Priority Questions.

National Treatment Purchase Fund.

Olivia Mitchell


2 Ms O. Mitchell asked the Minister for Health and Children if each consultant has been requested to provide the national treatment purchase fund, NTPF, with the list of public patients awaiting surgical treatment; if so, if such requests have been universally refused; his views on whether the provision of the lists of public patients to a State agency providing health services breaches patient confidentiality considerations; and if he will make a statement on the matter. [18518/04]

The national treatment purchase fund was established to identify patients who have been waiting longest for surgical treatment and to arrange treatment for those patients. The NTPF works closely with health boards and individual hospitals to obtain information on patients and the specific surgical procedure required in each case. Currently, the information collected by the NTPF is collected by hospital and specialty rather than by individual consultant.

The NTPF carried out a validation exercise on patients reported to be waiting for surgical treatments. As a result of this exercise it became clear that the number of patients reported to the Department includes those who are not immediately available for treatment or who would be unable to accept an offer of treatment for medical or other reasons. Therefore, the figures reported to the Department overstated the actual position at hospital level.

In collecting and providing data to the NTPF, hospital management depends on the co-operation of individual consultants. To date, the NTPF has treated some 15,000 patients. This could not have been achieved without the co-operation of hospital consultants. It would be fair to say that the NTPF did not receive universal co-operation in the beginning. There were difficulties with James Connolly Memorial Hospital and the Royal Victoria Eye and Ear Hospital, Dublin, as regards the small number of patients being referred by these hospitals to the NTPF. The NTPF is hopeful of a positive outcome following recent discussions with these hospitals. However, the NTPF is concerned at the very low level of referrals from St. Vincent's University Hospital, Dublin, and the Mid-Western Health Board. If a higher number of patients were referred by both St. Vincent's and the Mid-Western Health Board more patients would have been treated and their respective waiting lists could have been reduced dramatically.

It should be remembered that patients who have been waiting more than six months for treatment can contact the NTPF directly or through their general practitioners to arrange treatment.

When the NTPF initially began to collect information, concerns were raised by some hospitals about patient confidentiality issues. Clarification was sought and received from the Data Protection Commissioner in this regard. In the overall interest of patient care and treatment, as well as on the basis that hospitals collected the patient data for the purpose of patient treatment, the commissioner was of the view that disclosure to the fund is compatible with the purpose for which patients gave the details in the first instance. The commissioner has considered, therefore, that the Data Protection Acts do not prohibit the disclosure by a data controller — the hospital, in this case — of patient data to the treatment fund. Information supplied to the national treatment purchase fund is treated in the strictest confidence.

The fund does not request or retain the medical histories of patients. Medical notes associated with patients are not sought by the fund. It is in the best interest of patient care that details sought by the fund are provided by health boards and hospitals so treatment can be arranged for the patients concerned.

I recognise that some hospitals are co-operating with the treatment fund, but following the Minister's reply it is not clear to me whether hospitals or consultants are providing lists of patients. I find it utterly ludicrous that a State agency has to spend enormous sums of money on advertising on national radio to identify those public patients who are waiting for a public service, and that we cannot identify such people without recourse to advertisements on national radio. It seems to be a total waste of money. If consultants are not co-operating with the treatment fund, they are denying patients the opportunity to choose. They are making decisions on behalf of patients.

The Minister should take a strong line on this issue. Does he agree that the lists do not belong to consultants? The patients do not belong to the consultants. As patients of the State, they are entitled to receive treatment in whatever way the State can deliver it to them. It is totally unacceptable that such money — over €1.5 million last year — has to be spent on advertising. I do not know what the relevant sum is this year. My question was prompted by hearing advertisements for the national treatment purchase fund every time I turn on the radio.

I disagree with the Deputy's comments on the advertising, which is necessary and good.

It would not be necessary——

It acts as an additional lever for the system and helps people to know what they are entitled to. We should not underestimate the need for strong public campaigns to make people aware of what they can access and how they can access it. The treatment fund has received telephone calls from 9,272 people, of whom 2,145 were found to be eligible and were subsequently treated. I accept the Deputy's point about consultants giving lists of patients to hospitals. I pay tribute to the officials of the Department of Health and Children, from the Secretary General down, who orchestrated the mechanics of the establishment of the fund. I take advice from the chairperson and the chief executive officer of the fund on a regular basis. They advised me some time back about how best to proceed to get the fund up and running. The result has been very positive as up to 15,000 people have been treated.

We have identified a number of hospitals that have not co-operated to the extent that we consider necessary and correct. The chairperson of the treatment fund has advised me about how best to proceed. I have followed that advice to a certain extent and significant progress has been made from the beginning. That 15,000 people have had operations to date demonstrates that the vast majority of consultants are co-operating. There have been significant improvements in waiting times in many hospitals. I have a list of up to ten hospitals that are referring patients for over three months. A further nine or ten hospitals are referring patients for over six months. Progress is being made. It is not acceptable for the other hospitals——

The time for this question has elapsed.

Community Care.

Seán Ryan


3 Mr. S. Ryan asked the Minister for Health and Children if he will report on the waiting lists for public nursing home beds given that it is alleged that in the Dublin area there is a waiting list of up to 12.5 years; if, in light of this situation, he will consider availing of the country’s vacant beds in private nursing homes; and if he will make a statement on the matter. [18626/04]

As the Deputy is aware, the administration of health services, including the placement of people into long-term care, is, in the first instance, a matter for the Eastern Regional Health Authority, ERHA, and the health boards.

I am aware that the Dublin academic teaching hospitals, DATHs, have been encountering problems with delayed discharges of patients whose acute phase of treatment has been completed and who require to be discharged to more appropriate facilities. However, the claim that people might have to wait for up to 12 and a half years for discharge was, in my view, unjustified.

The Deputy may be interested to know that I have regularly met administrative and medical representatives of the ERHA, the area health boards and the DATHs and, at the most recent meeting, I was advised by the authority that it has commenced a programme to re-open public extended care beds. I am, therefore, fully cognisant of the issues involved. The Minister of State, Deputy Callely, is involved in these meetings.

I understand the ERHA has made strenuous efforts in recent months to recruit staff and that these efforts are beginning to show results. This has allowed for the re-opening of 93 public extended care beds to date.

Additional funding of €13.8 million has been provided to the ERHA this year to facilitate the discharge of patients from the acute system to a more appropriate setting, thereby freeing up acute beds. It allows for funding through the subvention system of additional beds in the private nursing home sector and ongoing support in the community. This funding has already resulted in the discharge of more than 350 patients from acute hospitals in the eastern region to different locations, the majority to private nursing homes.

The ERHA is actively monitoring the situation and working with hospitals, the area health boards and the private nursing home sector to ensure every effort is made to minimise the number of delayed discharges from acute hospitals.

The option of accessing beds in private nursing homes will be considered on an ongoing basis, bearing in mind that, for a variety of reasons, private nursing home beds often may not be suitable for the discharge of heavily dependent older people from acute hospitals.

My Department provides significant funding for the nursing home subvention scheme and more than €443 million has been allocated cumulatively over the past five years. In 2000, the budget available for the scheme was €48.439 million and, this year, €115 million was made available, which is an increase of 137%.

I will continue to monitor the situation to ensure that, to the greatest extent possible, problems encountered by older people in the greater Dublin area in accessing services appropriate to their needs are minimised.

The Minister stated that both he and the Minister of State, Deputy Callely, will monitor the situation but the reality is slightly different. The Minister's response to a recent request is unacceptable and shows a disregard for the needs of older people at a time when community care and home help services have been slashed.

Does the Minister accept that community care areas, especially those in the greater Dublin area, are reporting a 12 and a half year waiting list for long-term public nursing care, especially since the withdrawal of contract beds from the system in September 2003? Arising from that, does the Minister accept that hundreds of acute hospital beds are being inappropriately occupied by older people in acute hospitals, thus leading to ongoing bed shortages and long waiting periods on trolleys in accident and emergency units while, at the same time, more than 2,000 private nursing home beds are unoccupied? Is it not time we examined this area to try to deal with the problem? The Minister's response generally referred to subvention, but the real problem is that the people who cannot afford subvention are being told that they will be dead before they have access to a public nursing home in 12 and a half years' time.

I do not accept the basic content of the Deputy's argument. He is correct in one point in that it requires an overall package of measures which include community and nursing unit beds in the public sector, beds in the private nursing home sector, home care packages, which have been piloted in the Dublin region, and a more innovative approach to the procurement and securing of additional beds in the Dublin region. That is the reason we started out on the first public private partnership in health with a view to securing an additional 450 beds.

That is a long time away.

It is on the way. Unfortunately, due process must be entered into in the context of public private partnerships in that they must be advertised in theOfficial Journal of the European Communities and go through the entire design phase. That is taking its course, but it is happening and is the most effective way we can significantly increase, within the next two years, the availability of beds in community nursing units on the public side.

Historically, there has been a dearth of such public beds in Dublin because of the closure of many district hospitals in the 1980s and early 1990s. In the interim period, we have provided an increase of up to 137% in the cost of funding private nursing homes. Following discussions last year, additional funding has been given to the Eastern Regional Health Authority for a package of measures designed to free up acute beds and to allow the reasonable referral of patients, who have had acute treatment, to continuing care beds. This is done in a way to maximise allocation of beds and ensure value for money. This funding has resulted in approximately 330 people securing beds. The Department will continue to work with the Eastern Regional Health Authority in monitoring this and see how it can be improved.

The time for this question has concluded. Ceist Uimh. 4 in ainm an Teachta Cowley.

A Cheann Comhairle——

There are only six minutes for questions.

I only had one contribution. The Minister for Health and Children took up most of the time in answering.

The Deputy's contribution took almost two minutes. The Chair has no control over the length of time for questions.

It is unacceptable that the Minister takes up most of the allocated time and still gives no real answer.

I understand, but the way to change it is through Dáil reform. I call on the Minister to reply to Question No. 4.

Hospital Services.

Jerry Cowley


4 Dr. Cowley asked the Minister for Health and Children the reason a person (details supplied) cannot be transferred to a Galway hospital for the care she requires for a tracheotomy following an aneurysm operation complication; his views on the transfer to a Galway hospital from Mayo General Hospital; and if he will make a statement on the matter. [18550/04]

The provision of services to the person in question is a matter for the Western Health Board. However, after inquiries to the board, I have been advised that the patient requires long-term care, rather than acute care, due to the complexities of the case. The Western Health Board has worked closely with the person's family, the staff at Mayo General Hospital and other health board departments which would have had a role to play in securing an appropriate placement in Galway.

A transfer to University College Hospital, Galway was not an option as this hospital provides acute care and is not the appropriate place to admit patients who require long-term care. A second option was an admission to a Western Health Board long-term care facility such as Merlin Park Hospital or St. Brendan's Hospital in Loughrea. However, a referral had previously been made to the admission team responsible for such facilities. It was refused on the grounds that the consultant geriatrician involved does not admit people below the age of 65 years requiring long-term care.

The third option explored was placement in a private nursing home. A particular nursing home was identified and the following process was agreed. The Western Health Board would be in a position to fund such a placement, the cost of which would have in excess of the maximum which is available under nursing home subvention. A meeting of clinicians would take place to ascertain if the needs of the person in question could be met in this nursing home. The family and Mayo General Hospital staff would then be invited to visit the nursing home.

On confirmation that the Western Health Board would provide funding to support the person's placement in this nursing home, relatives visited it. The meeting between the team in Mayo General Hospital and the nurse manager of the nursing home took place recently. Unfortunately, despite a great willingness on everyone's part to facilitate this placement, it was concluded that the nursing home would not be in a position to meet the patient's extensive medical needs. This outcome was communicated to the person's family by the social worker in Mayo General Hospital who is the main contact with the family. Further options are being explored in consultation with the family. The board has assured me that it will work with the person's family and engage with them in any actions it takes on their behalf.

I thank the Minister for his reply but it is not acceptable. Previously, I attempted to raise this issue under Standing Order 31. The person in question is 48 years old, was born in Galway yet has been in Mayo General Hospital for the last two and a half years after suffering complications from a brain aneurysm. She now requires constant nursing care and has had a tracheotomy tube inserted.

The excellent care provided by Mayo General Hospital is readily acknowledged by her family. However, this lady lived in County Mayo for less than a year. When she fell ill, she was taken to Mayo General Hospital. Her 12 year old son must make a 100 mile round trip to visit her and is now suffering from lack of contact with his mother, although she can still hear and feel. The lady in question is being kept in an acute hospital because it is the only place in the region capable of caring for her. Why can she not be cared in an acute hospital nearer her family home?

When a relative of the lady, a constituent of the Minister's, contacted him at his Grand Parade office concerning the matter two years ago, he informed her it would be sorted out. The relative was sent to the Western Health Board and still nothing has been resolved. In answer to a parliamentary question submitted by me last February, the Minister replied that the matter would be resolved by the Western Health Board. Two years have passed and still there has been no resolution. This is unacceptable.

Every nursing home in County Mayo has been examined for a placement for the lady but none has the facilities for her care. She is not accepted by long-stay care institutions because she is not yet 65. Does the Minister think he has failed?

The Western Health Board told this family that the facility available, an eight-bedroom ward with Alzheimer's patients, is "not a pretty picture". We are trying to get this lady into a nursing home but none will take her because she needs so much care. The Western Health Board is sending people to nursing homes who require a high level of care which cannot be given there. Why is there no State facility for such people? Why is this lady being denied a place in a Galway hospital when she requires acute care? The Western Health Board said that nursing homes and long-stay homes are not suitable for her. Her 12 year old son lives in Galway.

We are running out of time. The Deputy must confine himself to a question.

The lady's 12 year old son needs care and contact. Has the Minister failed? Will he ensure a bed in a Galway hospital for this poor lady? What can a Mayo hospital do that a Galway hospital cannot do? Why must a Mayo hospital take this lady when her family lives in Galway?

An acute hospital is not the most appropriate place for her.

There is no other place for her.

I share the Deputy's concern. I do not give categoric guarantees in individual cases. I will do my best in the way everyone else does in this House, through the executive agencies responsible, in an effort to secure the best possible outcome for any individual.

The situation has gone on for two years. The lady is one of my constituents.

There is a mechanism or option which could be used by the Western Health Board to resolve this case. We put it to the board that we wanted this case resolved. It considered a number of options. Unfortunately the last one, a nursing home placement, did not work out — we thought it would — because of the consultations needed.

The lady needs acute hospital care.

Packages of care can be organised in different locations. One does not have to be in an acute hospital to avail of the package of care required in this case. Similar packages of care have been provided in other areas of the country in contexts different to acute hospital settings. No one would realistically suggest that we provide for cases such as this in an acute hospital setting. The case highlights the situation with the young chronic sick for whom there has been an historic deficit of suitable standalone units. I acknowledge that.

There is nothing suitable for this lady. She needs acute hospital care and it must be provided.

The health board should be in a position to facilitate a resolution in this lady's case.

Mental Health Services.

Dan Neville


5 Mr. Neville asked the Minister for Health and Children his views on the fact that the additional funding of approximately €90 million allocated since 1997 for ongoing development of mental health services is a manifestation of the total neglect of the services resulting in 83% of consultant psychiatrists having no access to a psychotherapist, 76% to a family therapist and 33% to an occupational therapist. [18519/04]

Substantial progress has been made in recent years in ensuring that those in need of mental health services receive the best possible care and treatment in the most appropriate setting. The Deputy is correct in stating that additional funding of approximately €90 million has been invested in mental health services since 1997. This funding has enabled real progress to be made in providing additional medical and health professional staff for expanding community mental health services, to increase child and adolescent services, to expand the old age services and to provide liaison psychiatry services in general hospitals. For example, in 1997 there were 207 consultant psychiatric posts and by 2004 this had increased by 74 to a total of 281. This includes an extra 19 child and adolescent psychiatrists, eight psychiatrists of learning disability, three forensic psychiatrists, 28 adult psychiatrists and an extra 16 old age psychiatrists.

In addition to the increased revenue funding outlined, substantial capital funding has also been provided to mental health services over the lifetime of the national development plan to fund the development of acute psychiatric units linked to general hospitals as a replacement for services previously provided in psychiatric hospitals. In addition to the 21 acute units now in place, a number of units are currently at various stages of development.

Health boards continue to develop a comprehensive, community-based mental health service. This has resulted in a continuing decline in the number of in-patients from 5,192 in 1997 to 3,966 in 2002 with a corresponding increase in the provision of a wide range of care facilities based in the community to complement in-patient services. There are now 411 community psychiatric residences in the country providing 3,146 places compared to 391 residences providing 2,878 places in 1997.

Additional information not given on the floor of the House

A very significant development within the area of mental health service provision in recent years has been the enactment of the Mental Health Act 2001. The main vehicle for the implementation of the provisions of the Act is the Mental Health Commission which was established in April 2002. The commission's primary function is to promote and foster high standards and good practices in the delivery of mental health services and to ensure that the interests of detained persons are protected.

The Mental Health Commission's strategic plan 2004-05, published earlier this year, indicates that one of its priorities for the commission is to put in place the structures required for the operation of mental health tribunals, as provided for in Part 2 of the Act. This year, additional funding of €3 million is available to the commission for this purpose. The commission is currently in discussion with my Department, the health boards and other relevant agencies to ensure that all elements of the organisational and support systems required are in place prior to the commencement of Part 2 of the Mental Health Act 2001.

Under the provisions of the Mental Health Act 2001 the commission has appointed Dr. Teresa Carey to the position of Inspector of Mental Health Services. A team of assistant inspectors has also been appointed. The inspector had indicated that she expects to commence a programme of inspections of mental health facilities from June 2004.

The Deputy has referred to psychotherapy and family therapy, services generally provided within the health boards by clinical psychologists. I recognise that service providers have experienced particular difficulty in recruiting clinical psychologists. One of the main reasons for this has been the very small number of post-graduate training places available for such professionals. My Department, together with the health boards' directors of human resources, have been examining various issues in relation to human resource planning for clinical psychologists in the health services, including the need to increase the number of postgraduate psychology training places on a planned and sustainable medium-term basis. It is worth noting that since 1999 there has been a threefold increase from 26 to 84 in the number of trainee clinical psychologists employed in the health services.

While substantial improvements have been made in recent years in the delivery of mental health care and in the quality of mental health facilities, I acknowledge that much remains to be done. To ensure that we continue to obtain the best possible return on our investment in this important area of health care, I appointed an expert group on mental health policy in August 2003 to review all areas of mental health policy and service provision. The group consists of 18 widely experienced people who are serving in their personal capacities. The membership encompasses a wide range of knowledge and a balance of views on many issues affecting the performance and delivery of care in our mental health services. The group is expected to complete its work in 2005.

The Minister is attempting to blind us with figures. However, does he not agree that funding of €90 million since 1997 is a national disgrace? It is approximately one and a half times what was spent on electronic voting and, at an average of €11 million per year, is €4 million less than was spent this year on Punchestown. This level of investment, the lowest of any of the medical services, totally ignores the one in four people who will suffer from a mental illness during their lifetime. Why is the national treatment purchase fund not available to those in need of assistance and on a waiting list for more than 12 months? Why is treatment for varicose veins considered more important than for depression when such procedures are available under the national treatment purchase fund?

With regard to figures quoted by the Minister, of the 400 clinical psychology posts funded, 180 are vacant. Why is this the case when the psychiatrists association, in its presentation to the Joint Committee on Health and Children, stated that 73% of all psychiatrists do not have a psychologist available to them? The association further stated that the presence of a multi-disciplinary team was connected to the improvement and cure of those being treated for psychological and psychiatric illnesses.

The Deputy referred to psychotherapy and family therapy services generally provided within the health boards by clinical psychologists. I recognise that service providers have experienced particular difficulty in recruiting clinical psychologists. One of the main reasons for this has been the very small number of postgraduate training places available for such professionals. My Department, together with the health boards' directors of human resources, has been examining various issues in relation to human resource planning for clinical psychologists.

For over seven years.

Much has been done, as the Deputy knows, and 35 clinical psychologists are in training at present. However, I accept that more needs to be done. Since 1999, there has been a threefold increase, from 26 to 84, in the number of trainee clinical psychologists employed in the health services. The Deputy is very well briefed by psychiatrists.

The Minister is also well briefed.

Allow the Minister to speak without interruption.

I attended an informative North-South meeting yesterday organised by the Irish Advocacy Network, a group which does much work with the users of services. Many attended from North and South and they were extremely disappointed that, despite sending invitations to psychiatrists from North and South, not one attended. Nonetheless, it was a fantastic meeting and good to listen to the users of the services, who have much to say about the provision of services. Users need to be listened to more, and I intend to do this.

I wish to ask a further brief question.

The time for this question is concluded.

Medical Cards.

Caoimhghín Ó Caoláin


6 Caoimhghín Ó Caoláin asked the Minister for Health and Children if he proposes to extend medical card cover to all persons under 18 years of age during the lifetime of this Dáil; and if he will make a statement on the matter. [18520/04]

Entitlement to health services in Ireland is primarily based on means. Under the Health Act 1970 determination of eligibility for medical cards is the responsibility of the chief executive officer of the appropriate health board other than for persons aged 70 years and over, who are automatically eligible for a medical card. Medical cards are issued to persons who, in the opinion of the chief executive officer, are unable to provide general practitioner medical and surgical services for themselves and their dependants without undue hardship. As a matter of course, the medical card income guidelines are revised annually in line with the consumer price index. The last such increase was notified in January 2004.

For those who do not qualify for a medical card there are a number of schemes which provide assistance towards the cost of medication, including the long-term illness scheme and the drug payments scheme. Many allowances such as carer's allowance, child benefit, domiciliary care allowance, family income supplement and foster care allowance are all disregarded when determining a person's eligibility. Given these factors and the discretionary powers of chief executive officers, having an income that exceeds the guidelines does not mean a child or other person will not be eligible for a medical card. It may still be awarded if the chief executive officer considers that a person's medical needs or other circumstances would justify this.

Persons aged 16 to 25, including students, who are financially dependent on their parents are entitled to a medical card if their parents are medical card holders. Those who are dependants of non-medical card holders are not normally entitled to a medical card except where they have an entitlement under European Union regulations or where they are in receipt of a disability allowance. Students who are financially independent of their parents are entitled to apply for a medical card in their own right and are assessed on the same criteria as all other applicants. The decision on whether a person is regarded as a dependant or as being financially independent is made by the chief executive officer of the health board on the basis of the circumstances of each individual case.

It is open to all persons to apply to the chief executive officer of the appropriate health board for health services if they are unable to provide these services for themselves or their dependants without hardship. In line with the health strategy, Quality and Fairness — A Health System for You, the possibility of extending the medical card by statute to various groups, including children, is under ongoing review in my Department in the context of the strategy's second goal.

Additional Information not given on the floor of the House.

As the Deputy is aware, the health strategy includes a commitment that significant improvements will be made in the medical card income guidelines to increase the number of persons on low incomes who are eligible for a medical card and to give priority to families with children, especially those with a disability. This should be viewed in the broader context of the strategy's emphasis on fairness and its stated objective of reducing health inequalities in our society. Due to the prevailing budgetary situation, I regret that it is not possible to meet this commitment this year, but the Government remains committed to the introduction of the necessary changes within its lifetime.

I am disappointed by the nature of the Minister's reply which outlines the prevailing position. Does he recall that on the previous occasion I raised the question, he stated it was due to the prevailing budgetary situation that he was unable to fulfil the Government's pre-general election commitment? Does he accept that, since making the statement last December, the budgetary situation has improved greatly and the economic trends are showing an upward turn? If there was any real excuse last December for the answer he gave, I do not believe it would apply currently.

Is the Minister aware that a married couple with two children, with a miserly income of €260 per week, will not qualify for free general practitioner care for their children? Does he agree this is scandalous in the Ireland of 2004? Has he any idea of the real hardship families are suffering, especially where the choice is between GP referral and prescriptions and the needs of everyday life? The Government's health strategy repeatedly stresses the vital importance of primary care, and the Minister rightly repeats it. Is he aware that many children are denied proper access to primary care because of the financial circumstances of their families? Will he explain why it is that the principle of universal qualification can apply to people over the age of 70 but cannot apply to children under the age of 18?

Does the Minister agree that the fact that so many families suffer in this situation reflects the inadequate threshold for qualification where the bar is much too low? It needs to be heightened in terms of the qualification levels. Does he propose in the course of this Dáil to extend medical card cover to all children under 18 years of age?

The Government programme is for five years. I indicated in reply to a parliamentary question in December and recently that the financial envelope allocated to me this year with which I must work does not facilitate increasing the medical card income threshold. I accept the thresholds are too low and that a certain category of people would benefit from an increase in them. Given that we are in Government for five years, I hope we will be in a position to fulfil a commitment we gave to extend medical card eligibility to approximately 200,000 extra people and to target it at those in greatest need.

It is fair to say that, over the past two years, the cost of the general medical services, GMS, scheme has increased dramatically. If one examines the graph over the past three years, there has been a dramatic increase in the cost of drugs and the number of prescriptions, including the arrival on the scene of new drugs which are more expensive. We had to provide an additional €200 million this year for the overall GMS budget just to maintain provision for current medical card holders in the population. It is also fair to point out that the increase in employment in recent years has taken many people above the income thresholds so the number of medical card holders as a percentage of the population has declined by a number of percentage points.

The Deputy voted for the extension of medical card provision to the over 70 year olds. The Deputy's policy platform would extend medical card provision even wider so it baffles me how he can criticise the extension of medical card provision to the over 70 year olds while, on the other hand, have a completely different view——

I did not. I asked why universal qualification only applies to one sector.

I call Question No. 7. The Minister without interruption.

Rhetorical questions can be condemnatory in intent.

The Minister's incompetence is the problem. It is a bad deal.

I have called Question No. 7.

Phil Hogan


7 Mr. Hogan asked the Minister for Health and Children if he or his Department has ever carried out an estimation of the cost of the provision of a free universal general practitioner service here, either a partial medical card service or to include all services currently covered for medical card patients; and if he will make a statement on the matter. [18408/04]

Health boards established pursuant to the Health Act 1970 are obliged by section 58 to provide general practitioner services free of charge to persons having full eligibility for health services. Responsibility for the determination of the eligibility of an applicant to a medical card is, by legislation, a matter for the chief executive officer of the relevant health board to decide, having regard to the individual circumstances of each case. Medical cards are normally issued to persons for whom, in the opinion of the chief executive officer of the local health board, the provision of general practitioner and surgical services for them and their dependants would cause undue financial hardship.

Negotiations with general practitioners who provide services for medical card holders in the GMS scheme have been conducted on this basis. Any plans to change the spirit or the extent of the operation of the GMS scheme in the area of eligibility would necessarily mean further negotiations with representatives of the medical and pharmacy professions. It is, therefore, extremely difficult to assess accurately the likely cost of the introduction of universal eligibility to a medical card. However, based on preliminary figures from the GMS Payments Board for the average national cost for the provision of GP services to medical card patients for 2003, it could cost in the region of €685 million per annum to provide general practitioner services to the balance of the population. To give free pharmacy services for the range of approved prescribed medications, again for the balance of the population and based on the 2003 preliminary figures from the GMS Payments Board, could cost in the region of an extra €1.64 billion. Neither of these figures takes into account any changes which may result in the fee structures for either GPs or pharmacists following negotiation with these contractors.

The Minister is correct that the current income threshold for medical cards is too low. It is half the minimum wage, which is, effectively, destitution. One must be destitute to qualify for a medical card. The reason I asked this question is to explore the possibility of something less than a full medical card service for people. Each taxpayer pays an average of €6,000 to the health service and, undoubtedly, the cost of the GMS is high and increasing.

Deputy, there is just one minute for supplementary questions.

I know and you are using some of it.

The Deputy should confine herself to asking questions.

Would the Minister accept that pouring money into a bloated hospital system is not giving value for money? Is he willing to explore the possibility, albeit that it might require new negotiations with pharmacists and general practitioners, of changing the focus of the health system towards one of prevention and primary care and of targeting specific illnesses rather than insisting that we should stay with the old medical card system?

I agree with the Deputy that we should continue to invest more in primary care and prevention. However, we must be careful in allocating available resources. We need to target and prioritise the resources. I favour targeting resources towards children and people with disabilities in the context of access to general practitioner services as the first priority. A blanket allocation of up to €600 million, and the amount could be even more given that this figure is estimated before any negotiations take place, would not be the best allocation of scarce resources.

That is not what I suggested. I was asking about a targeted approach as a halfway house. People with chronic illnesses, for example, have no medical card.

Many have and some do not because of the long-term illness card.

Does the Minister accept that the price of his failure to extend the medical card scheme is being paid by families on low incomes, including those with children? The Minister has reduced the total number of patients with medical cards by 100,000. People are losing out, although the Minister promised in the programme for Government that they would gain.

The Minister struck a deal with GPs under which they are paid almost four times more for treating a wealthy patient over 70 under the medical card scheme than a poorer patient over 70. Surely this is bad value for money and prevents the natural expansion of the scheme to provide for those most in need.

I do not accept that 100,000 people lost out because of a failure to increase the threshold for eligibility. The vast majority of those people are over the income limit because of the thousands of extra jobs that have been created in recent years. Whether or not we like to admit it, income levels for those with jobs have gone up substantially over the past five years and this rendered some people ineligible for the medical card scheme.

Income levels have not gone up substantially. Let us get real.

That is the reality. I have answered the Deputy's question.

I am talking about people on low wages.

Allow the Minister to continue without interruption.

Yes, but many who found jobs over the past four or five years went over the income limit for eligibility for the scheme and as a result did not receive medical cards.

The Minister should get real. They are still on low wages.

The Deputy has tried to have it every way on the issue of the over 70s for a long time. Prior to any agreement she was asking every day when we would strike a deal with the hard-pressed GPs. That was her position. Then she endorsed the extension of the medical card scheme to all those over 70 by voting for it. Irrespective of all her rhetoric, she trooped through the lobbies and voted for it.

I did not vote for incompetence.

Order, please.

I did not vote for the Minister's incompetence. He did not do the business.

This has had an interesting outcome in terms of value for money. There has been some evaluation of the extension of the scheme and it is showing good results in terms of the frequency of visits to GPs by elderly people and the resulting improvement in vaccination levels and general health. That is good value for money by anyone's standards.

As a general practitioner I am very aware of the difficulty people experience in accessing primary care services. If the Minister can increase access he will save money. When will he issue the 200,000 extra medical cards that are promised?

I have answered that question already. The Deputy knows the extensive contribution the State makes towards all the schemes and that GPs, pharmacists and so on do quite well out of the allocation.

I am talking about patients.

May I ask one more question?

Sorry, Deputy, we have gone over time on this question. We must be fair to other Deputies who wish to submit questions. Standing Orders must apply to everybody.

How can the Minister defend the lousy deal he made? The GPs had him over a barrel.

Cardiac Emergency Care.

John Bruton


8 Mr. J. Bruton asked the Minister for Health and Children if he has plans to ensure that portable defibrillators are available and accessible to persons in rural communities, large offices or commercial buildings; and if he will make a statement on the matter. [18449/04]

The cardiovascular health strategy, Building Healthier Hearts, which was launched by the Taoiseach in July 1999, refers to the need for early cardiopulmonary resuscitation, defibrillation and the provision of equipment and training to health professionals, particularly GPs in rural areas.

The most disadvantaged in gaining access to early intervention and treatment through all the links of the survival chain are those resident in rural communities, due to the fact that they are furthest away from hospital services. In recognition of this, a number of geographically large health boards have introduced projects to facilitate early response to chest pain or suspected coronary attack for people in isolated areas. Many health boards have developed programmes to train either professionals or members of the public in first responder skills. Many boards have purchased defibrillators for use by GPs.

Other initiatives have been taken. In the North Eastern Health Board area in 2002, 700 school children were educated on what to do in the event of a cardiac emergency. The Western Health Board introduced Community Action in Response to Emergency, a project that trains members of the public in first responder skills. In the north west, the existing Donegal pre-hospital project, referred to in Building Healthier Hearts as a model for other boards to follow, was expanded through the purchase of equipment and extended to Sligo and Leitrim. The Southern Health Board developed a first responder scheme in Dingle.

A start has been made in the provision of defibrillators in public places, including Dublin Airport and Blanchardstown shopping centre in the Eastern Regional Health Authority area. In Blanchardstown shopping centre, 22 customer care staff were trained in the use of an automated external defibrillator, five of which are placed strategically around the centre. Staff are retrained every 90 days at James Connolly Memorial Hospital, Blanchardstown. The lessons from this public access defibrillation pilot project will be examined to inform further developments in this area.

Notwithstanding the immediate and obvious benefits of the provision of defibrillators in public areas, it is also essential to have sustained services in place. All ambulances are now equipped with defibrillators and most ambulance staff have received appropriate training in the area. Six community resuscitation training officers and 21 hospital-based training officers have been recruited by health boards, improving the resuscitation skills of staff working in the community and hospitals.

I will ask a very brief question as my colleague, Deputy Timmins, who has a specific interest in this issue, wishes to contribute. From the Minister's point of view — I recognise that work is ongoing around the country — the main way in which the Minister can facilitate, encourage and support this system, which operates on a voluntary basis in some areas, is through the introduction of good Samaritan legislation, which is required to protect individuals who offer this kind of treatment. Will the Minister consider that?

I consulted the Pre-Hospital Emergency Care Council on liability issues for participants in first responder schemes and it has provided some observations. It sought legal advice on the exposure of an individual to litigation. It is now examining how best to disseminate that information to assist those participating in or considering establishing first responder schemes. I do not, therefore, believe we need a good Samaritan act. The Pre-Hospital Emergency Care Council has been a major catalyst in rolling out the first responder scheme and in informing best practice across the country. If it suggests it is necessary, I will be open to introducing legislation. However, it has not so far done so.

Is the Minister aware that many communities have bought defibrillators in recent months? In Wicklow ten such machines have been purchased by various communities. On the issue of insurance, the difficulty is that they might not be able to join in the first responders mechanism because they will not have enough volunteers in the community. I ask the Minister to keep an open mind regarding good Samaritan legislation. Will he initiate discussions with the Minister for Justice, Equality and Law Reform regarding the possibility of holding these machines in Garda stations if there is no other suitable place within the locality? In addition, will he examine, with the Minister for the Environment, Heritage and Local Government and the county managers, the possibility of including in county development plans a requirement that, where a development exceeds a certain size and attracts many people, such as the Blanchardstown shopping centre, the airport and Croke Park, these machines be available?

Yes. That is a constructive suggestion. I will work with the Deputy and the agencies he mentioned in requesting that.

It is extremely important that defibrillators are being provided. The Minister stated that they are in all ambulances, but the difficulty is in getting the ambulance to the person, particularly for treatments other than those related to heart problems. The Western Health Board area is unique in terms of the distance of bases from people. To achieve a proper standard of care, it is necessary to reach the person within the golden hour, but that is impossible in the Western Health Board area. Three bases are badly needed. Will the Minister address that problem, because no matter how many defibrillators there are, they are no good in an ambulance if the ambulance cannot get to the patient within the required time?

There has been a dramatic improvement in the ambulance service in recent years compared to four or five years ago. I continue to prioritise investment in ambulance services. The Department has approved training for the emergency medical technicians advanced programme which will train EMTs to the level where they can administer other drugs, particularly thrombolytic drugs, in cases of heart attack. That will require legislative change which it is hoped will be brought to a conclusion very shortly, following legal advice we have received.

Health Reform.

Arthur Morgan


9 Mr. Morgan asked the Minister for Health and Children the status of the Hanly report recommendations; if these recommendations have been amended; the way in which it is proposed to proceed with implementation; and if he will make a statement on the matter. [18490/04]

Ciarán Cuffe


51 Mr. Cuffe asked the Minister for Health and Children the status of the Hanly report; the elements of the report he has implemented to date; when he will implement the report in full; and if he will make a statement on the matter. [18476/04]

Willie Penrose


71 Mr. Penrose asked the Minister for Health and Children the progress made to date with regard to implementation of the recommendations of the Hanly report; and if he will make a statement on the matter. [18379/04]

I propose to take Questions Nos. 9, 51 and 71 together.

The Government is committed to progressing the implementation of the Hanly report for the benefit of all patients. I have established implementation groups for the Hanly report in both the east coast and mid-western regions. The groups will carry out the detailed work of identifying the services that should be provided in each hospital, in line with the Hanly recommendations.

Regarding hospital services outside these two regions, I have announced the composition of a group to prepare a national plan for acute hospital services. The group 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 reorganisation and development of acute hospital services, taking account of the recommendations of the national task force on medical staffing, including spatial, demographic and geographic factors. Neither the local implementation groups nor the acute hospitals review group has been able to meet due to the consultants' continuing industrial action. I again ask that all parties return to the table to progress the work of these groups.

I emphasise that the Hanly report is about developing hospitals, not closing them. In the mid-western region's acute hospitals, for example, we have increased the total staff numbers by almost 1,200 since 1997. We have provided an 80 extra consultants during that period and increased ambulance personnel by 77%. There have been important investments in Ennis, including a new €5.7 million acute psychiatric unit, and I have approved the appointment of design teams for further improvements in Ennis General Hospital and Nenagh General Hospital. These initiatives illustrate the Government's commitment to smaller hospitals as a continuing and vibrant element of our acute services.

Other key elements of the Hanly proposals are being progressed. Negotiations with the Irish Medical Organisation on the reduction of NCHD working hours are continuing in the Labour Relations Commission. A national co-ordinator and support team are overseeing the implementation process in the health agencies. Regarding the consultant contract, a number of meetings have taken place between officials of my Department, health service employers and representatives of the Irish Hospitals Consultants Association and the Irish Medical Organisation. These talks are also affected by the current programme of industrial action by the Irish Hospital Consultants Association.

On medical education and training, the sub-group of the task force which dealt with these issues has remained in place. The group has been asked to examine and report to me on the measures required to accommodate NCHD training in all postgraduate programmes and safeguard both training and service delivery during the transition to a 48-hour working week. A major national seminar was held last January involving all stakeholders including training bodies, employers and medical representative bodies. Drawing on the views expressed at this seminar and the ongoing work of the medical education and training group, draft proposals have been developed with a view to ensuring the provision of high-quality training for NCHDs in the context of the initial implementation of the 58-hour week and the eventual implementation of the 48-hour working week. I anticipate that these proposals will be submitted to me in the near future.

Is the Minister aware that the Taoiseach, the Minister for Defence and others have stated repeatedly that the Hanly report recommendations have in some way been amended? The Minister for Defence stated that in this House in relation to Nenagh hospital. Will the Minister with responsibility outline exactly where stands the Hanly report?

Noting that Hanly states that in time "in local hospitals there should not be a requirement for on-site medical presence overnight or at weekends", does the Minister accept that if adopted this would mean that most smaller hospitals will not be able to provide in-patient care or effective accident and emergency services since they both require 24-hour medical cover? Will the Minister accept that the Hanly proposals to downgrade local hospitals should be set aside because they are unworkable and unacceptable?

I do not accept what the Deputy has said. I answered a number of questions on this over recent months. I made the point earlier that following discussions with the chairman of the Hanly group in January it was agreed that there would be 24-hour medical cover in acute hospitals across the country. I explained the last time I was here that the health board in the Ennis and Nenagh area took a decision following submissions from the Irish Medical Council to advertise for the recruitment of emergency care physicians, qualified doctors——

For two years.

The Deputy should allow me to speak. This is in the context——

Deputy McManus, we want an orderly Question Time. A number of Deputies are offering.

Reference to the two years is in the advertisement, there is no secret about that. The point I make, and which I made then, is that this was not in response to the Hanly report. This was an immediate issue on which we had to respond, namely, points made by the Irish Medical Council in communications to the health board. Deputy Ó Caoláin, coming from Monaghan, is aware of the importance of the Irish Medical Council, which is a standard-setting body, and the royal colleges, the Institute of Obstetricians, the Royal College of Surgeons, the Royal College of Physicians or whatever, in influencing what eventually happens in acute hospitals and the configuration of services. It is better to have certainty on an overall national framework as to how our acute hospitals will be organised, rather than limping on depending on the latest six monthly review of a college, which can suddenly change the capacity of a given hospital and what it is doing.

Is the Minister aware that during the local election campaign, the Minister of State, Deputy Dick Roche, allowed a letter sent to him by the Minister to be published in the local press? In the letter he gave an undertaking that there would continue to be a full accident and emergency service on a 24 hour seven day a week basis at Loughlinstown hospital. This caused a certain amount of mystification as it is a flat contradiction of the recommendations of the Hanly report, which is supported by the Government. In the Hanly report, St. Columcille's Hospital is to become a local hospital that will no longer have a full 24 hour seven day a week accident and emergency service provided to the local community. Yet during an election campaign, the Minister put commitments in writing that the service is protected into the future. How does the Minister intend to square the circle? The Minister is now contradicting recommendations of the Hanly report, even though he accepted them.

There was a great deal of mischief during the election campaign and Deputies across the House were responsible and clearly took a decision, once the Hanly report was published, to milk it for electoral advantage.

They tried to but it backfired.

That was the agenda, irrespective of what the report said. It is a bit rich——

Will the Minister answer the question? We will run out of time. This is an old trick by the Minister.

I am answering the question. With all due respect to Deputy McManus, it is very rich of her to talk about pre-election promises and commitments. That is what she did.

There he goes again.

The Hanly report did not suggest that we close accident and emergency departments next week, next year or the year after. The framework is ten years at best. The report referred to the establishment of local implementation groups, which would have some flexibility in determining how services were to be organised locally.

Is the Minister trying to convince himself? He is not convincing anyone here.

We are starting with St. Columcille's. It is in a pilot area.

Exactly. A local implementation group has been established.

It has not met.

It has not met because there is an industrial dispute over medical indemnity as the Deputy knows. That is a fundamental issue.

I am not talking about implementation bodies.

I have been interrupted consistently since I gave my reply.

The Minister is in possession.

I am talking about the Minister's duplicity.

I could equally accuse the Deputy and the Labour Party of duplicity in the manner in which it conducted its electoral campaign, but I do not want to go down that road. We have established a local implementation group.

That is not the answer.

The fear was stoked up that accident and emergency departments would close next week, in six months, next year and the year after. They will not close and if local implementation——

The Minister's Cabinet colleague had to rush to the rescue in Nenagh hospital.

What of those that have already closed?

Did the Minister go to Nenagh?

The Minister is in possession.

I was down in Nenagh.

There was a bit of a dispute over that.

I was greeted by a group led by the Labour Party Senator there, who tried to make sure that I could make no announcement at all. There was almost a sense of disappointment that I went to Nenagh and that the Mid-western Health Board did what it did, as it upset the electoral game that was going on.

I have a question on St. Columcille's Hospital and the Minister is going all over the country. The Hanly report is committed to closing the accident and emergency department in a hospital in a pilot area. The Minister is claiming at the same time that he will keep it open. He cannot have it both ways.

The Chair has no control over the Minister's reply.

Deputy McManus gets upset and goes into high dudgeon. We have expanded services in almost every hospital in this country.

There were many people upset in my constituency and they showed it at the local election.

That is nonsense. I hope the Minister addresses the House to explain that claim.

I will address the House. Let us have a rational debate on this, one that we did not have during the local elections as the Opposition did not want one. A rational debate did not suit its purposes.

I wish to raise a point of order.

The Minister should check the facts.

The Deputy can check the report by Comhairle na nOspidéil. The tables show attendance in accident and emergency departments between midnight and eight o' clock in the morning. People have suggested to me that we need 21 senior consultants to cover two attendances per night. Is that what the Opposition is suggesting? If we propose some alternative, is that akin to closing the accident and emergency department? That is the kind of duplicity that has been articulated in recent months on this issue. I only want to improve the outcome for people.

The Minister's time is limited to one minute.

We come in here and ask the Minister questions that are relevant to our brief or to our constituency. I asked the Minister a question and he was not able or willing to answer it. The Minister is a disgrace. He says one thing at election time——

The Deputy should not play that game.

That is not a point of order. The Chair has called Deputy Olivia Mitchell. The Minister and Deputy McManus should resume their seats.

When the transcript of proceedings is available, we will see that the Minister has given a commitment that no accident and emergency department will close.

I want to ask a more immediate question about the Hanly report, which was originally set up to deal with the European working time directive. Does the Minister accept that Hanly has failed in that respect? On 1 August, hospitals all around the country will be completely unprepared to deal with it. Arrangements are being made to cancel some services and clinics and to hire GPs to work in the hospitals, although GPs themselves are an endangered species. Is Hanly basically dead on all fronts?

It was never the job of the Hanly group to negotiate the move to a 48 hour working week.

I beg the Minister's pardon, but it was.

It was set up to produce a configuration of how-——


If interruptions continue other Deputies will be deprived of the opportunity of putting their questions.

The Hanly group was established following the report on medical manpower a number of years ago. It was set up explicitly in a non-industrial relations and a non-political context, to start with a blank sheet and ask how hospital services should be organised in the Mid-West or the East Coast Area Health Board in the context of a 48 hour working week. They were explicitly told not to get involved in the industrial relations implications. That was a matter for the Government and the social partners, not the Hanly group. It is wrong to apportion blame to the Hanly group for any industrial relations difficulties in pursuing the 58 hour working week by next August, or the 48 hour working week by 2009. That is the factual position.

Does the Minister accept that services will be affected?

The bottom line is that services will not be affected as we approach the deadline.

I am here due to the frustration in sorting out patients in the Mayo general hospital and further afield. The Hanly report seems to get away from the real needs of the people. There has been a backtrack on the report regarding hospitals in Ennis and Nenagh. Originally it was supposed to be a nursing unit from nine o' clock in the morning to five o' clock in the evening, but we now hear about a GP on cover after that. Is the Minister stating that acute medical and surgical services by consultants around the clock will continue in Nenagh and Ennis?

When the second Hanly report is implemented in Mayo general hospital, we will lose the orthopaedic service we have due to a campaign I started ten years ago. We would not have that service now only for that campaign because the institute of orthopaedic surgeons did not want it. Vested interests are doing their damnedest to stop a campaign now. I sent in a request to the Mayo general hospital, which handles the urology service for Galway, for a gentleman with prostate cancer on 30 December 2003. To date that man has not been called. Ten new patients are seen every month by two surgeons who attend on alternate months. Is the Minister aware that that list dates back to 1996? The man concerned was put on that list last December. Is that acceptable?

Mayo General Hospital, Castlebar, needs a urologist but, under the Hanly report, will not get one. As regards orthopaedic services, people believed that one would hold what one had. We need to update our urology services. The Hanly report is a disaster. The distance from Mayo to Galway is virtually the same as from Galway to Dublin. Does the Minister expect people to travel to Galway for a 20-minute prostate operation? Is it acceptable that the man concerned, who has cancer, has been waiting since last December for a urology appointment?

The Deputy asked a number of questions. There has been no back-track on promises for Nenagh or Ennis hospitals. The Mid-Western Health Board, independently of me, had to respond quickly to communications from the Irish Medical Council on the continuation of services in the accident and emergency departments in Nenagh and Ennis hospitals.

It responded to public pressure.

The Hanly report is a ten-year document which did not suggest the closure or alteration next week or next year of the accident and emergency departments in Nenagh and Ennis hospitals. The Mid-Western Health Board submitted its model to the Department and the post was sanctioned. In the cold light of day, that is what happened. People put all types of spins on the matter prior to the election. However, I am not responsible for the outcome in that regard.

The Deputy is wrong to forecast doom and gloom in the context of the acute hospital review group considering acute hospital services across the country. The Government, led by Fianna Fáil with the Progressive Democrats, has invested significantly in Mayo General Hospital, an investment which has transformed the fabric of that hospital.

What about all those people awaiting services?

Order, please. I call Deputy Crawford to put his question.

I do not suggest there is not more to be done at Mayo General Hospital. However, at some stage in the process we must acknowledge, as I did on local radio recently, the enormous investment made in that hospital. The review group is examining issues such as peripherality. I have appointed a special planner and people from the regions to take on board the needs of people living in rural Ireland and its periphery. Hanly has not yet reported on the west. Deputy Cowley will be aware that the Fianna Fáil-Progressive Democrats Government has done more for the west in terms of adding medical services than any previous Government or coalition of parties.

The Chair has called Deputy Crawford.

It has improved areas such as cardiac surgery and radiotherapy.

Hanly denies any such services for Mayo.

The Deputy must face reality. I accept the Government has more to do.

I call Deputy Crawford to put his question.

Hanly denies that.

The Minister should listen to what is being said. He stated that it is wrong that anybody should have to wait six months to find out what is happening. However, that is what is happening in terms of Monaghan General Hospital, which is reviewed every six months.

The Minister did not visit the hospital prior to the recent local and European elections but visited it prior to the last general election. Accident and emergency services at Monaghan General Hospital closed during the first week in July 2002. During his visit, the Minister gave a commitment to five Oireachtas Members to do his best to have them reopened as quickly as possible. Is the Minister prepared to give to Monaghan General Hospital the same commitment he is making to the hospitals in Nenagh and Ennis? He has invested a great deal of money in the hospital in Castlebar.

I was delighted with Mr. Kevin Bonner's appointment to the review group. That group suggested that a minimum of €14 million was needed if the hospital was to reopen its accident and emergency service. However, the Minister provided only €2.7 million in that regard. Is that fair play to a Border area which suffered so much as a result of the Troubles? The Minister's representative, Mr. Paul Robinson, stated today on radio that he has overall responsibility in this area. The Minister can no longer place the blame on the health boards. Mr. Robinson stated that the Department has come a long way in terms of the development of hospital services in the eastern health board region.

Is the closure of Monaghan General Hospital to accident and emergency and many other services the way this Minister wants to go? Is he prepared to give a commitment to reopen services at Monaghan General Hospital, as he did in regard to the hospitals in Nenagh and Ennis?

The Deputy's question is based on the false premise that I——

It is based on facts.

——have responsibility in terms of what happens at the hospitals in Nenagh and Ennis. The health board came up with that proposal in terms of emergency care physicians in Ennis and Nenagh.

Is the Minister blaming health board members for that decision?

I am not placing the blame on them, I am stating the reality. This is not a question of placing blame. The health board looked at the problem innovatively in response to the Irish Medical Council which was threatening, in terms of communication to the board, to close accident and emergency services in Ennis and Nenagh. The board responded with its proposal which the Irish Medical Council accepted. That is the reality of the situation.

The North Eastern Health Board has drawn up proposals for Monaghan General Hospital, a matter of which I am sure the Deputy is aware. I urge Deputy Crawford and others to speak to the various interests in Monaghan with a view to getting people around the table. I understand the board recently produced a reasonable set of proposals. I met the Mid-Western Health Board and the medical board in Cavan, both of which urged that there be closer liaison between the two hospital campuses and that a set of proposals be tabled which could lead to constructive dialogue and engagement between the various parties with everybody signing off on the proposals to begin the journey onwards. Unfortunately there has been a lack of agreement between the parties involved. The degree of unwillingness of certain quarters to put their heads above the parapet and take risks in progressing some of the issues has held up progress.

The Deputy referred to the closure of on-call services at the hospital. Earlier I raised with Deputy Ó Caoláin the question of why the hospital originally went off-call — the Royal College of Anaesthesia undertook its own examination of services and came to the conclusion that they did not meet its standards. It pulled the rug on the continuation of on-call services at Monaghan General Hospital.

The Minister refused funding to bring the services up to standard.

We all know that but, unfortunately, what then happens is that political polemic takes over and we get more heat than light.

We must move on to the next question as the time for dealing with this question has elapsed.

That is what happened.

May I ask a brief supplementary, a Leas-Cheann Comhairle?

We have gone well beyond the 18 minutes allowed. We have gone way over the time. I ask the Minister to deal with Question No. 10.

I would like to state why Monaghan General Hospital is off-call. The Minister's proposal provides for cover from 9 a.m. to 5 p.m.

It involves 24-hour medical cover and includes a mechanism by which we can explore the issue further. If we could get people together, we would make progress.

Will the Minister give to Monaghan General Hospital the same commitment he has given to the hospitals in Ennis and Nenagh?

We must move on. The Chair has ruled that we will discuss Question No. 10.

I alone cannot sort out the problem. People in Monaghan have to take on some of the responsibility.

There are no boards to blame now.

I ask the Minister to deal with Question No. 10.

It is about time the Minister faced up to his responsibilities.

No, the Minister has not.

I have been very facilitative in terms of trying to create solutions.

No, the Minister has not.

I will say no more on the matter.

There is no point.

Deputy Crawford knows the answer as well as anybody else. Unfortunately, the political polemic has taken over.

We must move on to Question No. 10.

The Deputy knows it was the Royal College of Anaesthesia which dealt with the matter and it had a legitimate right to do so. Such issues require an imaginative response.

The Chair has called for Question No. 10 to be dealt with.

Hospitals Building Programme.

Dan Neville


10 Mr. Neville asked the Minister for Health and Children his views on the increased number of private hospitals built around the country; if he intends to give direction and leadership to this development through formal public private partnerships; and if he will make a statement on the matter. [18495/04]

One of the key goals of the Government's health strategy is to improve access for public patients through a significant increase in acute hospital bed capacity. The Government indicated in the health strategy that it was committed to exploring fully the scope for the private sector to provide some of the additional capacity required in the acute hospital sector. Towards this end, my Department has developed close contacts with the Independent Hospitals Association of Ireland.

For its part, the national treatment purchase fund, NTPF, purchases procedures from private hospitals in Ireland. Where it is not possible to treat patients within a reasonable period in public hospitals arrangements are made to refer the public patients for treatment in private hospitals having regard to quality, availability and cost. The majority of procedures funded by the NTPF to date have been carried out in private hospitals in Ireland. To date the NTPF has arranged treatment for some 15,000 patients who have been waiting longest on waiting lists.

The Minister for Finance has moved to promote investment in the private hospital sector. Section 64 of the Finance Act 2001 as amended by section 32 of the Finance Act 2002 provides for significant tax allowances for the construction or refurbishment of buildings used as private hospital facilities under conditions which will also benefit public patients. I expect that the health services executive, when established on a statutory basis, will promote a strategic partnership with the private hospital sector with the objective of securing enhanced treatment options for public patients.

I accept the Minister's comments regarding the purchase of services in the private sector. However, I am worried about the emergence of a large number of private hospitals in anad hoc, unplanned and unco-ordinated manner. That is not an optimum use of resources from anyone’s point of view. Does the Minister accept that those hospitals are emerging in response to market forces with people demanding services not available to them from the State in the quantity required or in any sort of timely manner? If the private sector can provide those services, why does the State not work in tandem with it, commissioning services from it so that there is some sort of co-ordination in the planning of hospitals around the country?

At a recent meeting of the Joint Committee on Health and Children, the Minister refused to give any kind of commitment to purchase radiotherapy services in Waterford, although there is a clear demand for them and a lack of capacity in the country as a whole. It defies understanding that we are not availing of the capacity provided by the private sector, given that incentives are being provided by the Department of Finance, as the Minister has said.

There is a one-minute time limit.

The direction in which we are going is leading to a duplication of resources. It is completely wasteful and we will end up with a far less equitable service. God knows the service lacks equity as it is. If we go down this route, the result will be that only those who can pay will have access to services.

Tax incentives and the treatment purchase fund have proved effective mechanisms to make use of additional private sector capacity in the system. They represent a complementary approach. For a whole range of procedures and specialties, there is no reason that some of the capacity demands should not be met by private sector hospitals being established, especially for day surgery, which has been the main driver for productivity increases in the acute hospital sector to date. There is a great deal of potential for increased capacity in day case procedures and surgical activities which may be funded through the treatment purchase fund. Some 50% of the population is now insured under private health insurance and the market can take a degree of additional capacity.

For the more major, supraregional specialties such as cardiac or neural surgery or radiotherapy, there is a need for synergy between the State and private sectors. However, the State sector has set out its stall. The Government has tried to build up capacity in radiotherapy, which we know was lacking historically. We had only one major centre at St. Luke's and two machines in Cork. That was the sum total of our radiotherapy infrastructure. Some years ago we gave a commitment to set up a radiotherapy unit in Galway. That was long before any private hospital facility was available and that is now almost ready. The building has been completed and the equipment is coming on stream. Staff are now being recruited.

What is the Minister's view on the fact that money is being lost to the Exchequer through the tax breaks the Minister for Finance, Deputy McCreevy, gave to encourage the provision of private day hospitals as a result of his being lobbied by a constituent? Had it been retained that money would have been more than enough to pay for the opening of almost €500 million worth of public facilities that had been closed or cannot be opened because money has not been forthcoming from the Cabinet. Does the Minister not think it bad value that we are losing money from our taxation system to build private day hospitals yet we cannot commission public facilities which are already built because not enough funding is being provided by the Minister for Finance? Such public facilities might be fully functioning if a relatively modest amount of money had been retained.

The Deputy is assuming the funding that went to hospitals through the tax relief scheme would not have gone elsewhere. We have a range of tax relief schemes of which people avail. Increasingly they are investing abroad in the global economy. Therefore, it is always important that one has mechanisms to attract and retain capital for domestic investment projects.

In Kildare.

There is no question that we have expanded the public service a great deal in the past five years. We have opened many new units and have several ready to open. Many were equipped but could not be opened until towards the end of the year. The Government is currently dealing with how to commission and open those units over the next two years, as they come on stream. There is an open question about the level of revenue. In theory, if one abolished the tax relief, some money should come back into the Exchequer but it could go elsewhere.

The Minister did not mention that some facilities have been waiting to be opened since last June which is a year ago. We are not talking about facilities that will come on stream by the end of this year. I am asking about facilities that are due to be opened or should have been opened many months ago but have not been opened.

That is the result of ongoing discussions regarding the opening and commissioning of those buildings, including the provision of equipment. The equipment is being provided in several of the units. There are issues with the other units to do with finance and the employment ceiling.

I am amazed that people have marched for a radiotherapy unit for the south-east. There were four massive marches and the Government was reduced to one Progressive Democrats and one Fianna Fáil member on Waterford City Council. Surely it will get the message. People are marching not to bring down the Government but for basic services. A radiotherapy unit in the grounds of Waterford Regional Hospital would provide the missing modality. As well as surgery and chemotherapy, it would provide radiotherapy. For less than the travel costs of transporting people where they do not wish to go, those facilities could be provided in Waterford. I ask the Minister how he can justify not providing that.

I also wonder about the money put into the treatment purchase fund. There is an old saying that if one gives a man a fish, one will feed him for a day, whereas, if one teaches him to fish, one will feed him for life. Where there are no consultants, there are massive waiting lists. For example, in Mayo General Hospital, 1,000 people are waiting for urology services and 1,500 for orthopaedics. What is the point in taking those people under the treatment purchase fund and paying people to carry out the work when one could open those facilities and have a local service without such long waiting lists? That quick-fix solution will not work. If one considers the numbers there and the treatment purchase fund itself, one sees that those people have been waiting on that urology list since 1996 which is eight and a half years. That is a long time to wait for the much talked about treatment purchase fund. What good is that to those 2,000 urology patients in Mayo General Hospital or the 1,500 orthopaedic patients who have been waiting for four years?

I do not know whether the Deputy is for or against the treatment purchase fund. Perhaps he should ask the 15,000 people who have had operations carried out under it for their views. We have done so and there is almost 96% approval.

I am amazed at the Minister.

One can do both and the waiting times have come down.

What about those still waiting?

I listed the hospitals in an earlier reply. In over ten hospitals, waiting lists are down to three months. In another ten, waiting lists are down to six months. Regarding specific issues, specialties and health boards, some issues might have to be resolved.

The Minister is using the wrong list.

No, I am using the treatment purchase fund list.

I call Deputy Crawford.

Some 15,000 procedures were carried out.

We have run over the time on this question.

How long will patients wait?

Is the Deputy for or against the fund?

They must wait eight years.

No one will ever have to wait for eight years under the treatment purchase fund. The wait is down to three months in some hospitals and six months in others.

Once they get on the list.

Allow Deputy Crawford to ask a brief question.

I will send them out to the Deputy's area next. He came in here one day and talked about 12 months. Rome was not built in a day.

The Minister forgets about one list.

I do not forget but let us get one list sorted out first.

Deputy Crawford has the floor. I ask Deputy Cowley to resume his seat.

A man will have to wait another eight years before he is treated under the treatment purchase fund.

Is the Minister aware that before Monaghan General Hospital was taken off call, it was serving patients from Northern Ireland under a similar fund? Is it good value for money to have a hospital such as Monaghan sitting less than fully utilised while buying treatment outside the country?

The treatment is good value for money. The figures have been done on that in terms of the costs of procedures and so forth.

The Minister refused to answer me before when I asked——

The Government invested in a new modular theatre for Monaghan Hospital. I said on countless occasions that, while I have no difficulty in increasing surgical activity there, it is not all one-way traffic. It is about time that the stakeholders in the area and the hospital got together and moved on. We have not moved on over the past two years as people found proposals unacceptable and refused even to meet on that basis. That is no way to progress the issue. I have given €2.7 million because I asked the heath board to advise me of the immediate requirement of Monaghan Hospital. I gave it on that basis having asked the health board to inform me what could be done.

While we will do more in the hospital, in terms of the organisation of the services, Cavan and Monaghan must work together. This notion that they are both operating in splendid isolation cannot be sustained. Deputy Crawford needs to tell people the truth about that. If we work in that way, we can make progress. If politics were to be taken out of the matter for about six months, something might be sorted out. I say that genuinely.

Did I not try to take it out of it?

The Deputy did and I give him credit for that.

Substance Misuse.

Kathleen Lynch


11 Ms Lynch asked the Minister for Health and Children his views on the report of the Oireachtas Joint Committee on Health and Children on alcohol misuse by young persons; and if he will make a statement on the matter. [18359/04]

Dan Boyle


29 Mr. Boyle asked the Minister for Health and Children the steps he intends to take to implement the recommendations of the Oireachtas Joint Committee on Health and Children on alcohol abuse; and if he will make a statement on the matter. [18486/04]

I propose to take Questions Nos. 11 and 29 together.

I welcome the publication of this report and thank the members of the Oireachtas Joint Committee on Health and Children for its time and efforts in its preparation. I have outlined my concerns on the matter of alcohol abuse and on the measures being taken to address this issue in the House on a number of occasions. The strategic focus of my Department as regards alcohol abuse is on the implementation of the recommendations contained in the interim report of the strategic task force on alcohol and on the interdepartmental group established to progress its recommendations.

Progress has been made in a number of areas since the publication of the interim report of the task force. In the December 2002 budget, excise duty on spirits was increased. As a result, spirits sales significantly decreased, confirming the international research that increased taxes influence alcohol consumption. It is expected that this decrease in consumption will contribute towards a decrease in alcohol-related harm in the medium term.

A number of measures in the Intoxicating Liquor Act 2003 address issues such as serving alcohol to intoxicated customers and so forth. The task force recommended that legislation be introduced to reduce the exposure of children and adolescents to alcohol marketing. The heads of a Bill have been agreed by Government and work is ongoing on its preparation.

As regards the recommendations calling for research and systematic data collection, my Department has undertaken extensive research on alcohol-related issues. The task force is finalising a second report which will bring forward a further set of recommendations aimed at tackling this problem. However, I have requested officials from my Department to review the report of the Oireachtas Joint Committee on Health and Children and to identify areas where progress can be made.

I thank the Minister for his reply and wish to ask him about specific recommendations made in this report. One relates to the increase in excise duty on alcopops. The Minister has made the point that increasing excise duty has an impact on consumption. Does he agree with the committee's findings that the excise duty on these products should be increased significantly? In light of his pending legislation, does he agree that there should be an end to alcohol advertising and sports sponsorship? Is he comfortable, for example, with the idea that the GAA accepts so much sponsorship from companies that promote alcohol to such a degree? Is this something he can live with or does he intend to deal with this issue of advertising and sponsorship effectively in his legislation?

In terms of taxation, that in the first instance is a matter for the Minister for Finance.

Does the Minister have an opinion?

We submit representations on an annual basis for increased excise duty on alcohol, especially spirits. As I said in my reply, they were accepted and there was a significant increase in the duty on spirits and alcopops in the budget before last. The reduction in alcopop consumption was dramatic in the aftermath of that budget increase. We took action on that and it resulted in a decline in the sale of spirits in the aftermath of that budget increase.

In terms of the advertising issue, I suspect we cannot have a total ban. This is a matter we will explore with the European Commission. Our initial legislative response is to examine advertising in so far as it is directed at young people and children and in so far as they are exposed to wrong advertisements in terms of content. The legislation will affect both the content and timing of the advertisements. These are issues we are examining. It should be borne in mind, however, and I have some experience of this in terms of the tobacco legislation, that the Internal Market pillar of the European Union treaty is strong and not easily circumvented in terms of a total ban on the advertisement of a product such as alcohol. It could be argued, for instance, that one drink is not bad for a person but four or five are. That is the difficulty. These are matters we are exploring with the Office of the Attorney General. I do not believe a total ban is possible.

In terms of sponsorship, almost every sport is affected. It is wrong to single out any one sport as regards sponsorship because nearly all major sports have alcohol companies as major sponsors. One can go from the Heineken Cup to the Amstel Champions League to Guinness and the GAA and so on in terms of major sport sponsorship. I am not comfortable with that. My views have been placed on record on regular occasions. Again, we want to concentrate on preventing sponsorship of under age activities and activities in which young people engage. If we can achieve that on the advertising and sponsorship fronts, an important step forward will have been taken.

We have commissioned a significant degree of research with general practitioners and with consultants in terms of the accident and emergency situation as regards alcohol issues. It is a matter of getting a better analysis of what is happening among the general population, including those who present at hospitals or visit their GPs. That research will inform further policy developments. We have succeeded in getting the governing bodies of colleges to change their policies and have more proactive alcohol controls on the campuses of many universities. One clear example was where a drinks company sponsored young students to promote, sell and give free alcohol to societies and guilds. That practice has been stopped on our university campuses. There has been an improvement in awareness and so on. We will study the recommendations of the committee and will be pleased to discuss them further.

Most of the actions to which the Minister has pointed are reactive. These include the increase in excise duties, advertising charges, identity cards and a raft of other measures that are reactive. I wonder if he has given any consideration to proactive measures. The Minister for Finance has provided tax breaks to a number of sectors, including for the provision of multi-storey car parks and holiday homes to name just a couple. He cannot inform us of the actual cost these represent to the Exchequer and it would be difficult to measure their social contribution. There would, however, be no question of the social value and contribution of tax incentives for the provision of alternative leisure pursuit opportunities for young people.

I invite the Minister to examine this area as regards young people in general and not just those who are under age. It is highlighted repeatedly that there are limited outlets for young people within great swathes of this State. Recommendations to remedy this would include alternative evening leisure pursuits and non-alcohol bar opportunities so that young people would have a choice. I do not believe it will happen just by expecting the economic forces to create it, even if the Progressive Democrats might recommend it. It will need encouragement, direction and support. What is the Minister's response to those points?

I agree there is a need for a proactive approach. We are adopting such an approach. I support the No Name Club, an organisation which engages in the activities mentioned by the Deputy. It is led by the great former Kilkenny hurler, Eddie Keher. The club has set up branches across the country and is quite strong in some counties. We have helped it to appoint permanent co-ordinators. It organises activities for young people, with no alcohol as the key theme, and is working quite well. We need to support such organisations on an ongoing basis. We also need to support abstinence movements which go into schools to educate young people about alcohol, etc.

In the educational context, the Walk Tall programme in primary schools has been proactive in introducing a well thought-out and well researched multidisciplinary programme. It introduces children to the benefits of developing strong character and independence of thought and mind. Above all, it teaches children about self-esteem and trust so they can have confidence in themselves. This is particularly important when children are threatened or presented in an environment of peer pressure, with alcohol or other addictive substances.

The lottery grant has been superb in bringing about a transformation in sports facilities throughout the country. We cannot keep saying for the next 20 years that things are as bad as they always were, as that is not the case.

Things are as bad as ever in some counties.

There are far more sports halls in parishes than was previously the case.

What happens when people leave the sports halls?

The drug task forces have been quite useful in some areas of significant economic disadvantage.

People need somewhere to go as an alternative.

The task forces have undertaken important steps such as the development of alcohol-free café facilities, etc.

As a member of the Joint Committee on Health and Children I am biased but I think the report we have produced is very good. The €2 billion that is being wasted every year could be saved if alcohol was used properly. The Minister knows that such funds could be put to good use in many hospitals. The moneys could be used to open the 26 elderly assessment beds which have been lying idle in Mayo General Hospital since 2001, or to do something about the 14 trolleys that are downstairs for older people who are not fit to go to nursing homes. No beds are available for such people who have been sent in by their GPs.

The money could be used at Beaumont Hospital.

The Minister did not come to the Joint Committee on Health and Children to discuss the radiotherapy report, even though he had promised to do so. He kept putting it off.

That is not true.

He announced a week in advance that he would not come to the meeting.

We are talking about alcohol.

The Minister did not turn up for the radiotherapy meeting. He gave notice a week in advance that he would not meet the joint committee to speak about the radiotherapy report.

We are not talking about radiotherapy.

I mention the Minister's failure to attend as a member of the committee that produced the report under discussion. The Minister will agree that the report on alcohol misuse has some good elements. I was disappointed that its central recommendation that there should be a ban on alcohol advertising within two years was completely rejected.

It was rejected by the Government.

No, the Deputy is wrong.

A statement was issued saying that it was not a practical situation.

I did not issue any statement.

It was in the media. I hope the Minister will state that he favours a total ban on alcohol advertising within two years. It would be a wonderful thing. Is the Minister prepared to allocate the necessary resources to ensure the laws that are in place to tackle alcohol misuse are implemented? I refer to the proposal to recruit 2,000 additional gardaí, for example. The recruitment of so many extra gardaí would do wonders for the situation.

The Deputy should have ran for Europe.

One cannot even have a smoke.

Sport is promoted in this country from a health perspective. The Minister constantly talks about the promotion of sport, which we read about in the media. I have doubts about the merits of a total prohibition on alcohol advertising. I would like to make a point about the sponsorship of sporting activities. Would it not be fair to signal to organisations which depend on alcohol sponsorship that the days of such sponsorship are coming to an end? If one is to speak about the promotion of sport among young people, it is hypocritical to allow sport to be associated with alcohol.

I wish to discuss the issue of banning this and that. I think Deputy Mitchell is right to signal that the legality of what we do in respect of advertising and sponsorship has to be teased out properly before we make a move in that regard. While it is the case that one of my spokespersons pointed out on my behalf the difficulties of the committee's blanket absolute recommendation that all alcohol advertising be banned, I remind Deputy Cowley that I did not reject anything. There are hurdles to be jumped in terms of EU law. I welcomed the joint committee's report.

What about those who are targeting children?

I am working on that. We are drafting legislation on advertising and sponsorship in so far as it applies to children and young people. We think we are on a strong footing on public health grounds.

Written Answers follow Adjournment Debate.