent within the system, as shown by the way specialist services are being concentrated in certain hospitals. As a result, regional hospitals, such as my local one in Tralee, are in danger of being downgraded. The hospital there is being denied the necessary resources either to maintain existing services or provide those which have been promised. I drew attention to many such examples in the past year. A constant battle must be waged to ensure that existing services are maintained. The level of uncertainty that this creates is unsettling for both the staff and those who rely on the service. Fortunately, most of the concerns raised had a positive outcome, but hospitals should not to have to operate in an atmosphere of constant uncertainty over resources.

Centralising specialist services, especially in areas such as oncology and radiology, will result in extremely ill people having to travel long distances to receive the care they require. Such facilities are overly concentrated in the main population centres and we have already seen the tragic consequences of this approach in several parts of the country.

One suspects that the report of groups such as the national task force on medical staffing which recommended the centralisation of services will not be to the benefit of existing services. I have no doubt that the authors of the report were sincere in their expectation that the changes would lead to an improvement in the level of provision. There is a danger that the Government will use reports like this as an excuse to make cuts.

Another issue of concern is the lack of democratic control over health boards. This is not enhanced by removing locally elected representatives from boards. While the system was far from perfect, at least local people felt that, through the people they elected, they had some input in the manner in which the health boards operated. In the absence of local democratic accountability, there is a danger that health boards will come increasingly under the control of the Department and they will lose touch with their original purpose. It is vital that a mechanism exists to scrutinise departmental directives and provide an informed view independent of the Minister.

Mr. Connolly

Health care in Ireland has steadily deteriorated in recent years and it has now reached crisis point. Health is a topical issue, but for all the wrong reasons. The issue of health is hardly ever out of the news. This is especially true in my area which comes within the remit of the North Eastern Health Board where we have heard of roadside deaths and roadside births. Consultants have been sacked and suspended. Investigation teams have been set up. We need look no further than Monaghan General Hospital for an example of a malfunctioning hospital. This hospital has been off-call for the past 18 months. Staff are paid on a 24 hours a day, seven days a week basis, yet an ambulance is not allowed to take a patient to the hospital, which is nothing short of farcical. If someone has a heart attack in the town, he or she can be brought there in a car but, if an ambulance is called, the patient will be brought to Drogheda, Cavan or somewhere else with the attendant medical risks imposed by the delay in getting to a hospital.

Cavan General Hospital is not fit to cater for the current volume of traffic which goes through it. It is similar to Dublin in recent years where trolleys are in widespread use. I do not think patients in any Dublin hospitals have had to lie on mattresses, but we have experienced that. Patients recovering from elective day surgery procedures have been put into a room which they described as a boiler room in which a boiler cut in and out on a regular basis. Is this an adequate hospital service?

Since Monaghan General Hospital was taken off-call in July 2002, elective surgery has been cancelled in Cavan General Hospital on an ongoing basis. That is unacceptable. Last Friday a report to the North Eastern Health Board stated that major surgery will be removed from Cavan General Hospital, a hospital which performed up to 90 major operations per year, and transferred to Our Lady of Lourdes Hospital, Drogheda. A number of hospitals will not be functioning in a year's time if the Minister does not put Monaghan General Hospital back on-call. The extra volume which has gone to Cavan since that time is creating many of the current problems in the North Eastern Health Board.

Up to 120 reports have been commissioned over a period: the Brennan report on health funding, the Prospectus report on health structures, and the Hanly report on medical staffing. Many people, including me, have major difficulties with the Hanly report. People are up in arms about it, including rural general practitioners and consultants. The Hanly report proposes to locate centres of excellence around the coastline. Large areas in the centre of the country will be neglected, which is not acceptable.

The health strategy, which was launched with great fanfare, promised equal access to all, irrespective of geographic location. The stated aim is to treat everybody equally, but this is far from the case. The strategy fails miserably in that regard.

The Hanly report proposed a consultant-led service as the best way forward. Every scratch does not need to be seen by a consultant. Senior registrars in hospitals are more than capable of fulfilling a greater role. There is a role for small hospitals to provide a level of service where an immediate response is required, especially in emergencies cases such as heart attacks, major haemorrhages or when children develop appendicitis or have asthma attacks.

Reference is also made in the Hanly report to smaller hospitals providing accident clinics with nurse practitioners. What is forgotten is that nurse practitioners must operate under consultants. The absence of consultants at night in smaller hospitals places a question mark over the operation of nurse practitioners. This is one of many flawed aspects of the report. Reference is also made in the report to paramedics. While they do a fantastic job, emergency medical technicians are not trained to the level of paramedics, although they have helped deliver babies.

No financial constraints were attached to the Hanly report. It identified a need for 3,000 more beds in the system, yet there is no indication that they are coming on-stream. In Limerick, for example, there was talk of an extra 300 beds, but there is no sign of them as yet. The accident and emergency department is closing in Ennis General Hospital. The accident and emergency department in Nenagh——

Mr. Martin

No, it is not.

Mr. Connolly

It is closing. There is no point in denying it.

Mr. Martin

Lies and damned lies.

Mr. Connolly

It is closing to patients being brought there by ambulance. That will take place. Why are people up in arms about it in that case?

Mr. Martin

It is because the Deputy is telling them untruths.

Mr. Connolly

I regret that I have no more time.

Mr. F. McGrath

I welcome the debate which allows us time to review the dismal record of the Government on the health issue, which was a major concern for many people prior to the previous general election. It is time to look at the facts and the reality for patients. The Government's record in the past two years is a disgrace when we look at what patients experience at present.

I urge the Minister to listen to the following audit. We still do not have an MRI scanner for children in Our Lady's Hospital for Sick Children in Crumlin. Some 27,212 people are on hospital waiting lists. We still have patients on trolleys. In the disability sector, 1,382 persons with intellectual disabilities are on residential care waiting lists, 621 seek day care places and 823 still await respite care.

We have 25,000 elderly people in long-stay beds or nursing homes and a further 13,000 elderly people in need of high to maximum dependency care continue to live at home without back-up services. We have had cuts in home help services while other health boards have made savings of €15 million at a time when our elderly are neglected. This is the record of this Government and it is about time that it decided to live in the real world. It has failed to deliver despite two years of power and significant extra revenue.

The Government has also failed to abolish the means test for the carer's allowance. This is a further attack on the most vulnerable in our society. The Government's record on resourcing day-care centres in disadvantaged communities is a national scandal. To make matters worse, it has turned its back on the most needy in society.

It is now telling people they do not have the right to a quality health service in their own districts. Instead of working with them, the Government has attacked them and undermined our health care staff. Most recently, our so-called macho boys went out to hammer our 1,500 consultants. Let me remind the Government that these people work 65 hours per week, suffer appalling stress, have shocking resources at their disposal, are vulnerable to multi-million euro lawsuits and pay over €100,000 for their insurance cover although they save thousands of lives each year. However, our Minister and Taoiseach attack them through the media. The consultants will be working in our health service and saving lives for many years after most of the Cabinet members have moved on to other issues.

This kind of debate and the negative attitude of the Government must end. It is the most right-wing Government since the disastrous coalition in 1974. We all remember how bad that was. There is ongoing tension in the health care system between what is the right thing economically and the right thing ethically. Successive Ministers with responsibility for health boast about the amount of money spent on the health service. Although most civilised societies espouse the concept of equality for all, this ideal rarely corresponds with the reality. Issues concerning the allocation of resources for and within the health care system are arguably the most difficult issues facing us today. As a former teacher, I am acutely aware that we also have huge allocation decisions to make in education if we are to ensure that our education system is to be an instrument of equality.

In health care and education, situations present themselves in which decisions must be taken, and alternatives must be selected which will bring advantage to some and which may leave others disadvantaged. A political ideal or a constitutional right might assert that every person has an equal claim to health and education, but this aspiration is not always realised in Ireland. Choices need to be made about which patients and which treatments will be given priority and which students will go to university. In cases where there seems to be a contradiction in choosing some to ensure fair advantage may be given to all, it is essential that we consider, however tentatively, the ethical grounds upon which choices may be made.

There is both an economic and ethical dimension to the problem of allocation. The basic economic problem is how society's scarce resources can be most efficiently allocated, in light of economic facts and predictions, to satisfy human needs and desires. The key ethical dilemma concerns choosing the means by which we can guarantee justice in the distribution of available resources. It is time we had a vigorous debate on this topic, in which the voices of users and carers are clearly heard and acted upon.

Against such a backdrop, it behoves all of us in politics to provide the leadership society needs if we are to create a just society that all our citizens deserve. We should all remind ourselves of Karl Marx's advice: "Philosophers have only interpreted the world. The point, however, is to change it."

This motion is about change and hence I am giving it my total support. I urge every other Deputy to support it also and I commend Deputies Ó Caoláin, Crowe, Ferris, Morgan and Ó Snodaigh for bringing it before the House.

An Ceann Comhairle

I call on Deputy Gormley. He has just under six minutes remaining.

Mr. Gormley

Six minutes. I believed I had ten minutes. Nevertheless——

An Ceann Comhairle

As as the Deputy knows, there were 40 minutes in the slot.

Mr. Gormley

The Ceann Comhairle should not worry. I can deal with it. Flexibility is the name of the game. I warmly commend this motion to the House. It is timely and it speaks for itself in its detail.

Today on Report Stage of the Public Health (Tobacco) (Amendment) Bill 2003 I said I was disappointed with aspects of that Bill. I suppose the main attraction of the Bill for the Minister was that it distracted from the crisis in our health service. The Minister has been living a charmed life. The accident and emergency crisis and the problem of waiting lists are ongoing, yet the focus of attention has been on the so-called smoking ban. As I stated previously, the smoking ban has been somewhat diluted by some of the provisions because we will now have smoking and non-smoking sections in pubs and people will be exposed to secondary smoke.

The Minister knows quite well that smoking and alcohol abuse are the primary sources of much illness in this country. That is why the Public Health (Tobacco) (Amendment) Bill 2003 is so vital. It is vital that we get it right and do not capitulate to vested interests in any way.

This motion is comprehensive and refers to promises made at the time of the general election. These promises have since been abandoned, which would appear be par for the course, but the problem is that people are suffering badly as a consequence. When one considers the enormous wealth we have generated in Ireland and the recently published statistics on our quality of life, one will realise that we rate very badly. One reason is that we do not spend enough on health The OECD ratings might demonstrate that we reached the EU average but this is simply not the case. We now have a capacity problem and the only way this can be dealt with is by spending a greater percentage of our gross domestic product on health.

It has been claimed very often that we are misspending and misdirecting money. The Brennan report and the Deloitte & Touche report have been commissioned, yet despite very thorough work, no smoking gun has been found. We have often tried to make fall-guys of the health boards. They recently came before the Oireachtas Joint Committee on Health and Children and we quizzed them on why three of them were running a surplus. They are not guilty of misspending but of being over-prudent. The reason they gave us is that they felt under pressure from the Department of Health and Children, which in turn is under the cosh of the Department of Finance.

There is an ideological problem, namely, that the Government is a right-wing Government, as stated by Deputy Finian McGrath. It has a policy of low taxation and low spending and therefore issues such as education, health and the environment do not receive the priority they should.

The publication of the Minister's health strategy was mentioned. I remember the day vividly because the launch was in the Mansion House, accompanied by much fanfare. The lighting arrangements were fantastic and resembled a Pink Floyd concert. Much was spent on it, the spin doctors were present, everything was glitzy and great and it was suggested that the Minister would solve the health crisis. It has not turned out like this.

Mr. Connolly

Was Royston Brady's boy band there?

Mr. Gormley

He had not entered the Mansion House at that stage but I am sure he would have been there had he the opportunity.

In retrospect, the health strategy produced by the Minister in 2001 looks more like part of an overall strategy to ensure a successful outcome for the Government in the last general election than a long-term programme for reform and investment in the health service backed by serious political commitment to implement it. The demeanour and public utterances of the Minister for Finance, Deputy McCreevy, make it clear that no new Exchequer funding will be forthcoming for the health service until serious structural reforms are implemented.

The Green Party believes that the low tax, low spend economic policies of Fianna Fáil and the Progressive Democrats have limited the options available to the Government to respond to the growing crisis in the health service. The Government's self-serving rhetoric about the need for greater efficiency and accountability in the health system is an attempt to distract from the fact that it is not prepared to invest in the kind of health service available in other EU member states. There has been a plethora of reports such as Prospectus, CAPITA, Brennan and Hanly, all of which further centralise the health service. Will they improve the health service? Will they deal with the accident and emergency crisis? Will they deal with the capacity problem? The answer is "no" because that action requires further funding and the Government is not prepared to invest in the health service.

Minister for Health and Children (Mr. Martin)

I move amendment No. 1:

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

"commends the Government and its commitment to provide a high quality health service directed at those most in need and acknowledges:

—that equity of access is one of the key objectives which underlines the health strategy;

—recognises the extensive additional resources, both capital and revenue, which have been allocated to the health services since 1997 and welcomes the increase of over 200,000 patients treated in acute hospitals in that period;

—endorses the innovative health service reform programme which has been initiated by the Government as reflected in the health strategy, Quality and Fairness A Health System for You, and in its consideration of the Brennan and Prospectus reports;

—welcomes the report of the national task force on medical staffing (the Hanly report) which outlines a blueprint for the reduction in the working hours of non-consultant hospital doctors and provides a model for developing services in the regions around the country which includes doubling the number of consultants;

—notes the reduction in waiting lists, and in particular notes the significant reductions achieved in the last year in the number of adults waiting more than 12 months for in-patient treatment in certain specialities, e.g., cardiac surgery down by 78%, gynaecology down by 65%, vascular surgery down by 60%;

—commends the national treatment purchase fund for arranging treatment for over 11,000 patients since July 2002;

—acknowledges the 34% increase from 1,292 to 1,731 in consultant numbers which has taken place in the last six years;

—notes the 32% increase in the number of nurses since 1997;

—endorses the Government's investment in providing an extra 568 beds for public patients only;

—acknowledges the investment of €46 million into GP co-ops which has provided 24 hour GP availability around the country;

—notes the investment of €400 million in the development of appropriate treatment and care services for people with cancer. This includes an additional 85 consultants;

—commends the €54 million investment in the cardiovascular strategy which has resulted in a 200% increase in cardiology procedures and the recruitment of 109 cardiac rehab staff, 139 health promotion officers and 17 consultant cardiologists around the country; and

—commends and supports the Minister for Health and Children in his approach to modernising the health system through the development and implementation of strategies underpinned by solid investment."

I thank the Sinn Féin Deputies for tabling this motion for debate. It is a lengthy one full of great detail but ultimately empty of substance because it is not intended to make a constructive contribution to health policy. Its sole purpose is to allow the Deputies to claim that they are committed to action on the many serious health issues facing our country or perhaps more particularly their constituencies. While Sinn Féin likes to claim that it is a unique political force, it has abandoned one tradition about which it has talked at length. This motion confirms that it is no longer concerned about the politics of condemnation. In almost every policy area, Sinn Féin is fine on the attack but does not feel it necessary to propose alternatives. It is the only party in this House that has never proposed an alternative budget.

Caoimhghín Ó Caoláin

The Minister was not present. How does he know what we said? He absented himself.

Mr. Martin

In this motion alone, it calls for many billions in extra expenditure

Caoimhghín Ó Caoláin

How does he know what we said? He absented himself.

Mr. Martin

Sinn Féin believes that I should resign because I have not provided it. It presents an image of a country where no choices ever have to be made. To it, details are for other people. Sinn Féin's lack of interest in having a debate can be seen by the fact that it refuses to acknowledge any progress in any area. It will not let the facts get in the way of its attacks. It crassly misrepresents initiatives which have been taken or are well under way. It will not acknowledge the achievements of the Government which has delivered the largest sustained programme of real-term increases in the history of our health services.

Approximately 200,000 more people are being treated in our hospitals than were before this Government and the previous Government took office. Last year there was a 42% reduction in the number of adults waiting more than 12 months for in-patient treatment and a 39% reduction in the number of children waiting more than six months. Work is well under way on more than 80% of the health strategy's actions. Exchequer funding for health as a percentage of gross national product is the highest figure for almost 20 years even though we have been through a period of considerable economic growth.

The motion deals with almost every area of the health services and it would not be possible in the time allotted to me to deal with each area in detail. I will, however, try to deal with as many as possible. I will set the areas in the context of the most comprehensive reform programme in the history of our health services and show how progress is being achieved step-by-step and point to areas which need further action. I apologise to no one for the fact that this is the first Government to set out specific service objectives. Unlike the Opposition, we do not seek the easy comfort of trading in vague generalities when specific proposals are required.

People are at the core of delivering more and better services and we have consistently invested in the training and employment of health professionals. The staffing figures for the public health service have increased from approximately 68,000 in 1997 to an unprecedented 95,800. According to the Brennan commission, ten out of every 11 additional employees recruited since 1997 are engaged in duties of direct service to patients and public. There was no evidence to support the perception that administrative staff, rather than those providing a direct service, have disproportionately absorbed additional resources allocated to the health service in recent years. Two thirds of health service personnel formally classified as management-administrative staff directly provide services to the public. It is estimated that only 6% of health service personnel are employed in a purely administrative capacity. These administrative staff work in areas that are critical to the effective running of the health services such as payroll, accounts and human resource management, including training.

Since 1997, an additional 482 consultants have been appointed, representing an increase of37%. Over the past three years, an average of 106 extra doctors per annum have taken up duty in Ireland as permanent consultants for the first time, a rate of increase unprecedented in our health services. Since the end of 1997 there has been a 130% increase in the number of occupational therapists, a 71% increase in speech and language therapists and a 37% increase in the number of medical-dental personnel working in the health services, all of whom make a genuine contribution to extra and additional care.

The Opposition likes to claim there is a nursing crisis. It never has the honesty to include the fact that 8,200 more nurses work in the system now. In 1997, there were 25,233 wholetime equivalent nurses employed in the public health system. By the end of September 2003, this figure reached 33,442. The annual number of nurse training places has also increased by 67%. Long-term progress means long-term investment in facilities. Absent from the opening speeches of the Opposition was an acknowledgement that, in the past three years alone, the health capital budget involved €1.7 billion.

Caoimhghín Ó Caoláin

The Minister was not present. How does he know what we said? He absented himself. Who is he codding?

Mr. Martin

I was present. I heard Deputies Gormley and Finian McGrath and I heard Deputy Ó Caoláin on the monitor.

Caoimhghín Ó Caoláin

How does the Minister know what we said?

Mr. Martin

Anybody who is honest about the scale of development will acknowledge that progress is being made in addressing the historical deficits in health infrastructure. A range of major projects have been completed, are in planning or under construction across all health care programmes. Capital funding provided under the national development plan for health services has allowed for the commencement of important initiatives in other health areas such as putting in place new infrastructure to support and develop the area of information and communications technology. A rising population and rising expectations put pressure on our acute hospital system which must be met.

While we must increase overall activity, we must also focus on those who wait the longest. I do not expect the Opposition to use any of its time pointing out that we are seeing a significant reduction in waiting times for public patients. The number of adults waiting more than 12 months for in-patient treatment in the target specialities was cut by approximately 42% last year. At the same time, the number of children waiting more than six months for in-patient treatment in the nine target specialities was cut by 39%. Our single-minded focus on this issue has created this progress with real results.

The national treatment purchase fund will now take a significant lead in reducing waiting times for patients on waiting lists. The number of patients treated by the fund continues to grow. It has arranged treatments for more than 11,000 patients. The fund operates on a patient specific basis. It arranges treatment in a confidential manner and is committed to assuring and monitoring quality standards in clinical treatment and patient care. Health boards outside the eastern region report that, in general, those adults reported to be waiting more than 12 months and children reported to be waiting more than six months have either been offered treatment under the fund or have conditions that are too complicated or outside the remit of the fund. The progress achieved by the fund has halved the qualifying time barrier. Thus, in most instances, the fund will facilitate adults waiting six months for an operation or children waiting three months. The feedback received from patients who had treatment arranged by the fund indicates that they are satisfied with the quality of care they receive. In a survey carried out last year 96% of respondents rated their experience of treatment as good, very good or excellent.

Caoimhghín Ó Caoláin

The Minister is perpetuating the private health service.

Cecilia Keaveney

At least these people receive treatment.

Mr. Martin

These are public patients who have been longest on the list, whom we target specifically and who have now received treatment. It has been a dramatic intervention in that area and has achieved real results.

Caoimhghín Ó Caoláin

The Minister is providing opportunities for the private services. The Minister should tackle the nub of it.

Cecilia Keaveney

People should tackle those who attack them in the first place.

Mr. Gormley

Unfortunately, the Minister will not be present to hear them.

Mr. Martin

There has been a significant increase in the number of emergency medicine consultants in the past five years with an increase in posts from 16 in 1999 to 51 in 2004. This equates to triple the number of consultants over the past five years which I oversaw. I wanted to see more consultants. It amuses me that people started putting their hands up when we began to do that.

Mr. Gormley

Is the Minister talking about the Minister for Defence, Deputy Smith?

An Ceann Comhairle

Deputy Gormley already had his chance.

Mr. Martin

Rather than decreasing services, as the Opposition suggests, the Government has clearly invested. We have appointed more clinicians in key areas.

Caoimhghín Ó Caoláin

The Minister is presiding over the loss of service.

An Ceann Comhairle

Deputy Ó Caoláin, if you do not desist from interrupting, the Chair will have to take appropriate action.

Caoimhghín Ó Caoláin

No doubt.

Mr. Martin

The provision of private care in public acute hospitals has been a long-standing feature of the Irish health care system. The consultants' common contract includes a provision to allow consultants treat private patients in public hospitals. This did not occur today or yesterday. Beds in public hospitals are designated public or private. The references to a two-tier structure fail to recognise that while half of the State's population have private health insurance only one fifth of beds in public hospitals are designated for private use and that public hospital charges for the care and treatment of privately insured persons contribute in excess of €150 million annually to public hospital income.

The challenge is to ensure that the established mix is kept in check and continues to provide an appropriate balance in national arrangements. The Government's health strategy, Quality and Fairness — A Health System for You contains a commitment to improve access to hospital services for public patients. We will achieve this goal through a series of integrated measures. An extra 568 acute hospital beds are in use as a result of the investment of €118 million. This is a central part of the health strategy that we have implemented in hospitals throughout the country.

Aengus Ó Snodaigh

They are the same ones the Minister closed last year.

Mr. Martin

I also provided an additional €12.6 million to facilitate the discharge of patients from hospital to more appropriate accommodation. Again these beds have been put in place all around the country.

I am committed to ensuring that private practice within public hospitals will not be at the expense of fair access for public patients. The negotiation of a new consultants' contract is one of the key objectives outlined in the health strategy. The key factor necessary for the achievement of this objective is the co-operation of the medical organisations, namely the IMO and the Irish Hospital Consultants Association. It was necessary to take into account the recommendations of the Hanly report before negotiations could begin. It is surely common sense to have a detailed description of the desired staffing model for hospitals before negotiating the required contract. As a result of the process we have used to get to this stage, we have a recommended model which is backed up by detailed studies of best practice fully involving the medical professionals.

A management team, comprising officials from my Department, the Health Service Employers Agency, health boards and hospitals, has met on a number of occasions since then to produce a management position paper. The management team met the IMO and IHCA in December 2003 to discuss the selection of an independent chairman, the setting of an agenda and the agreement of a timeframe for forthcoming substantive negotiations. It was intended that negotiations would get under way in February 2004. However, notification has been received from the IHCA that due to my decision to proceed with the introduction of the new clinical indemnity scheme, it is currently not in a position to send a delegation to negotiations on a new contract. I regret this decision and I take this opportunity to invite the IHCA and IMO to proceed with these important negotiations.

Ultimately the Government had to act on the basis of the wider public interest and put in place the arrangements, which it believes are in the best interests of patients, hospitals, taxpayers and doctors. I reject the unfounded accusation by Deputy Finian McGrath of alleged attacks I have made on consultants. I have not done so.

Mr. F. McGrath

It has been reported extensively in the media.

An Ceann Comhairle

I ask Deputy McGrath to allow the Minister to speak. He had his opportunity.

Mr. Martin

That is not the same as the Minister saying it. The Deputy should check the record. The introduction of the clinical indemnity scheme was necessary to protect the taxpayer.

Mr. F. McGrath

It should have been done better.

Mr. Martin

Surely someone who aspires to be on the left wing of the House would consider this a most noble objective in itself.

Aengus Ó Snodaigh

The Minister is being protected by the Chair.

Mr. Martin

The Opposition decries the Government as being very right wing. Our measure was clearly designed to protect patients, the taxpayer and ultimately the consultants.

The Sinn Féin Deputies, no doubt to be joined by most of the Opposition, have continued with their attempt to crudely misrepresent and ignore the contents of the Hanly report. There is no drive towards centralisation in hospital services. At the core of the Hanly report is the retention and development of local access to acute hospital care. The report recommends the decentralisation of a large proportion of the elective care and other services currently delivered in large acute hospitals to smaller, local hospitals. Currently, hospitals such as Limerick Regional Hospital and St Vincent's Hospital deliver a volume of in-patient, day-care and out-patient workload almost five times as large as that delivered in hospitals like those in Ennis, Nenagh and Loughlinstown. Properly resourced, local hospitals such as these can do much more and eliminate the need for people to travel outside their own region for most procedures.

The report addresses the key issue of how to provide safe, high quality acute hospital services, 24 hours a day, seven days a week, and do so as the working hours of our junior doctors are reduced in line with EU law to 48 hours a week. In response, the Hanly report recommended that we put in place a consultant-provided service, harness the contribution of all our hospitals and provide a wider range of appropriate services and procedures in local hospitals, including that in Loughlinstown, which will mean a better service for patients. Deputies have deliberately refused to acknowledge this. I challenge anyone to tell me how doubling the number of consultants in a given region will lead to a reduction in services. It is the big lie that is being peddled by the Opposition because the local elections are coming and winning local election seats is more important than the truth.

Ms O. Mitchell

That is not the big lie and the Minister knows it.

An Ceann Comhairle

The use of the word "lie" is not appropriate in the House.

Mr. Martin

That is what is going on here. The debate——

An Ceann Comhairle

I ask the Minister to withdraw the word "lie" please.

Mr. Connolly

He can leave it in, it is all right.

An Ceann Comhairle

The Minister used the word "lie".

Mr. Gormley

The Minister said it was a big lie.

Mr. Martin

I was referring to the general debate outside the House, not to what has been said here tonight.

An Ceann Comhairle

I require the Minister to withdraw the word.

Mr. Martin

There is crass misinterpretation outside the House.

An Ceann Comhairle

Withdraw the word "lie".

Mr. Martin

Outside the House statements have been made.

An Ceann Comhairle

Withdraw the word "lie".

Mr. Martin

I withdraw the word "lie". There is a crass misinterpretation of what is going on. The Hanly report will result in a dramatic change for those in the west and the mid-west. What has been the history of patients in those regions? It has meant trips to Dublin on an ongoing basis for a whole range of cancer and heart services.

Mr. Gormley

Patients still have to go from Donegal to Galway.

An Ceann Comhairle

Deputy Gormley, I ask you to allow the Minister to continue without interruption.

Mr. Martin

That is the history and that is what we want to and will change. We have begun that change over the past five years. Galway University Hospital now provides radiotherapy and will soon provide heart surgery. The big story for the west is that the Fianna Fáil-Progressive Democrats Government was the first one in the history of the State to introduce a full range of services so the people of the west will no longer have to habitually travel to Dublin for a range of services.

Cecilia Keaveney

Hear, hear.

Mr. Martin

The Opposition condemns that and has attempted to do so on an ongoing basis.

Ms O. Mitchell

We are not talking about that.

An Ceann Comhairle

Allow the Minister to speak without interruption.

Mr. Martin

The Hanly report recommends investment in local hospitals to provide more services for patients, including elective medical and surgical procedures, out-patient services, pre-natal and post-natal maternity services and better access to diagnostic facilities. It states that a full range of acute hospital services should be available within each region so that patients should not have to travel outside their region other than for specialised supra-regional or national-level services.

Aengus Ó Snodaigh

Unless they live in Monaghan.

Mr. Martin

The Hanly report does not propose the closure of any hospital and the Opposition should acknowledge this.

Aengus Ó Snodaigh

Certain members of the Cabinet should acknowledge it also.

An Ceann Comhairle

Allow the Minister to speak without interruption.

Mr. Martin

Nor does it propose that any accident and emergency departments or maternity units should close.

Mr. Connolly

It is not possible to give birth at 1 o'clock in the morning.

Mr. Martin

Instead, the report makes specific recommendations for reorganising seven general hospitals in only two health board regions — the east coast and mid-west — and sets out a series of principles for the future organisation of hospital services nationally. The current and future role of hospitals outside the mid-west and east coast will be examined as part of the preparation of a national hospital plan by the recently established acute hospital review group.

Last Friday I established the groups, which will guide the further implementation of the report in the two areas, the mid-west and east coast. Every hospital in the regions is represented on these groups and each group consists of representatives of the public interest. There are no diktats, just an opportunity for regions to help deliver more and better services in the context of 24-hour medical cover in hospitals. For the first time in more than three decades we now have a commitment to support all hospitals and to develop regional services. The crass cynicism of many Opposition politicians would be difficult enough to take, but particularly so because they have again refused to present credible alternatives.

Caoimhghín Ó Caoláin

That is wrong.

Mr. Martin

The fact that this motion seeks to condemn our record on cancer services shows how little its framers know about the facts. The Government is committed to the ongoing development of cancer services. Since 1997, there has been a cumulative additional revenue investment of approximately €550 million in the development of these services, including €15 million which was allocated this year. This substantial investment has enabled the funding of 87 additional consultant posts in key areas such as medical oncology, radiology, palliative care, histopathology and haematology.

Caoimhghín Ó Caoláin

It is in the brochure.

Mr. Martin

An additional 245 clinical nurse specialists have also been appointed in the cancer services area. In the same period, approximately €87 million in capital funding has been allocated specifically for the development of cancer-related initiatives.

The benefit of this investment is reflected in the significant increase in activity which has occurred. The key goal of the national cancer strategy in 1996 was to achieve a 15% decrease in mortality from cancer in the under 65 age group in the ten-year period from 1994. The recently published Deloitte evaluation of the 1996 national cancer strategy demonstrated that this figure was achieved in 2001, three years ahead of target. If Sinn Féin was interested in a constructive debate it would have had the grace to admit this.

The Government agrees that a major programme is now required to rapidly develop clinical radiation oncology treatment services to modern standards. Furthermore, the Government has agreed that the first phase of such a new programme should be the development of a clinical network of large centres in Dublin, Cork and Galway providing services for adjoining regions. These centres will collectively have the staff and treatment infrastructure to permit a rapid increase in patient access to appropriate radiation therapy and will form the backbone of the future service expansion. In addition, the Government has also decided that in the future development of services, consideration should be given to developing satellite centres in Waterford, Limerick and the north-west.

I am committed to seeking additional Exchequer resources to implement the report's recommendations. In 2004, ongoing revenue funding of €3.5 million is being made available for the supra-regional centres in the south and west. Immediate capital developments in the south and west will result in the provision of an additional five linear accelerators. This represents an increase of approximately 50% in linear accelerator capacity. We will also provide for the appointment of an additional five consultant radiation oncologists. We currently have ten consultant radiation oncologists nationally. This will result in significant improvements in the numbers of patients receiving radiation oncology in the short term. Regarding the eastern region, I have asked the chief medical officer of my Department to advise on the optimum location of two radiation treatment facilities in Dublin. A detailed request for submissions is being finalised at present. This has been endorsed internationally as a signally significant policy platform and blueprint for the development of radiotherapy services across the country. People should avoid undermining what is a very significant achievement for the sake of short-term electoral gain.

Ms O. Mitchell

The Minister should not lecture us.

Caoimhghín Ó Caoláin

The Minister has the gall to say that.

Mr. Martin

We have a great opportunity to get it right in terms of radiotherapy treatment.

Mr. Gormley

The Government is getting it wrong. It should get it right.

Mr. Martin

We are getting it right. Repeatedly Opposition politicians ignore the people who know about these matters; they say they are just consultants and that what they are saying is rubbish.

Caoimhghín Ó Caoláin

Does the Minister not do that? Is he not responsible?

Ms O. Mitchell

The Minister is in charge.

Mr. Martin

We are bringing about a dramatic improvement in access to radiotherapy treatment and facilities. I announced the extension of the national breast screening programme in March last year. Under the extension, two static units are proposed in host hospitals in Cork and Galway at which breast surgery will be performed for women in the south, west, mid-west and north-west. Under the extension, approximately 150,000 women in the target population aged 50 to 64 years will be eligible for screening. Detailed planning is under way regarding the roll-out of the programme.

In another major achievement in public health, we have had significant success on one of the most feared illnesses, meningitis. There has been a dramatic 96% reduction in the number of cases owing to the success of the meningococcal group C immunisation campaign which I launched in October 2000. This campaign, which targeted children and young adults up to 22 years of age was implemented in three phases, the final phase of which was completed early in 2002. The meningitis C vaccine which costs more than €70 million is now incorporated into the primary childhood immunisation programme. It is a very good example of value for money and has had a profound impact in terms of saving lives and reducing morbidity from meningitis C in particular. We await a vaccine for meningitis B.

In the context of the cardiovascular health strategy we are told that all we have done is commission reports. There is a dramatic story to tell regarding cardiovascular health, which is the biggest killer in Ireland. We have appointed 139 health promotion officers providing guidance on smoking cessation and 113 primary care and pre-hospital care personnel. The Heartwatch programme which I introduced in October 2002 is recruiting 14,000 patients with identified coronary heart disease and diabetes and 328 hospital-based professionals have been employed. Funding has been provided for the employment of 17 additional cardiologists, the largest ever unprecedented increase in cardiologists across the country in the history of the State. A total of 109 additional cardiac rehabilitation staff are now employed, so that today most acute hospitals treating people with heart disease have developed structured cardiac rehabilitation services.

To those who say this or that hospital is to be downgraded, I say that we have invested to the degree that these hospitals now have cardiac rehabilitation. In Ennis and hospitals across the country there are cardiac rehabilitation facilities because of the investment we put in and which is ignored whenever we have a debate on these issues. It is having a dramatic impact in terms of the quality of care. The immediate benefits include: stronger intersectoral partnership in Irish health promotion; reductions in emergency call-to-treatment times; regional self-sufficiency for non-invasive diagnostic procedures; increased availability of new services such as chest pain clinics and cardiac rehabilitation; about a 200% increase in certain cardiology procedures with something like a 24% reduction in the waiting list for cardiology procedures; a 47% increase in the frequency of prescriptions for cardiovascular disease for people covered by the General Medical Service Payments Board; a dramatic increase in prescriptions of statins, and so on; and an increase in the numbers now being detected with treatable conditions such as chronic heart failure. We are well on the way to reducing our status as the top country in the EU in terms of heart disease.

In terms of smoking prevalence, we have had singular success in terms of the broad range of measures we have introduced ahead of other countries in Europe, particularly in terms of reducing in the last four years alone the incidence of smoking by anything up to 5%, which is quite a significant increase in a short timeframe. That has not happened because of idleness. It is because of clear action and intervention and taking on the interests in terms of the tobacco issue, which will ultimately have a profound impact in reducing heart disease.

Regarding the primary health care strategy, we have again achieved significant progress. In October 2002, I approved the establishment of an initial group of ten primary care teams — one in each health board area. These projects are building on the services and resources already in place in the locations involved so as to develop a primary care team in line with the interdisciplinary model described in the strategy. In addition, in the hospital reform programme that is being undertaken, we are preparing specific plans in the Mid-Western Health Board and East Coast Area Health Board to improve primary care facilities there as well.

The GP out-of-hours co-operative is not about reports. It is about real action on the ground and real development. The GP out-of-hours co-operatives, which started in Ireland in 1999, are now in place in 23 out of 26 counties. I provided for the support and development of out-of-hours co-operatives on a national basis and prioritised them. Up to €46.5 million has been allocated. We now have out-of-hours co-operatives in all of the health board areas. The majority provide full out-of-hours cover. Unfortunately the ERHA is the one area which provides limited hours of operation. That is not the fault of the Government. There are issues that need to be dealt with. The level of patient satisfaction with the service offered by the co-operatives is very high from both the patient and provider perspectives.

Cross-Border initiatives have also been referred to. Sinn Féin likes to present itself as the only group interested in developing all-Ireland services. I have worked with Sinn Féin Minister, Bairbre de Brún, on an ongoing basis. We have significantly ramped up cross-Border co-operation and we have been pushing forward forcefully in this area.

Discussions have been taking place between the North Eastern and North Western Health Boards and their equivalent health boards in Northern Ireland for some time on the question of cross-Border out-of-hours services for patients in the peripheral Border areas. A submission is being made to progress the initiative by the Northern Ireland boards under INTERREG. CAWT, Co-operation and Working Together, has been working with the departmental officials, North and South, since the NSMC health co-operation agenda got under way. By virtue of its remit of encouraging, facilitating and developing cross-Border co-operation in the development of health and social services, CAWT was appointed by the two health Departments to project, manage and co-ordinate the development of a number of proposals currently under consideration. These projects relate to a cross-Border first responder scheme, emergency planning community fora and major incident emergency plan. There have been other developments in the context of dermatology and other specialties utilising resources on both sides of the Border. We are totally committed to that.

The proportion of medical card holders has fallen as the country's economy has improved, and the economy has grown dramatically owing to the policies of the current Government. The unemployment rate has been halved. The numbers in employment since 1997 have increased by over 400,000.

Ms O. Mitchell

I thought employment was falling. What about the past two years?

Mr. Martin

If there are 400,000 extra people working it is logical that as a result of that, more people would be outside the medical card scheme because of income thresholds and so on. Equity in the health services is addressed by more than the medical card scheme. The many improvements in publicly-funded services which have been put in place since 1997 and which have borne fruit in terms of, for example, reduced waiting lists and increased public hospital activity as a result of the implementation of the cancer and cardiovascular strategies, have brought significant benefits for public patients.

In addition, while the percentage of the population covered by medical cards has decreased with the growing economy, the resources devoted to the general medical services scheme have increased very significantly over the last number of years to over €1.1 billion this year. This again shows the Government's commitment to covering the cost of medical services for the less well-off. In the programme for Government, we are committed to expanding that during our term of office.

The first national goal of the national health strategy, Better Health for Everyone, deals explicitly with population health and the issue of health inequalities in Ireland. It sets out a range of actions which are specifically directed at disadvantaged groups and which are concerned with ensuring that these groups do not continue to suffer ill health. This is the most important action we can take for disadvantaged groups to ensure that they do not get sick in the first instance.

Following an extensive consultation process with disadvantaged groups, carried out under the auspices of the working group on NAPS and health, NAPS health targets were included in Building an Inclusive Society, the Government's review of the national anti-poverty strategy, and taken on board in the national health strategy. Actions to reduce inequalities include implementing a programme of actions to achieve NAPS health targets for the reduction of health inequalities, specifically targets to reduce gaps in premature mortality between the highest and lowest socio-economic groups and between Travellers and the rest of the population.

An Leas-Cheann Comhairle

The Minister should conclude.

Mr. Martin

The Opposition's approach is to promise everything but never provide a framework within which anything can be achieved. We have taken a different and more difficult road of publishing the most comprehensive reform programme in over 30 years. Our current structures cannot achieve the level and quality of care we want because they were not designed to do so. The programme involves the radical restructuring of the health service and the Department of Health and Children. It is a significant change management programme involving an organisation with a budget of over €10 billion per annum and staffing in excess of 100,000. The implementation of the reform programme is under way and will result in a single unitary national structure for health service planning and delivery. The key elements will include: a major rationalisation of existing health service agencies, including the abolition of the existing health board-authority structures; the establishment of a health services executive, which will be the first ever body charged with managing the health service as a single national entity——

Caoimhghín Ó Caoláin

And an end to all democratic accountability.

Mr. Martin

——the establishment of a health information and quality authority to ensure that quality of care is promoted throughout the system; and the reorganisation of the Department of Health and Children to ensure improved policy development and oversight. The new structures are to be operational on 1 January 2005, which is an ambitious target by anyone's standards. The Cabinet committee on health has been up and running for some time.

Mr. F. McGrath

People are still lying on trolleys.

Ms O. Mitchell

The Minister has used approximately five minutes of Opposition time.

Mr. Martin

I will let the Opposition worry about protecting the status quo. We will get on with reforming structures so that more money goes straight to where it is needed, namely, direct patient care. In these Private Members’ debates on health, the method of attack frequently changes as another bandwagon presents itself.

Caoimhghín Ó Caoláin

That is shameful.

(Interruptions).

Mr. Martin

What never changes is an absolute refusal to acknowledge progress where it exists or the reality of the initiatives which will deliver further progress. I thank the Deputies opposite for tabling the motion.

Caoimhghín Ó Caoláin

It is time to go, Minister.

Ms O. Mitchell

I wish to share my 20 minutes — I presume we will still have that amount of time — with Deputy Neville.

I thank Sinn Féin for the opportunity, yet again, to speak on the issue of health in this House. On the numerous occasions we have had these debates, each of us has related the shortcomings of the health service, the litany of failures, shortages, rationing, increased charges, inaccessibility, inequity, queuing, queuing to queue and misery of the long-term ill and the disabled and those who are lost in the community, who do not appear in any statistics and who are suffering most under this regime. We have all seen patients lying on trolleys. These people are the visible, tangible and quantifiable manifestation of all that is wrong in the health service. In many instances, however, the real suffering caused by what is happening in the health services is evidenced by the people who have fallen through the safety net and who are being discharged from hospitals into totally inadequate care.

The stories to which I refer are told in the House, in newspapers and on television. However, the Minister behaves as if none of them has anything to do with him. It is as if he is in denial. He appears to believe that if he does not acknowledge a crisis, there will be none. Listening to him tonight, one would think that everything in the garden is rosy and that we have a health service that is almost the envy of the world. It makes one wonder why we would come into the House to criticise it.

The Minister is increasingly out of touch with reality and disconnected from what is happening in the health service for which he holds responsibility. He floats in a little world of his own above all the chaos and misery. He moves from one carefully managed press conference to another, making self-congratulatory speeches and announcements about his reform programme, the money he has spent, his strategies and what he has done in the past and will do in the future. These speeches are undoubtedly delivered with the greatest of sincerity but they in no way relate to what is happening in the health service. Neither do they reflect the litany of human misery stories that every other public representative hears each day but which strangely the Minister never appears to hear.

There is a frightening divergence between what the Minister and his increasingly dysfunctional Department say is happening and the position in our hospitals and communities. The only explanation for this divergence is that the Minister is either grossly incompetent or is so out of touch with what is happening in hospitals and the health service that he is truly delusional. One way or another, members of the public have decided that this emperor has no clothes, and it is too late for him to try to change their minds. They will never be persuaded that he will do the business for them.

They believed the Minister in the past when he promised them a world-class service but gave them shortages and service rationing of Soviet proportions. They believed him when he promised 200,000 extra medical cards. Since then, far from expanding the service he has withdrawn 46,000 medical cards. They believed him when he promised 3,000 additional beds but instead he closed 200 beds in Dublin. They believed him when he promised enhanced GP services in an almost utopian single-site range of multidisciplinary paramedical services, but instead, general practice is in virtual crisis throughout the country and even the few pilot sites about which he boasts were not funded. They believed him when he promised equity and increased access. However, when it eventually emerged hidden in the Hanly report, the reform programme suggested closing two thirds of the country's accident and emergency departments, effectively reinforcing regional disadvantage, despite the fact that it is supposed to enhance regionalisation. They believed him when he promised an IT strategy for the health service which was to be published in 2001, but in 2004, it has still not appeared.

It is said that if one cannot measure it, one cannot manage it, and that is certainly true of the health service. The Minister cannot measure the number of patients, the number on waiting lists, the demand for services, the number of doctors and nurses, the number of deaths or the number of people aged over 70. He cannot count, cost or screen. He has no databases, he cannot record or retrieve information, he has no patient identifier system and he cannot do recalls. All the Minister can do is blunder from one uninformed decision to another. He then has the brass neck to inform us that e-health will be the highlight of the EU Presidency and is one of his major priorities.

As if that was not enough, the much talked about reforms which were to revolutionise the health service are floundering on the altar of inaction. The only action on the horizon is that designed to get rid of elected members of health boards, and one can see why this is being done. The only element of accountability, the only people who might be in a position to ask the difficult questions on behalf of the public are to be removed in the first stage of reform. The bureaucrats, managers and administrators will undoubtedly remain in place. These are the people who are charged with making the system less bureaucratic. To help them reduce bureaucracy, streamline administration and minimise the structures in the health service, the Minister and his Department are already planning to establish a further dizzying number of new bodies. The Department will be at the top, and beneath it will be the interim health service executive, the national hospitals office, the four regional health offices, the health reform project office, the national steering committee, the acute hospitals review group, the Hanly implementation committees and the Minister's 13 planning committees. While these committees are involved in endlessly meeting and making submissions to each other and securing their long-term futures, the real, urgent and difficult issues will be ignored.

The Minister has made tough statements about equity of access and limiting consultants' contracts so that they will only be able to do public work. However, we were left waiting for decisions in this regard and matters were just left hanging. Nothing ever happened, no decisions were made, there was no clarity and no indication of whether there is Government thinking on this matter. Into this vacuum came the private sector, making major investment decisions and doing what the Minister should have done. The Minister should at least give some indication of what will be Government policy in the future but instead there has been total silence, which is his way of dealing with difficult issues. Procrastination, obfuscation and "Get it off my desk at all costs" is the thinking which characterises the Minister's style of leadership.

Zero progress has been achieved on the European working time directive due to be implemented in August next, which is the most critical and immediate area of public policy and on which clear thinking, leadership and decision making are most needed. Of greater concern is that there is no sense of urgency.

In almost every hospital, especially outside Dublin, there is a rising sense of panic and a slowly dawning realisation that no doctors will be available to run its service come August, yet nobody seems to care and nobody is doing anything about it. Those working in hospitals foresee the closure of their accident and emergency departments, maternity services, wards and, ultimately, hospitals. They will close not as a result of Government policy or any Government decision but simply because no one has planned to stop it.

In the two pilot regions in which the Hanly report structures are to begin in August, no more progress has been achieved and no more decisions taken than anywhere else. August is looming but not a single extra consultant, bed, ambulance or anything else has materialised. In short, the promise of the Hanly report is turning out to be precisely as people feared, namely, a ploy to close services in some areas with no concomitant improvements elsewhere. While this may not be what the Minister intended, his incompetence and indecision have meant it is precisely what people are getting.

The motion calls for the Minister to resign. I disagree because he should not be let off so easily. This is his mess and he should clean it up. His predecessor described the Department of Health and Children as Angola, which is possibly the case because of the number of landmines in it, many of which were laid by the current Minister, who should not leave the Department until every one of them has been removed or the electorate has thrown him out of office.

Mr. Neville

I welcome the opportunity to speak to the motion and thank Sinn Féin Deputies for introducing it. I wish to address the part of it which "deplores the continuing failure to reform and resource mental health services resulting in continuing hardship for people with mental illness and the failure of the State to meet international human rights standards in this regard".

The Minister continues to ignore his responsibility for mental health services. In 2004, apart from a small extra allocation to the Central Mental Hospital, no increase was made to the financial allocation for the mental health service in 2003. The Government has again chosen to ignore the great stress, pain and suffering caused by the scandalous lack of resources available to deliver a semblance of a mental health service. The proportion of the health budget devoted to mental health now stands at just 7%, yet one in four people will suffer from a psychiatric condition at some time in their lives.

The Minister has again abandoned any policy to reduce the incidence of suicide. The recent announcement of a new national strategy committee is a smokescreen for inactivity. There is no need to formulate a national strategy on suicide when such a strategy has been in place since January 1998, the date on which the report of the national task force on suicide was published by the then Minister for Health and Children, Deputy Cowen. This report made 86 recommendations on ways to prevent suicide and parasuicide, yet six years after its publication, the Minister has decided that a strategy committee should be formed to implement them.

I will cite comments made by then Minister when he launched the national task force report on 27 January 1998. He stated:

I attach great importance to the formulation of a suicide prevention-reduction strategy as outlined in this report. In order to tackle this growing tragedy in our society, it is essential that a clear, systematic approach aimed at the prevention of suicide and suicidal behaviour is put in place. My Department will immediately write to all the statutory agencies with jurisdiction in suicide prevention strategies, encouraging them to pursue the implementation of the recommendations in their respective areas as a matter of urgency. I have already instructed my Department to put in place a mechanism to co-ordinate and monitor progress in this area.

Six years later, we learn that a strategy committee must be established to do this.

In response to the publication of the national task force report in 1998, the chief executive officers of the health boards established the national suicide review group. The terms of reference of the group were to review trends in suicidal behaviour, co-ordinate research and make recommendations to health board chief executive officers. It was a toothless organisation which, again, provided cover for the inactivity of the Minister. Despite being hailed as the engine for implementing the recommendations of the national task force on suicide, six years later a second organisation is being established to do precisely that. This approach is a smokescreen for inactivity and allows the Minister to refer to the work of the new national strategy group when queried on suicide prevention. The recommendations of the national task force on suicide are as relevant and urgent today as they were in 1998. The strategy must be simply to introduce the 86 recommendations it made.

Society will be judged on how it protects and deals with its weakest members. Surely those with psychiatric illness are among the weakest in society. The Government practically ignores this group and mental health services are neglected and in a crisis characterised by decreasing funding, inequitable distribution of resources, antiquated and poorly maintained facilities and poor community support services. This has resulted in low staff morale, insufficient treatment and care programmes and higher involuntary admission rates to hospital.

The internationally respected psychiatrist, Professor Anthony Clare, has stated that the mentally ill are now the most systematically stigmatised group in our society and are the lepers of today. The Government stands condemned for its neglect of the mental health sector and its failure to vindicate the human rights of people with mental illness. Amnesty International's concerns in this regard prompted it to declare last year as the year of mental health and it campaigned to promote the human rights of those who suffer from mental illness.

A rapid response is required in community settings and early intervention services are needed in the mental health area. There is overwhelming evidence that psychiatric services concentrated on rapid response in community settings are superior to more conventional services. I call on the Government to introduce an early intervention service to provide a rapid response service for patients with severe mental illness, thus ensuring that patients are visited at home and other appropriate settings, including general practice.

Community-based day centres are rarely located in hospitals. These services should be styled on the hospice home service. Early intervention teams should be multidisciplinary and include senior psychiatrists, psychiatric nurses, social workers, psychologists, occupational therapists and an administrator. The overall philosophy should be to treat all mental disorders outside a hospital in the first instance, with particular emphasis on working with other agencies, providing home treatment where necessary, and taking a collaborative approach to care which involves the patient as an active participant in treatment decisions.

After-care services should be available to patients discharged from hospitals following treatment for psychiatric illness. We know that people who leave psychiatric institutions within two weeks are between 100 and 200 times more likely to take their lives than the general public. The introduction of this early intervention service should be carefully planned with particular emphasis on manpower planning.

Long-stay accommodation is, for the most part, in an unacceptable state. Some institutions are in bad need of repair and symbolise a different era. All psychiatric institutions in a poor state of repair should be closed down where practicable or refurbished where this is not practicable. They should be replaced by modern, purpose-built hostels for long-stay patients.

Acute patient units should be provided in general hospitals for patients in need of acute, short-stay treatment. Modern specialist facilities should be made available for the relatively small number of long-term severely disturbed patients. Younger patients, functionally psychotic patients and patients with intellectual disability should be segregated to ensure they do not share the same ward.

An awareness campaign is urgently needed to address negative attitudes to mental illness. The low level of public awareness of all areas of the mental health service limits access to the service for those in need of it. The Minister should, through the media, introduce a public awareness campaign on all aspects of mental illness and on positive mental health issues.

There is a serious lack of psychiatric services for prisoners. While Ireland has the second lowest crime rate in Europe, it also has the highest prison suicide rate. A small task force should be established to examine and make recommendations on the provision of psychiatric services to prisoners who suffer from a mental illness. There are no psychiatrists, psychologists or mental health services staff on the committee established by the Minister for Justice, Equality and Law Reform to examine the treatment of mental illness in prisons. It is a disgrace that our prisons continue the use of padded cells for those who are suicidal or suffering from severe mental health problems.

The practise of discharging prisoners who are homeless and suffering mental illness back onto the streets is also a disgrace. Each health board should provide specialised hostel accommodation for at least three months to those discharged from mental institutions.

Debate adjourned.