Priority Questions.

National Cancer Strategy.

Dan Neville


2 Mr. Neville asked the Minister for Health and Children when the national cancer strategy will be published; and if he will make a statement on the matter. [10919/04]

The national cancer forum is currently developing a new national cancer strategy. This strategy will build on the progress made during the implementation of the 1996 national cancer strategy and set out the key priority areas to be targeted for the development of cancer services over the coming years. The strategy will have regard to developments and best practice in other jurisdictions and will make recommendations on the organisation and structure of cancer services nationally.

A significant body of work has been undertaken in the development of the strategy to date. Representatives of the national cancer forum have met with representatives of the Eastern Regional Health Authority and all health boards. The forum wrote to over 90 professional bodies, voluntary bodies and other stakeholders to obtain their views on cancer treatment services. Members of the public have been consulted through advertisements placed in the media.

As part of the preparation of the new strategy, an evaluation of the extent to which the objectives of the 1996 strategy have been met has been carried out by Deloitte Consultants. This report was published in December 2003. The key goal of the 1996 national cancer strategy was to achieve a 15% decrease in mortality from cancer in the under-65 year age group in the ten year period from 1994. The Deloitte evaluation demonstrated that this reduction was achieved in 2001, which was three years ahead of target.

As part of the development of the strategy, sub-groups of the national cancer forum were established on genetic screening, organisation of cancer services, evaluation and outcomes, evidence based medicine, genetics, nursing and patient issues. The work of these sub-groups is informing the development of the new strategy, which it is expected will be completed in July.

In regard to the implementation of the 1996 strategy, since 1997 there has been a cumulative additional investment of approximately €550 million in the development of cancer services. This includes an additional sum of €15 million which was allocated in 2004 for cancer services. This substantial investment has enabled the funding of 90 additional consultant posts in key areas such as medical oncology, radiology, palliative care, histopathology, haematology and radiation oncology. An additional 245 clinical nurse specialists have also been appointed in the cancer services area.

The benefit of this investment is reflected in the significant increase in activity which has occurred. For example, the most up-to-date figures show that the number of new patients receiving radiotherapy treatment has increased from 2,402 per annum in 1994 to 3,809 in 2000. This means that an additional 1,407 patients are accessing these services, representing an increase of 58%. It can be taken that the figure has increased significantly since then because of further expansion.

The number of new patients receiving chemotherapy treatment has increased from 2,693 in 1994 to 3,519 in 2000, representing an increase of 30% nationally. Given the appointment of additional oncologists since then, it can be taken that this number has increased. Breast cancer is the individual site-specific cancer which has received the most investment in recent years and in-patient breast cancer procedures have increased from 1,336 in 1997 to 1,839 in 2001, an increase of 37% nationally.

I thank the Minister for his reply. He stated the national cancer strategy will be available in July, as he had promised. What role will the national cancer forum have in advising and influencing the strategy? How can it have influence as it has not met or deliberated since May 2003 and has difficulty in meeting due to circumstances of which the Minister knows? Does the Minister accept he identified the forum as the main advisory body in the development of the strategy? Has he received any recommendations on the deliberations of the forum regarding the radiotherapy report?

On the latter question, the chairperson of the forum--——

I asked about the forum itself.

The forum has endorsed the radiation oncology strategy. The chairman of the forum has communicated to me that he thinks it is the best model.

It is the forum rather than the chairman which recommended it.

I presume the chairman is communicating with me on behalf of the forum. In any event, it was the previous forum which established, following my request, the radiation oncology expert group — I hope the Deputy follows the sequencing in regard to that initiative. The radiation expert group was charged with providing the model for Ireland for radiotherapy facilities at an international, world class standard. It is interesting that the American Cancer Society visited Ireland this week and that its leading members have endorsed the model produced by the expert group as ideal and in accordance with best world practice. Other international experts on cancer, such as the National Cancer Institute, have also endorsed the radiotherapy strategy and have stated it is an ideal opportunity for Ireland to get it right for the Irish people and to ensure better outcomes, survival rates and so on.

With regard to the cancer strategy, it is the forum which is predominantly charged with that work in consultation with the officials in secondary care within my Department, specifically those within the cancer area of responsibility, who have worked with the forum in this regard. I met the chairperson of the forum following the evaluation carried out by Deloitte Consultants. Various sub-groups were formed from the forum to deal with specific areas of the strategy, particularly in the context of screening and the advisability of taking that route.

Does the Minister accept that because of the Irish Hospital Consultants Association's dispute, the forum has not met since May 2003?

The Irish hospital consultants' dispute has only arisen in the past two months.

Does the Minister accept the forum has not met since May 2003?

The consultants are not participating on any committee or body, which is regrettable, particularly as the Department is making a significant effort on behalf of taxpayers and Government to resolve issues for the benefit of consultants, the hospital system and so forth.

Does the Minister accept the forum has not met since May 2003?

Hospital Services.

Liz McManus


3 Ms McManus asked the Minister for Health and Children the meaning of the promise that 24-hour medical cover will be retained by local hospitals in regard to the commitment given by the Taoiseach on 5 March 2004; if the 24-hour cover at accident and emergency services will be provided by general practitioners and junior hospital doctors or by qualified accident and emergency consultants; and if he will make a statement on the matter. [10918/04]

I have asked the groups dealing with the implementation of the Hanly recommendations in the mid-west and east coast regions to ensure that medical cover will continue to be provided overnight in each acute hospital. The issue will also form a part of the work of the acute hospitals review group which is to develop a national hospitals plan in line with the principles of the Hanly report.

Medical cover means that a doctor is available to provide a medical assessment or treatment overnight. The grade of doctor called on to provide medical cover will be in line with anticipated patient need. There may be a number of options for ensuring appropriate overnight medical cover. These could include, for example, consultants, doctors in training, general practitioners, medical officers or a combination of these, depending on the circumstances.

The issue of medical cover relates to services for patients who need medical attention overnight. I look forward to constructive proposals emerging from the two local implementation groups and the acute hospital review group in this regard.

We will work to ensure that arrangements for overnight medical cover are in keeping with the requirements of the European working time directive, under which no doctor may work for longer than an average of 58 hours per week by 1 August this year. This will reduce to no more than an average of 48 hours per week in August 2009.

I have already taken a number of steps to develop further the services being provided in smaller hospitals. In Ennis General Hospital I have given approval for the appointment of a design team to plan for infrastructural improvements. This underlines that I am committed to developing smaller hospitals appropriately rather than closing or downgrading them, as some have claimed.

Regarding accident and emergency services, I have put in place a number of initiatives to deal with pressures in emergency medicine departments. An additional 20 consultants in emergency medicine have been appointed and a further nine appointments are in train. This more than doubles the number of emergency medicine posts in place since 2000 when there were just 21 such posts. The total is now 51 approved emergency medicine posts.

The Mid-Western Health Board has recently advertised for a number of emergency care physicians. These are fully registered doctors who will complement service delivery in emergency departments in the region. I have also announced my intention to provide, as soon as possible, extra resources for the roll-out of training for emergency medical technicians.

I have provided €21.4 million to facilitate the discharge of patients from the acute system to more appropriate settings, thereby freeing up acute beds. I have also taken steps to reduce the extent to which emergency medicine departments must deal with injuries and conditions which are more appropriate to the primary care setting. A total of €46.5 million has been allocated for the development of out-of-hours co-operatives since 1997.

Will the Minister accept that his answer demonstrates the deep confusion about the Hanly report recommendations? Is he aware that the implementation body in the East Coast Area Health Board region has not met yet and will he comment on that? Does his response mean that he is now in conflict with the Hanly recommendation on local hospitals? The report states on page 68: "Ultimately there should not be a requirement for on-site medical presence overnight or at weekends." Is the Minister saying that has now been shelved? It seems to be clear now that what the Minister means is that accident and emergency services will no longer be available in local hospitals and that at least is consistent with Hanly.

The decision and recommendation in Hanly is to downgrade accident and emergency to the point where it is meaningless in the sense that it is specifically described in the report as a minor injuries unit which is nurse-led, open during the day, not open at night and all medical emergency care is directed to a major hospital. This is specific in the Hanly report. Will the Minister now acknowledge publicly that accident and emergency services in these local hospitals in the pilot areas, which obviously are the model for everywhere else, will be put out of existence if Hanly is implemented?

There are industrial relations problems at present affecting the participation of consultants on a variety of committees. It is no surprise that applies to the local implementation groups in respect of the Hanly report. The Deputy did not need Question Time to elicit that information because it is a fact. It is delaying the situation and the progress of the implementation groups and their work and that is regrettable. I do not believe the action is justified, especially given the work being done to resolve the medical indemnity issue.

The Minister should stick to answering the questions I have asked. He should not go down that cul-de-sac.

I want to have time to answer the Deputy's question about whether or not the groups have met. I have explained why they have not met. The Deputy knows the reason but she asked the question.

In terms of overnight medical cover, I met David Hanly last January. As far as he and his group are concerned, if this can be organised within the requirements of the European working time directive, there is no issue. We will provide overnight medical cover.

The Hanly report uses the term "ultimately" and that does not mean next year or the following year and if it can be done without having to do that, we will do it. It is not as if every line of the report is set in stone and that is my policy in terms of that issue. It is wrong to state that accident and emergency services will close or be reduced. The Hanly report does not state that. The report makes it clear that 70% of what is going through accident and emergency services will continue to be dealt with by such services in smaller hospitals.

Some people have a nerve to go on about emergency services given that, up to the year 2000, there were 20 emergency care consultants in the entire country. They have deliberately given the false impression that emergency care consultants were available at night in every hospital. That was never the case. Deputy McManus and every Deputy in the House is aware of that.

The Government wants to take proper and effective action on behalf of patients and that means, above all, providing funding for the training of emergency medical technicians to an advanced level so that the first point of contact with a patient on the side of the road is much more effective. In the past, emergency medical technicians were not legally allowed to administer drugs. Development of primary care in the regions and the physical upgrading of hospitals, including emergency treatment rooms, is taking place in Ennis, Roscommon and other hospitals. Significant investment has been made. Accident and emergency services will continue to be provided in these hospitals. It is important to put that on the record.

This is just huffing and puffing on the part of the Minister. This is bluster and rubbish.

The local elections are on the way.

I refer the Minister to page 63 of the report which states: "All hospitals providing emergency care must have acute medicine, surgery and anaesthesia on site." That means an irreducible minimum of 21 specialist doctors. That is written in stone as far as this report is concerned. The Minister can pretend and try to obfuscate all he likes but this report has been accepted by his Government. Just because local elections are coming up does not let the Minister off the hook. The report is a serious document which has been accepted by him and its recommendations are crystal clear. According to the report, emergency services cannot be delivered in local hospitals because they will not have 21 specialists. It is an irreducible minimum. Both the Minister and I know that local hospitals do not have that capacity at present.

With all due respect, the Government has accepted the Hanly report.

Then the Minister should live up to it. He should have a bit of courage.

Deputy McManus is exploiting the content of the Hanly report to try desperately to win votes for her party in the local elections. She is deliberately——

Is the Minister saying I am misquoting?

——exploiting the contents of the Hanly report.

What is the Minister doing?

The Chair calls Question No. 4.

That is what the Deputy is doing. She knows very well, as do all Deputies, that there never was overnight cover by 21 senior consultants in surgery, anaesthesia or medicine in any hospital.

Will the Minister deal with Question No. 4?

I want to clarify a point. It is right and proper that victims of major trauma——

Medical emergencies.

——should go to the hospital where the most appropriate treatment is available. We should not cod people——

The Chair has called Question No. 4.

——by pretending that alternative services are better for them when they are not.

The Chair has called Question No. 4.

Medical emergencies, not major trauma — emergency care.

Infectious Disease Screening Service.

Caoimhghín Ó Caoláin


4 Caoimhghín Ó Caoláin asked the Minister for Health and Children if the number of patients in hospitals here infected with MRSA has been recorded; if he will provide the figures; the way in which this compares with the rates of MRSA infection in other States; the strategies in place to deal with this so-called hospital superbug which is causing much concern for the hospital system; and if he will make a statement on the matter. [11057/04]

This is a lengthy reply. There are a number of tongue twisters in this reply and I ask the Deputy to bear with me. The National Disease Surveillance Centre collects data from hospitals on methicillin resistant staphylococcus aureus, MRSA, bacteraemia, otherwise known as bloodstream infection or blood poisoning, as part of the European antimicrobial resistance surveillance system, EARSS. This is a voluntary system and, as such, not all hospitals participate. Nevertheless, the participating hospitals in Ireland represent at least 95% of the population, the highest level of participation of any country involved in EARSS.

The EARSS data for Ireland approximates the true total number of cases of MRSA bacteraemia in Ireland. In 2003, 477 cases of MRSA bacteraemia were reported in Ireland. MRSA is a resistant form of a common bacteria known as staphylococcus aureus. The proportion of staphylococcus aureus bacteraemia caused by MRSA in Ireland in 2002 was 42.7%, while the proportion for the last quarter of 2003 was41.7%. While there does not appear to have been a significant increase in the overall proportion of infections caused by MRSA in recent years, the proportion is one of the highest among European countries participating in the EARSS.

The level of antibiotic resistance in Ireland in terms of MRSA is one of the highest in Europe, second only to the United Kingdom and Malta. Two of the reasons for this, and the responses to date, are as follows. One of the common strains of MRSA in Ireland is highly contagious and it is particularly difficult to control its spread. This strain is also observed in the United Kingdom and partially explains the reason both the UK and Ireland have such high MRSA rates. The national MRSA reference laboratory at St. James's Hospital can now identify individual strains of MRSA and reports this back to each hospital. Having this information helps each hospital to identify whether it has a problem with a particular strain of MRSA and to decide on appropriate control measures.

The overuse of antibiotics in hospitals is the second key issue. The hospital antibiotic sub-committee formed as a result of the strategy for the control of antimicrobial resistance in Ireland, SARI, has completed draft guidelines for hospitals on promoting prudent use of antibiotics. Many of the regional SARI committees have also appointed clinical pharmacists to individual hospitals to improve antibiotic prescribing habits. A pilot project on promoting more rational use of antibiotics has been funded by my Department, through the SARI national committee and recently commenced in the Midland Health Board region.

Additional Information not given on the floor of the House

In 1999, my Department asked the National Disease Surveillance Centre to evaluate the problem of antimicrobial resistance in Ireland and formulate a strategy for the future. The NDSC gave detailed consideration to these issues and drew up the strategy for the control of antimicrobial resistance in Ireland, which I launched on 19 June 2001. This report contains a wide range of detailed recommendations to address the issue of antimicrobial resistance, including a strategy to control the inappropriate use of antibiotics.

The SARI recommendations can be grouped into five main categories: surveillance of antimicrobial resistance; monitoring of the supply and use of antimicrobials; development of guidance on the appropriate use of antimicrobials; education of health care workers, patients and the general public; and development of principles regarding infection control in the hospital and community setting.

The strategy for the control of antimicrobial resistance in Ireland recommended that a national SARI committee be established to develop guidelines, protocols and strategies on antimicrobial resistance. This committee was established in late 2002 and as part of its remit provides advice to the regional SARI committees in each health board area, established as a result of the strategy's recommendations. The national SARI committee is comprised of a wide range of experts in the field.

Tackling the problem of antimicrobial resistance is a multifaceted issue which will require action on a number of fronts. Implementation of the strategy is taking place on a phased basis and will take a number of years to complete. To date, approximately €12 million has been allocated by my Department to health boards to enable them to implement measures to control antimicrobial resistance. It is ultimately a matter for each health board chief executive officer to determine the priorities in each region. These priorities should take account of the recommendations in the SARI report and the relevant regional SARI committee.

Much of the funding is designated for improving hospital infrastructure for control of infection and appointing additional microbiologists, infection control nurses and other health care professionals involved in the control of infection. There is still some progress to be made to meet the numbers of such professionals required, as outlined in the SARI report, but significant progress in making additional appointments has been made in the past two years.

At national level, MRSA bacteraemia is now included in the revised list of notifiable diseases, which means hospitals are legally required to report cases of serious MRSA infection to the departments of public health in the regional health boards and to the NDSC.

The SARI infection control sub-committee recently completed a consultation process on national guidelines for hand hygiene in health care settings. Hand hygiene is a key component in the control of MRSA and the final guidelines will be available in the next two to three months. The sub-committee is also updating national guidelines on the control of MRSA, which it is hoped will be available later this year. Each of the health boards has a regional SARI committee, which has been developing regional interventions to control hospital infection, including MRSA.

Methicillin resistant staphylococcus aureus or MRSA, a term both of us will find easier to accommodate, is the most significant antibiotic resistant bacteria found in our hospitals. This was acknowledged by the Minister and in the 1999 North-South study. Does the Minister accept that antimicrobial resistance is a serious and growing problem in many of our hospitals?

I noted the Minister highlighted that statistics are not available in every case. Is he aware that the death rate from MRSA in Britain increased from 13 in 1993 to 114 in 1998 and that it has also been acknowledged that MRSA was a factor in the deaths of many thousands of other patients? These are alarming statistics.

The Minister will recall stating in June 2001 and today that we have a high rate of MRSA infection by northern European standards. How is this rate being measured? Are deaths from MRSA being recorded as such? Can we compare current and past rates of infection? How accurate is the statistics gathering exercise on MRSA now and how accurate was it in the past? The answers to these questions will give us a clearer picture.

As the Minister will be aware, in January 2000 the intensive care unit at Belfast City Hospital was forced to close because of MRSA infection. MRSA and other hospital based infections are causing increased worry to patients, their families and the wider community and having a significant impact on health care delivery. Have all the recommendations of the 1999 North-South study on MRSA been implemented and, if not, why not?

I accept that this is a very serious issue. In June 2001, we launched the strategy for the control of antimicrobial resistance, the SARI document formulated by the National Disease Surveillance Centre, which records the incidence of MRSA. The NDSC publishes figures on its website, although these need to be updated. A national SARI committee, established to develop guidelines, protocols and strategies on antimicrobial resistance, resulted in the establishment of a regional committee in each health board area consisting of experts from a broad range of fields.

My Department has allocated €12 million to date to assist health boards in implementing measures to control antimicrobial resistance. Additional microbiologists, infection control nurses and other health care professionals involved in the control of infection have been appointed. MRSA has also been included in the revised list of notifiable diseases, which means hospitals are legally required to report cases of MRSA infection to the departments of public health in the regional health boards and the National Disease Surveillance Centre.

While hospitals must report the incidence of MRSA, this does not necessarily apply to deaths given that there may be multiple reasons involved in the death of a person. The Deputy is correct, however, that MRSA could be a factor in complicating an already serious condition, particularly for elderly patients who may suffer from a number of health problems. In such circumstances, contracting MRSA makes recovery difficult.

The SARI infection control sub-committee recently completed a consultation process on national guidelines for hand hygiene in health care settings. Hand hygiene is a key component in the control of MRSA and final updated national guidelines on the control of MRSA will be available in the next two months.

I do not understate the importance of antimicrobial resistance. The chief medical officer of the Department is leading the charge on the issue which is being taken seriously. All hospitals are aware of the problem and have protocols in place to try to reduce, minimise and contain outbreaks which may occur.

One of the recommendations of the North-South study of 1999 was that each hospital have a written antibiotic policy with appropriate audit of implementation. Has this essential recommendation been implemented? Is surveillance of MRSA ongoing North and South?

The Minister indicated that not all hospitals are attentive to this area. This is a matter of grave concern and a deficit that needs address. Will he ensure, if he is not already doing so, that the matter is pressed on all hospital managers and administrators?

What has been done to research and redress the significant regional variations in MRSA incidence identified in the 1999 study? Such research could shed light on administrative and managerial policies. Are the real statistics on MRSA emerging? As I stated, and the Minister agreed with my point, MRSA, as a contributory factor to death, is being understated. The reality is that its impact is much greater than indicated by the statistics.

Many people being subjected to catheter and other invasive procedures are very anxious. I am not overstating this matter as I have spoken to people who have major concerns about family members facing such an operation.

To be fair to all concerned, the national SARI committee has communicated with all hospitals. As I indicated, Ireland has the highest participation rate of any country involved in the European antimicrobial resistance surveillance system, with participating hospitals covering 95% of our population. I accept, however, that we must ensure that all hospitals are involved. I cannot state definitively that all hospitals are participating in the system but I will pursue the matter and revert to the Deputy with details.

EU Directives.

Dan Neville


5 Mr. Neville asked the Minister for Health and Children the progress on the implementation of the European working time directive for non-consultant hospital doctors to be introduced by August 2004; and if he will make a statement on the matter. [10920/04]

Ireland will be legally obliged to begin applying the conditions stipulated in the European working time directive to doctors in training from 1 August 2004. I am determined that every effort will be made to effect these employment rights from that date. As part of the early preparation for implementing the European working time directive, a national joint steering group on the working hours of non-consultant hospital doctors was established in June 1999 and reported in January 2001.

In order to reduce non-consultant hospital doctors' hours, the group recommended that the following measures must be progressed: a reduction in the number of grades of doctor on call at any one time; the introduction of cross cover arrangements; the introduction of centralised rostering and shift work; and changes in skill mix and practice for other grades of hospital staff.

Following from this work, the national task force on medical staffing also recommended the introduction of a consultant-provided service, a significant increase in the number of consultants and the adoption of a team-based approach to consultant work. In line with this and with the role proposed for non-consultant hospital doctors, the task force report outlined that there should be a significant reduction in the number of NCHDs as the number of consultants increases. The objective must be to reverse the current ratio of more than two NCHDs for every one consultant.

There are some important reasons for this approach. First, even if it was desirable, it would not be possible to recruit sufficient extra NCHDs to cover existing rostering arrangements under the European working time directive. This is particularly the case in smaller hospitals where there are already problems in maintaining the current numbers of NCHDs. Second, best practice requires that doctors should be recruited to accredited training posts to ensure the provision of quality patient care and appropriate clinical decision-making.

Medical manpower managers appointed under the NCHD 2000 agreement are overseeing the reduction in NCHD working hours and they are essential to the phased implementation of the Hanly report recommendations, especially where roster management is concerned. Latest returns indicate that well in excess of 60% of NCHDs will be compliant with the actual 58-hour requirement of the directive by 1 August 2004. However, difficulties arise when the specific details contained in the directive are applied, that is, rest breaks and compensatory rest. These issues are being considered and will be progressed on an ongoing basis.

Negotiations between health service management and the Irish Medical Organisation on the reduction of NCHD hours have taken place in the Labour Relations Commission on a sporadic basis over the past 18 months. Progress to date has been slow and a number of key issues have yet to be agreed. The Hanly report clearly outlines that we need to establish a working group in each hospital to implement the required measures and to monitor progress in the reduction in NCHD hours. A national implementation group is also urgently required to co-ordinate the work being undertaken at local level and to monitor progress. These groups should include appropriate hospital managers, consultants, NCHDs, nurses and other relevant health-care professionals.

The urgent need to establish these groups at both national and local level has been discussed with the Irish Medical Organisation at the meetings in the Labour Relations Commission. However, to date, the IMO has refused to agree to their establishment. The IMO has been lobbying for many years to achieve a significant reduction in NCHD working hours. That aim could be progressed by full participation in the national and local implementation groups.

Additional information not given on the floor of the House

CEOs of both health boards and voluntary hospitals and hospital managers, together with senior officials from the Department and the Health Service Employers Agency, are in regular contact to reduce NCHD working hours and are identifying the various steps at national and local level which are required to implement the directive by 1 August. In addition, a national co-ordinator and support team have been seconded to oversee the implementation process in the health agencies and to provide direction and guidance on specific issues. Work is also progressing on the development of IT software to record NCHD working hours.

In February 2002, the medical education and training, MET, project group of the national task force on medical staffing was established to prepare an implementation plan, for medical education and training arising from the requirements of the European working time directive and the proposal for a consultant-provided service. The MET group is continuing with this task and I expect to have interim recommendations on meeting the training requirements within the European working time directive in the near future.

The CEO of each health board and each voluntary hospital has responsibility for the management of the workforce, including the appropriate staffing mix and the precise grades of staff employed within that agency, in line with service plan priorities, subject to overall employment levels remaining within the authorised ceiling. Hence, the recruitment of health service staff in 2004 and beyond will take place in the context of the implementation of each agency's service plan, taking into account new policy initiatives such as those necessitated by the implementation of the European working time directive for doctors in training.

On 27 January, I announced the composition of a group to prepare a national plan for acute hospital services. The group is chaired by Mr. David Hanly and contains a wide range of expertise from the areas of medicine, nursing, health and social care professions and management. It also includes an expert in spatial planning and representation of the public interest. The group has been asked to prepare a plan for the interim health service executive for the reorganisation of acute hospital services, taking account of the recommendations of the national task force on medical staffing, including spatial, demographic and geographic factors. Rapid progress is reliant on all parties commencing this urgent work and preparing the plan for acute hospital services which will further help to implement changes in the reduction of working time for doctors in training.

The existence of significant difficulties and the relatively short timeframe available in no way alleviate our legal obligations arising from the directive and only serve to emphasise the urgency of making rapid progress on implementation. Excessive working hours are unsafe for both doctors and their patients. The necessity to deliver appropriate training to our doctors while maintaining necessary levels of service provision will present a range of challenges. I am convinced, however, that this also presents a unique opportunity to improve training, services and the working lifestyles of all NCHDs.

The fact that the necessary groups are not established impedes the progress made in meeting the deadline. With just four months to go before the deadline and with 40% non-compliance with the directive, does the Minister accept that there will be severe difficulties to meet that deadline of 1 August? Will he outline the situation on employers, bearing in mind that a breach in this directive will result in a €1,500 fine for a first offence and a €500 fine for each day of non-compliance? Does the Minister agree that the experience is unique to Ireland, despite the statement of the Taoiseach that such difficulties were experienced all over Europe? Is he aware that the European Commission has pointed out the special difficulties in Ireland that do not apply to other European countries?

I do not agree with the Deputy. The Government will do everything it can to achieve progress on this issue. There will be a legal obligation on the State after 1 August as a result of this directive. It is regrettable that the partners are not coming to the table with the enthusiasm that I anticipated, given the amount of campaigning in 2000 on the hours that junior doctors work. We negotiated a generous package at that time on overtime with junior doctors. It is time to do sensible things about the hours people work in our hospitals for the benefit of all concerned.

The situation on the directive across the EU is that many countries have articulated difficulties, not so much with the directive, but with some of the court judgments that have interpreted the directive, in particular the SiMAP and Jaeger cases. The judgments of these cases define the European working time directive. Issues emerging from that include compensatory rest periods and the issue of on-site on-call. We have paid on-site on-call since 2000 as part of the deal to which I referred. In other words, if one is on call on the site, it means one is working. The problem now is that if a doctor is called out for an hour or two, there has to be an immediate provision of compensatory rest. At the request of other countries, as part of the Irish Presidency, we prepared a paper in the health working group which was submitted to the employment Ministers who have primary responsibility for the directive. Rather than undertaking a major review of the directive itself, they are considering issues such as compensatory rest periods and reference periods, that is to say the period over which average weekly working time is calculated — it is currently at 17 weeks. The Commission has sought views on the need for longer reference periods, for example 12 months.

This is not something that is unique to Ireland. We want to change the equilibrium between junior doctors and consultants, which is not satisfactory. We need a consultant provided system.

What about the difficulties experienced, especially by smaller hospitals, if they do not meet the directive and are subjected to daily fines?

I explained that. There is a legal obligation on us and we are vulnerable if someone takes a case against us and we are not compliant.

Hospital Services.

Paul Nicholas Gogarty


6 Mr. Gogarty asked the Minister for Health and Children the action he has taken to ensure that patients presenting with infectious tuberculosis can be treated at Peamount Hospital until such time as an acceptable alternative for both chronic and acute cases is provided; if he has commenced a review of practices and procedures at Peamount Hospital in view of the recent events involving the refusal by management to receive new admissions, including one seriously ill case from the Mater Hospital; his views on the lack of a timeframe for the implementation of the hospital’s new five-year strategy, and equally important the opposition to the plan among staff members, referring general practitioners and community groups. [11117/04]

Responsibility for the provision of services at Peamount Hospital rests with the Eastern Regional Health Authority. The background to the future organisation and delivery of respiratory and tuberculosis services can be found in a report of a review carried out by Comhairle na nOspidéal, published in July 2000, on respiratory medicine. This report found that, in line with major advances in medical treatment, the optimal in-patient care of patients with respiratory diseases, including tuberculosis, is more appropriate to local acute general hospitals, staffed by consultant respiratory physicians and other consultants and supported by an array of investigative facilities.

While recognising the valuable role which Peamount Hospital had played for many years in the delivery of respiratory services, Comhairle na nOspidéal did not regard it as an appropriate location for the future treatment of TB patients, especially those requiring ventilation and specialised treatment for other symptoms, for example, heart disease, HIV etc. who may present with TB.

Comhairle na nOspidéal subsequently appointed a committee to advise on the implementation of the 2000 report. The report of this committee endorsed the recommendations in the 2000 report and was adopted by Comhairle na nOspidéal in April 2003. Specifically, the committee recommended that Peamount Hospital should play an active role in the provision of a range of non-acute support services, including pulmonary rehabilitation, within the South Western Area Health Board. For example, it recommends that patients who have been treated in the nearby St James's Hospital and other major acute hospitals, and who require ongoing rehabilitative care, could be transferred to Peamount Hospital for completion of their care.

In addition to the Comhairle advice on this issue, the board of Peamount Hospital has developed a strategic plan for the development of services at the hospital. The hospital employed external support to assist it in this process and advise of developments in the wider health care environment. The strategy adopted by the board proposes considerable enhancement of existing services and development of new services in the areas of rehabilitation and continuing care of older people, persons with intellectual disabilities and adults with neurological or pulmonary illness.

On 22 March 2004, two of the senior medical personnel at Peamount Hospital secured interim High Court orders restraining their removal from their positions. The interim injunctions were granted to the medical director and senior medical officer at the hospital. The matter arose by virtue of the termination by the hospital board of the medical director's post and revised arrangements for the senior medical officer's post arising from the new arrangements for the delivery of services at the hospital.

The hospital's admission policy on admissions to its TB and non-TB respiratory units has been clarified following the granting of a further interim injunction by the High Court on 31 March 2004, which stated that admissions to Peamount Hospital required hospital management approval. I understand that a full hearing in the High Court is scheduled for 19 April 2004.

Additional Information

The admissions policy provides that all new referrals to the hospital must first have been assessed in an acute general hospital. The recent transfer of a patient with multi-drug resistant TB, MDRTB, to Peamount from the Mater hospital where he had been stabilised, is consistent with this approach. It also provides that the transfer of patients from other hospitals to Peamount must be considered in the context of such patients being non-acute and on the basis of the transferring consultant being fully aware of the facilities and staff available at Peamount. This is in line with the recommendations of the Comhairle report on the future organisation and delivery of respiratory and TB services. Peamount does not have a Comhairle approved consultant respiratory physician on its medical staff. Elective scheduled admissions will be postponed until after 19 April 2004, which is the date set for the full High Court hearing, and rescheduled after that date. Current patients with a diagnosis of malignancy will be admitted at the discretion of medical staff. The out-patients department will continue to be maintained.

In light of this clarification of the hospital's admissions policy, a consultative process has now been initiated by the ERHA with all referring hospitals and health boards to ensure that there is full awareness of Peamount Hospital's admissions policy. Within the functional area of the authority, hospitals are being asked to liaise with public health personnel regarding support requirements for patients with TB. The authority will also put in place contingency plans to manage patients locally.

Services in the hospital such as phlebotomy and x-ray will continue to be available to the local community and indeed much of the discussion to date has related to how Peamount can more effectively meet the primary care needs of the local population. After discussion with local GPs it is clear that key concerns have arisen regarding the management of older people with chest infections and respiratory difficulties. The authority is in continuing discussion with Peamount as to how these services will be maintained. This approach will be supported by the appointment of a consultant geriatrician to Tallaght and Peamount hospitals, approved by Comhairle, with two sessions per week specifically committed to Peamount. A joint consultant post in rehabilitation medicine is also being established between the National Rehabilitation Hospital, NRH, and Peamount. Existing day and residential services for older people, people with intellectual and physical disabilities continue to be provided.

I am advised that the direction which Peamount is now taking will see it developing its overall role and its support for acute hospitals, general practitioners and the community of the surrounding area and is in line with its duty of care to patients and its commitment to the provision of the highest quality of care to existing and future patients.

It is my view that the chief executive of Peamount, Mr. Mullen, has acted negligently and incompetently regarding patient care at the hospital, and he should resign his position immediately. He has disregarded the advice of the leading experts on TB, the advice of diligent staff and of referring general practitioners in the wider community.

It is absolutely out of order to name people in the House, and the Deputy is aware of that.

Does the Minister agree with this statement? In light of the ongoing complicity regarding patient care at Peamount and the dispute over the flawed five year strategy, does the Minister acknowledge that he is hiding behind the smokescreen of a legal argument and that he has the power to investigate and intervene if necessary on an issue of national public importance relating to patient care, especially because the Eastern Regional Health Authority funds Peamount?

Is the Minister aware that the main argument used by the managers of Peamount is utter nonsense, namely that they are acting on the advice of Comhairle na nOspidéal, as the Minister is today? This is because Comhairle's advice is just advice and can and has been ignored on countless occasions. Moreover, Peamount once wrote to Comhairle na nOspidéal stating it was ignoring its advice. This represents another U-turn.

Will the Minister also acknowledge that it is in the interest of patient care that the excellent work being carried out in the TB unit and in St. Teresa's be allowed to continue on the same terms as before until a new strategy is put in place, notwithstanding that the staff are in a state of major unrest because they believe the current strategy is flawed and that there was inadequate consultation?

Given that the members of the board of management are acting like sheep on this issue and that the chairman is equally culpable, what will the Minister do about the issue? Will he be as courageous as he was regarding the smoking ban? He can investigate and intervene. The ERHA has the power to lever the funding on Peamount. Apart from the courts issue, which is separate and to which I will not refer, what has happened in Peamount in recent weeks is scandalous.

I do not wish to be facetious but there are times when issues such as this arise. I have the highest respect for the individuals and the clinical issues involved, but there is sometimes a case for the medical community to gather in a large hall to sort out this type of matter.

Comhairle na nOspidéal is made up of a majority——

Comhairle's advice on services is non-binding.

——of medical personnel in terms of advising on strategies for the best deployment of medical personnel to achieve the best results for patients in a wide range of specialties.

It is unfair to suggest that the manager of a specific hospital is incompetent or negligent. This remark should be withdrawn in fairness to the individual concerned who cannot defend himself in the House. The manager and the hospital have received advice from the chief medical officer based on the Comhairle report. Even a lay person could see difficulties in Peamount continuing as a hospital given the absence of the requisite multidisciplinary consultant teams one would think would ordinarily be required for the admission and treatment of those who are acutely ill with TB. For example, the absence of a full-time respiratory physician and anaesthesia in the case of ventilation difficulties should be borne in mind. We have always been advised in terms of maternity and other specialties that the sooner they are located in acute hospitals and major teaching hospitals, the better.

That concludes Priority Questions.

I have one short supplementary question.

I accept there are probably issues to be considered in terms of implementation and the creation of a transitional period for such implementation. This Chamber cannot organise everything in every hospital in the country.

It has nothing organised.

That concludes Priority Questions.

May I ask one supplementary question since we are in ordinary time?

The Deputy is aware of the rules. It is a priority question and——

We are in ordinary time.

That does not matter. It is a priority question. We will proceed to Question No. 7, which is one of the ordinary questions. I remind Members that supplementary questions and the answers thereto are subject to time limits of one minute.