Dáil Éireann debate -
Friday, 23 Feb 2007

Vol. 632 No. 3

Medical Practitioners Bill 2007: Second Stage.

Minister for Health and Children (Ms Harney)

I move: "That the Bill be now read a Second Time."

It has been argued that trust, rather than deference, authority, control or contracts, is the fundamental glue that binds people together in our modern, educated and liberal society. In many aspects of the new and better Ireland we are creating and experiencing the old glue of deference to institutions and submission to authority is being removed. Not only has such behaviour lost its binding force, but it is no longer appropriate to the type of society we want to have. It is important that we replace one binding force with another based on mutual respect, accountability and agreed standards. The new structures we are developing need to support relationships of trust.

Few relationships require more trust than the relationship between a patient and a doctor. Like all relationships within society, the personal relationship between patients and doctors and the more general relationship between the public and the medical profession have changed in the past 30 years. It would be wholly wrong and counterproductive to allow ourselves to facilitate the development of an adversarial doctor-patient relationship based on contracts, threats of litigation, mutual fear and suspicion. The role of the Government and the legislators in this Parliament is to take a better route by putting in place structures, laws and processes that support a real and respectful relationship of trust between the public and the medical profession. The development of such a relationship is the fundamental purpose of this legislation.

The Medical Practitioners Bill 2007 updates and modernises the regulation of medical practitioners by the Medical Council. It is acknowledged that the current legislative framework which is almost 30 years old needs to be revised. The Health and Social Care Professionals Act 2005 has been agreed and further legislation governing pharmacists, nurses and midwives will be considered in the near future. Therefore, the Bill before the House is part of a set of legislation aimed at enhancing patient safety, which is at the heart of the health reform agenda, and the accountability of health professionals.

The Bill has been the subject of extensive consultation and consideration. When I published the draft heads in 2006, I was pleased that many organisations and individuals responded with comments on the proposals. A total of 58 submissions were received from members of the public, patient groups, individual doctors and their representative organisations, the third level sector, medical specialist training bodies, Departments, State agencies and other interests. In addition to that consultation process, the Medical Council and other bodies organised seminars to allow the public to debate and identify the key issues which were to be addressed. As the Minister for Health and Children, I am pleased to bring this much needed legislation to the House.

The need to act decisively is more evident than ever following the publication of the reports of various health care inquiries, including the inquiry into events at Our Lady of Lourdes Hospital in Drogheda. The Bill is consistent with the Government's commitment, as outlined in the health strategy, to strengthen and expand the provisions for the statutory registration of health professionals, including doctors. If we are to maintain the trust of patients in the doctors who treat them, we need to demonstrate and maintain quality at all levels. Patients want to know that the service they receive from doctors is based on the evidence of best practice and meets the highest standards. Improving quality involves implementing internationally recognised evidence-based guidelines and protocols and ensuring professionals engage in ongoing education and commitment. The maintenance of trust requires that deficiencies in practice are identified at the earliest possible stage, corrective actions are taken and future progress is monitored. If we are to put people first, we should ensure patients are given more influence and responsibility.

One of the priorities of this legislation is to strengthen and clarify accountability. In April 2006 the Department of Health and Children issued a framework for corporate and financial governance to all statutory bodies, including regulatory bodies, which operate under its aegis. The provisions of the legislation are in line with the Department's framework. The governance procedures and arrangements outlined in the Bill are accepted as normal by public bodies across the wider public sector. The various bodies under the aegis of the Department will have to produce statements of strategy, annual business plans and other documents. The Medical Council's annual accounts will be audited by the Office of the Comptroller and Auditor General. The laying of such documents before the Oireachtas will give the public a chance to see how the Medical Council and other bodies are fulfilling their statutory delegated functions. Some argue that these provisions increase the potential for ministerial or political interference in the workings of the council, but that is not the case. The provisions are about openness, accountability and responsibility which should be embraced by any statutory body undertaking public functions in a modern and democratic society, rather than political interference.

I do not doubt that doctors are working in a much more demanding environment than they previously did. While evidence-based guidelines, tighter professional standards and increased patient rights and expectations are welcome and necessary, they add to the demands faced by doctors. Such forms of accountability will be strengthened by these legislative proposals. This legislation will ensure members of the public are guided, protected and informed in order that they can be confident that doctors are properly qualified, competent and fit to practise on an ongoing basis. Importantly, it will support doctors by allowing them to demonstrate the high standards they strive to maintain on an ongoing basis. It will increase the trust doctors have in the profession and their continuing personal and professional competence and strengthen the confidence of the general public in those who treat them.

The principles contained in the Government White Paper, Regulating Better, have informed the new system of regulating the medical profession. Those who drafted the Bill considered the requirement that consumers should be placed at the top of the policy agenda. The regulation of any profession is enhanced by opening its systems to the new ideas of people who are not members of the profession. In providing for the membership of the Medical Council I have been conscious that the regulation of doctors cannot solely be the remit of doctors themselves with minimal input from patients and other professionals. There are many interested parties and stakeholders who have an important role to play in the regulation of the profession, including patients, employers and other caring professionals who work alongside doctors on a daily basis. However, in opening up the system of regulation it is necessary to take a broader view.

Education is key to quality medical practice, as is research. I have endeavoured to ensure the third level sector, as well as those representing the broader science and humanities areas, are represented. I have also included a representative from the Health Information and Quality Authority. The Medical Council's functions under the legislation will be significant in setting and monitoring standards and quality and this new membership will only serve to enhance that role. The council exists to regulate the medical profession, not to represent the interests of that profession or any constituent group within it. The public interest comes first and everything in the Bill, including the membership of the council, is designed with that in mind.

While it has always been normal practice for medical practitioners to register with the Medical Council, some isolated incidences of non-compliance have occurred during the years. Consequently, for the first time the legislation imposes a clear requirement on all medical practitioners to register with the Medical Council before engaging in the practice of medicine and includes offences with significant penalties attached for breaches of these requirements. The Bill empowers the Minister for Health and Children to designate titles for the sole use of those registered medical practitioners or particular classes of registered medical practitioners on the basis of specific criteria. Such criteria include the potential for harm to the public, as well as the existence of a defined scope of practice. This will help to guide members of the public in their dealings with medical practitioners as to the level of competence of the medical practitioner responsible for their care.

Registration procedures will be more streamlined for all. A new register, including divisions for those undertaking specialist training, those with specialist qualifications and those undertaking a more general scope of practice, will be clear. The system of temporary registration for doctors from outside the European Union will be discontinued, in order to allow for those doctors who have given such significant support to our health service to enjoy the same benefits of registration as their Irish and EU-qualified colleagues and peers. For the first time, doctors with suitable non-EU specialist qualifications will be able to gain direct access to specialist registration. Provisions are also included to help doctors holding refugee status to become registered.

Legal registration and the consequent right to practise a profession confer a professional privilege which demands the adoption of a consistent and ongoing high standard of professional conduct for each registered medical practitioner. We are all aware, however, that sometimes things go wrong. Therefore, a comprehensive fitness to practise structure which can act quickly and appropriately in such circumstances is required. A central feature of the Bill is the adoption of a contemporary approach to fitness to practise issues. In this modern and contemporary context, the Bill provides for a number of routes for complaints and concerns to be addressed, rather than just the existing complex legal process of a fitness to practise inquiry. A mediation process for less serious complaints by agreement of the parties concerned is provided for. The Bill also includes a means for a complaint to be referred to the statutory complaints process established under the Health Act 2004, or to the procedures of another body or authority, or for the referral of a matter to competence assurance procedures, where appropriate.

Openness and transparency in procedures must be demonstrated. During the years it has been of significant concern that fitness to practise procedures are conducted behind closed doors and that the Medical Council is precluded by the existing legislation from disclosing any details regarding the conduct of inquiries. Arising from these concerns, I have decided that fitness to practise inquiries will be held in public. In order to allow for individual situations where this may not be appropriate, provision is included for the fitness to practise committee to decide to hold all or part of an inquiry in private, depending on the circumstances. Any such decision must be taken as a result of a request by a witness, including the complainant or the doctor concerned, to hold proceedings in private. The committee and the council are obliged by legislation to undertake their functions in the public interest. Any decision to hold proceedings in private must satisfy this public interest test.

As a demonstration of the commitment to the support of medical practitioners, a health committee is provided for in order to assist individuals with health issues. However, this procedure should only be used where the committee and the council are satisfied that this can be achieved without risk of harm to patients.

The support of doctors and the protection of patients also require the modernisation of medical education and training processes. Provisions on medical education and training have been significantly developed over those included in the 1978 Act. The overall approach is consistent with the broad thrust of the recommendations of the Fottrell and Buttimer reports on medical education and training at basic and specialist level. As recommended by the Prospectus report entitled, Audit of Structures and Functions in the Health System, streamlining of health service agencies will be progressed further by the dissolution of the Postgraduate Medical and Dental Board established under the 1978 Medical Practitioners Act. The Health Service Executive will assume a significant role in the development and co-ordination of medical education and training, in co-operation with the Medical Council and the medical specialist training bodies. The Medical Council's role in education and training has been significantly redrafted to provide more clarity on the requirement to set standards and develop guidelines to assist all.

This country has bitter experience of what can happen when appropriate systems and supports for the maintenance of ongoing competence and high standards in medical practice are absent. Isolation of medical practitioners, even when working in a hospital setting, can lead to outmoded and outdated practice being continued, to the detriment of and, in some cases, damage to patients. The Lourdes Hospital inquiry report brought such matters into sharp focus. I am determined that we will learn and move on from these matters. As a result, Judge Maureen Harding-Clarke's recommendations have had a strong influence on the drafting of this legislation. Her recommendations for the reform of education and training and ongoing competence assurance structures have been studied and will be implemented in a number of ways.

While we can never guarantee that mistakes will not happen again, this legislation provides an important opportunity to learn from the past and put in place necessary elements to limit the impact of mistakes in the future. In this regard, I consider it significant and imperative that all employers of medical practitioners, not least the Health Service Executive, have been given statutory responsibilities with regard to the maintenance of the professional competence of qualified medical practitioners. The Medical Council will have a leadership role in ensuring doctors comply with what is a new legal statutory requirement for them to maintain their professional competence on an ongoing basis. This will require much commitment from all parties, individual doctors and the teams within which they work, their employers, the medical specialist training bodies and the Medical Council as the regulating competent authority of the profession.

Recognising the importance of these matters, I have ensured the Bill contains provisions which will allow funding for the administration of competence assurance structures and other matters to be provided for the Medical Council. While the council will continue to be funded in the main by the medical profession through the payment of registration fees, I recognise that the State must also share the burden of the costs involved in such issues. There is no doubt that regulation imposes economic costs. However, I consider that these costs will be offset in this case by such benefits as the quality assurance of the competence of medical practitioners; the addressing of public information deficits; strong public representation; the modernisation of the statutory registration and fitness to practise processes; and the bridging of shortfalls in education and training levels.

Deputies have been provided with an explanatory memorandum which sets out in more detail the content of the Bill. I wish to highlight some key elements of the new system of regulation.

Part 1 includes standard provisions relating to commencement, interpretation of terms and repeals. Part 2 section 6 sets out for the first time a statutory objective of the council, which is "to protect the public by promoting and better ensuring high standards of professional conduct and professional education, training and competence among registered medical practitioners".

Section 7 outlines in clear terms the functions of the council which relate to the registration of medical practitioners, the regulation of their education and training at all levels and matters relating to the recognition of qualifications of medical practitioners. The council's functions also include the setting of standards of practice, including advertising, and ethical guidance for medical practitioners, the handling of complaints and inquiries relating to the conduct of medical practitioners, and proactively advising the public on all matters of general interest relating to the functions of the council, its area of expertise and the practice of medicine.

Section 9 provides for the Minister to give general policy directions to the council concerning its functions, but this specifically excludes matters relating to ethical guidance, complaints, inquiries and sanctions. The Medical Council was established in 1978 as a statutory body, subject to oversight by the Minister for Health and Children. It cannot and does not operate in an independent way, despite the views expressed by some. It is important that it has regard to public policy, particularly with regard to areas such as medical education and training.

Section 11 outlines the council's power to make rules and details a range of matters for which the council may make such rules. Rules will be subject to publication in draft form for public comment and all rules of the council must be laid before the Houses of the Oireachtas.

Part 3 provides for the council to prepare a statement of strategy, an annual business plan and an annual report on its activities. A modern public body with powers and responsibilities delegated to it must demonstrate to the public how it plans to undertake its statutory functions and account for its progress and achievements in this regard. Part 4 includes provisions for the membership, committees and staff of the Medical Council.

Section 17 outlines the membership of the Medical Council, which shall continue to consist of 25 members. The membership has been significantly rebalanced. As I have consistently stated, it is my belief that public confidence in the Medical Council requires that a majority of its members should not be doctors. These members will represent a wide variety of interests and experience.

Section 20 outlines the council's power to establish committees to perform any of its functions and provides that persons who are not members of the council may be included in the membership of committees. This will allow all committees of the council to co-opt additional expertise, both medical and non-medical, as required.

The various sections in Part 5 of the Bill deal with the accounts and finances of the Medical Council. The council will continue to be funded by fees paid by the medical profession, but the Minister may provide financial assistance for the administration of competence assurance or other matters with the approval of the Minister for Finance.

Part 6 of the Bill is concerned with a new system of registration of medical practitioners. Sections 37 and 38 are new provisions which make clear that medical practitioners who wish to practise medicine in the State must be registered, unless acting lawfully in another professional capacity.

Sections 39 and 40 provide for the Minister to designate titles which are reserved for use by certain medical practitioners. This could cover, for example, the use of the title "specialist". Offences and significant penalties for breaches of registration requirements are included in this part of the Bill. Section 43 establishes the register of medical practitioners to consist of four divisions: the general division, the specialist division, the trainee specialist division and the visiting EEA practitioners division.

Sections 46 to 49, inclusive, provide for registration in the different divisions of the register. Provisions are included to allow doctors who hold refugee status and who have had difficulties in the past providing the necessary documentation to prove they are in good standing to become registered and to work as doctors in this country. I am pleased that medical practitioners with suitable non-EU specialist qualifications will, for the first time, be able to gain direct access to specialist registration. This will open the door for many senior, qualified international doctors to come to work in Ireland and use their considerable talents and experience for the benefit of Irish patients.

Section 50 concerns the transposition of relevant articles of Directive 2005/36/EC on the recognition of qualifications. This section relates to temporary and occasional provision of medical services by medical practitioners who are already lawfully registered or legally established in another member state.

Part 7 relates to complaints regarding medical practitioners and the procedures for the handling of complaints. The sections outline the expanded grounds for complaint, what actions the new preliminary proceedings committee can and must take, and includes new provisions governing mediation, referral to other authorities and keeping the complainant informed. The committee may appoint persons to assist investigations, if required. The provision allowing for an emergency application to the High Court for an immediate suspension in the public interest is continued.

Part 8 relates to procedures to be followed by the fitness to practise committee in conducting inquiries, once a prima facie case has been established under Part 7. The fitness to practise committee must have a majority of persons who are not medical practitioners. It covers the conduct of the hearing, which generally will be held in public, the powers and protections relating to witnesses and evidence and the report to be given to the council following the completion of an inquiry.

Part 9 relates to the imposition of sanctions by the Medical Council following a finding against a medical practitioner. The role of the High Court in the confirmation of sanctions imposed is maintained and provision is made for rights of appeal to the High Court. The council will be required to notify various stakeholders regarding sanctions imposed, including publication, in the public interest, of such matters.

Part 10 provides for the roles of the Medical Council and the Health Service Executive with regard to the education and training of medical students, interns and medical practitioners undertaking specialist medical training. The provisions of this Part are influenced by the recommendations of the Fottrell and Buttimer reports on medical education and training. It is clear that medical education and training must be undertaken in partnership by the various stakeholders and this part of the Bill emphasises that requirement for co-operation and consultation.

The HSE's new role is also influenced by the dissolution of the Postgraduate Medical and Dental Board under Part 12. The HSE will now be responsible for the co-ordination and development, including funding matters, of medical and dental specialist education and training.

The role of the Medical Council was outlined in a minimalist fashion under the Medical Practitioners Act 1978. Sections 87 and 88 now outline in clear terms the role of the council in setting standards and guidelines on medical education and training, and monitoring adherence to those guidelines. The council will continue to be the body which inspects and approves medical training programmes and institutions at basic, intern and specialist level, and to approve medical qualifications. The Medical Council will also continue to act as the competent authority for the recognition of EU medical qualifications. Relevant articles of Directive 2005/36/EC on the recognition of qualifications are transposed in this regard.

Part 11 is new to the system of regulation of medical practitioners as it outlines new requirements for the maintenance of professional competence of registered medical practitioners. The Medical Council, the HSE and other employers and individual medical practitioners are given statutory responsibilities by this part. The Medical Council must satisfy itself as to the ongoing maintenance of professional competence of registered medical practitioners and must establish a scheme or schemes for this purpose. An appropriate link to fitness to practise procedures is included, where concerns arise as a result of a doctor's participation in the scheme.

Part 12 provides for the dissolution of the Postgraduate Medical and Dental Board and the transfer of its staff, assets and liabilities to the HSE.

Part 13 provides for a number of miscellaneous matters, including a power for the Medical Council to investigate unregistered persons and new provisions regarding licensing for the practice of anatomy. The opportunity is now being taken to modernise provisions dating back to 1832, by giving the council an appropriate anatomy inspection and licensing role.

Schedule 1 outlines the enactments and statutory instruments to be repealed or revoked. Schedule 2 provides for the rules on membership, tenure of office and meetings of the Medical Council, which shall continue to hold office for five years.

As I said at the outset, this Bill marks a further significant step in the process of strengthening and expanding provisions for the statutory registration of health professionals as set out in the health strategy. It is further confirmation of the Government's commitment to the delivery of a reformed health service which has as its core objective the maximisation of the level and quality of care provided to patients in the years ahead. Protecting patients and supporting doctors is at the heart of the policy behind this legislation and I urge Deputies to support the principles it outlines. I commend the Bill to the House.

Dr. Twomey

The Medical Practitioners Bill 2007 is about protecting the potential 4 million patients in the country and this is what must be foremost in our debate. As a doctor I am a registered member of the Medical Council, but my role today is as a politician and representative of the people. As both a doctor and a legislator, I welcome the legislation.

While I welcome almost all the proposals in the legislation, I have some concerns. Our most important focus in this debate must be on whether we protect patients. I have been involved in the medical profession for the past 20 years where I have seen more than my fair share of arrogance. This arrogance annoys me and I would like to see it rooted out, as would the majority of people in the health care area.

Ms Harney

We cannot legislate against arrogance.

Dr. Twomey

Certainly not, otherwise the Government would have to go too.

Ms Harney

If the Deputy puts down an amendment, I will look at it.

Dr. Twomey

There are doctors who should not be practising medicine and it is important we remove them from involvement in the care of patients. I hoped to hear the Minister indicate in her contribution the number of doctors she feels should not be practising medicine and the number of complaints received by the Medical Council that have had serious consequences for patients. Many of the complaints dealt with by the council do not go much further than the discussion and mediation type process mentioned by the Minister, but a small number of cases are incredibly significant. These concern negligence, incompetence and abuse of power. These cases are the ones we must root out and the ones with which we are concerned in this legislation.

There are currently approximately 9,000 doctors caring for patients. We have 2,500 consultants, 2,500 general practitioners, 4,000 junior doctors, more than 500 public health doctors and doctors involved in training students and young doctors in our universities. These doctors need the support of strong, robust legislation which will help in rooting out the type of bad doctors mentioned by the Minister.

In the past 20 years I have worked in the areas of both accident and emergency and care of the elderly where I have seen my fair share of people dying and of hairy moments. I have had to make life and death decisions, especially in the accident and emergency area with patients arriving in after road traffic accidents. One always sits back afterwards and asks whether one did the right thing.

Some areas of my training as a junior doctor left a lot to be desired. One occasion always stands out in this regard. On my first day in the job as a paediatric doctor I was asked to administer chemotherapy to young children under the age of 12. I was expected to insert a needle into the lower base of the child's spine and set up a drip as the nurse held down the child. The consultant in charge at the time showed me how to do one and then put on his coat to leave. Although I had never done the procedure before, he was going to walk away after showing me once how to do it. This legislation will not stop people acting in this manner, but it will stop junior doctors from being stupid enough to proceed with a procedure without supervision where something might go wrong.

We must focus on this type of bad practice and ensure our doctors are trained properly. If I had been stupid enough to go ahead and try the procedure on the second child without supervision and it went wrong, I would have been the person brought before the Medical Council and the High Court and the consultant could wash his hands and say he expected I should have been competent enough to do it or should have asked him to show me again. As the Minister knows well, some consultants can be overbearing and junior doctors may be afraid to ask them questions.

I worked with the same consultant in the accident and emergency department on another occasion when a young child was brought in with suspected meningitis. As we both rushed to beat the clock, we could see the meningitis rash growing on his leg. Then I saw the other side of that consultant. I saw the fantastic expertise he could apply in seconds to save the child's life. These are the sort of issues we should consider when examining the practice of medicine which is an extremely difficult profession. Nobody in the House, unless he or she has worked as a doctor, nurse or health care professional, can realise the life and death decisions that must be made or how a single decision can have disastrous consequences for the patient.

Doctors cannot use the excuse of systems failure, that something did not work or someone did not do his or her job, because of the high standards they set for themselves, whether looking after children with cancer, someone who has been mangled in a road traffic accident, or providing dignity and care to elderly people who may suffer from pneumonia or are about to die. As the Minister knows, there are more than 1 million discharges from our hospitals each year, up to 12 million outpatient interactions and 22 million GP consultations a year. We should also take into account the millions of interactions that happen with doctors, nurses, nurses and patients, domestic staff and other allied health care professions and consider how they all help to make the system work.

The Minister spoke about trust. The Government needs to wake up to its responsibilities in this regard. Leas Cross has been described by Ministers as a systems failure. The Government had 18 months notice of the issue before the "Prime Time" programme put it in the public domain. I believe the Government knew well in advance what was happening there but refused to do anything about it.

Ms Harney

That is not true.

Dr. Twomey

Patients are still dying from MRSA in our hospitals and the HSE, which the Minister has put in charge of our health services, has only draft guidelines to deal with the issue. MRSA is not something that happened today or yesterday. The death of Mr. P.J. Walsh at Monaghan General Hospital was also described as a systems failure, but it was, in some respects, a result of the failure of the Government to provide the people in the north east with a proper health service.

The Minister's failures are in the area of legislation. Fine Gael and the Labour Party have promoted the idea of a patient safety authority. The Minister has caused some confusion in this regard. The explanatory memorandum to the Medical Practitioners Bill states that an explicit definition of the role of the Medical Council is that it is the competent authority to protect the public interest. I believe the public interest is best protected by the setting up of a patient safety authority.

I urge the Minister to take this on board because of the complexities we have discussed, not just the complexities within the medical profession but also those within nursing. Nurses are becoming more autonomous because of the way we want the health service to work and in a few short months they will have the responsibility of prescribing for patients. Physiotherapists and occupational therapists must be considered also. Our health care system is rapidly evolving and the Minister must keep in step with it.

The Minister has not shown great commitment in Government to keeping in step with these changes as evidenced by the fact that the legislation promoted in the health care strategy in November 2001 has yet to be implemented to a significant degree to protect patients in our health care system. Therefore, in some respects it is the Government that is letting down patients in the area of trust.

There is one subject we should discuss, namely, how the Minister does a disservice to our 9,000 doctors. She has never spoken about the Medical Practitioners Bill without directly relating it to what happened in Our Lady of Lourdes Hospital and the Neary report. Nobody justifies what Dr. Neary did, but demonising everybody by continually mentioning the Bill and the Neary report together tries to sell the message that every doctor is somehow a Dr. Neary in sheep's clothing. It is regrettable the Minister has taken this line because the majority of doctors are fully behind the Bill and have been calling for it for the past 20 years. If there are discussions about minor points of it, then they should be seen as such. The Minister should not try to kill all discussion by saying that if somebody goes against aspects of this Bill, he or she is somehow a supporter of the behaviour in which Dr. Neary was involved.

One would not know from reading the transcripts from the Medical Council whether the three consultants who went to Our Lady of Lourdes Hospital were stupid, arrogant or naive. I do not know what was in their minds. They did not go there as consultant doctors looking after patients. Most would say that the three involved are good and compassionate doctors, but when they went to Our Lady of Lourdes Hospital they crossed another boundary. They went as experts and exonerated a colleague who should not have been exonerated.

Ms Harney

I do not think they went there.

Dr. Twomey

I think they did because they met him.

Ms Harney

I thought the inquiry was held over lunch.

Ms McManus

It was held in his house.

Dr. Twomey

In any case, they exonerated Dr. Neary and that was wrong. If those guys think that they are getting a bad run of it in the media or from some of their own colleagues, they brought it upon themselves because they went there as experts and their role changed.

Subsequently, those three individuals were censured by the fitness to practise committee of the Medical Council, but the Medical Council itself let them off and that was wrong. There should have been significant sanction by the Medical Council because what those three guys have done to the medical profession has left an indelible stain on the character of all consultants, a fact which the council must deal with. The fact that Dr. Murphy, who will probably be particularly angry on reading these comments I make about him, took so long to resign as president of the Royal College of Physicians shows in some respects how out of touch he can be. That disconnect exists, not only among consultants but in certain elements of this Government in the way the Minister is approaching this very important issue within the health services.

In some respects, what the Minister is doing to the Medical Council is unique. Personally, I do not care whether it has a lay majority or a professional majority. What everybody is talking about is protecting patients, but the element of the Bill about which most doctors have complained to me is that while there may have been a few arrogant individuals within the medical profession who had some say in what was going on in the Medical Council, the idea of arrogant Ministers taking control of the Medical Council is probably worse for patients in the long term.

The Minister was in Wexford last Sunday and when I was in the church just up the road from her——

Ms Harney

Praying for me, I hope.

Dr. Twomey

Believe it or not, the priest asked the congregation to pray for democracy.

Ms Harney

Good.

Dr. Twomey

I think he realises how delicate democracy can be. Fianna Fáil has been in power for 18 of the past 20 years and that party does not particularly care about what is being discussed here, as is evident from the fact that none of its members is here this morning. Fianna Fáil is more interested in controlling the organisations that give leadership. It controlled the unions, the local authorities and the former health boards. By that way, one can instil either active or passive support. In other words, some people in the councils would proclaim to be strong Fianna Fáil supporters, seeing their advancement coming from that because the party has been in power so long, or they must passively support Fianna Fáil, pressure being brought to bear because the party is such a dominant political organisation.

It is ironic that the Progressive Democrats Party has overseen the continuation of this policy. In its own lust for power, it allowed changes to the Freedom of Information Act 1997 and even allowed its own Minister attempt to gag the media. Now that the PDs are redundant to Fianna Fáil, they have left it in a stronger position than when their party was formed 20 years ago.

This is a fear that the autonomy enjoyed by the Medical Council will be taken away. As the Minister correctly pointed out, the Medical Council exists to protect the public interest, not to protect doctors. Since the Minister refuses to set up a patient safety authority, there is no other organisation that can protect the public interest in the way the Medical Council can at present. There may be a gagging clause imposed on the Medical Council because of the ministerial role. However, the Minister will be gone after the summer and, God forbid, we might have another Michéal Martin in the Department who cannot make up his mind to save his life, not to mind the lives of 4 million patients.

A Deputy

Deputy Twomey will be there then.

Dr. Twomey

I hope so. In fact, if I were Minister for Health——

Ms Harney

At least Deputy Twomey wants the job. Deputy Gormley told us he would not like the job.

Mr. Gormley

That is if I had a choice.

Ms Harney

I have the quote.

Mr. Gormley

It would not be my firstchoice.

Dr. Twomey

——I would not like to have that sort of a power because absolute power is always abused. I do not mind if the Medical Council has a lay majority, but it must not have direct linkage with Government which is bad for patient care in the long term.

The Minister has been long enough in politics to know that we need a strong independent Medical Council. It does not matter whether the council has a lay majority, but it must be independent. When one looks at the proposed membership of the Medical Council, which the Minister sees to some degree as a proxy for the patient safety authority of which I speak, it includes a representative from the Health Service Executive; the Higher Education Authority, who could even be Mr. Kelly, the man the Minister sacked; An Bord Altranais; the health and social care profession; the Health Information and Quality Authority; and the Independent Hospitals Associations of Ireland. The representation will be quite broad and in some respects will take up a proxy role for a patient safety authority. Therefore, it is very important that future Ministers should not have such strong control.

I am sure the same concerns have been made known to the Minister in the context of training. According to the Minister, the training of specialist doctors in the future will be handed over to the HSE. If I have learned anything over the past two years it is that I would be slow to hand over responsibility for the future training of doctors and specialists to the HSE.

The Minister must take a long look at what is happening with the HSE. Recently, I picked up a press release from the middle of 2004 when I was clearing through some papers in my office. The press release announced with great fanfare the individuals in charge of the financial directorate, the human resources directorate, the primary care and continuous care directorate, the National Hospitals Office, the IT directorate and the shared services directorate. Not one of those individuals remains in his or her job, and one of the directorates seems to have been effectively abolished. With an organisation that is obviously either in a state of flux after two years or slowly imploding, it is dangerous to hand over medical post-graduate training of doctors and dentists, the training of specialists and consultants, to a body that might not know where it is going.

The IT directorate, for instance, which is a simple one to view, was given €80 million from one year's budget to spend on small projects and by November last they had not spent one cent of it. That was the same directorate which was telling us that PPARS would be a fantastic addition to the health care services, whereas the Minister is waiting until after the election to switch it off. It is not for fun that we say this. There are great consequences to a Minister having control over the health service, especially the training of doctors.

Consider the contention that the Minister must have control over general policy. Can the Minister set standards for general policy on who can be registered with the Medical Council and the specialist training doctors can claim to have received? By implementing general policy, the Minister could implement the recommendations of the Hanly report by stealth, which report is still Government policy. She could restrict doctors' training by way of issuing a general policy to the Medical Council, thereby effectively closing small hospitals right across the country. This issue has been touched on. In this regard, one should consider the way the Royal College of Surgeons and the Royal College of Physicians have been setting harsh guidelines for accident and emergency units. These guidelines could have closed small units around the country in the past three years.

The Minister's setting of standards for trainee doctors will be dressed up as protecting the patient but it is actually the implementation of Government policy to suit politicians. It is to prevent politicians from getting it in the neck at election time from members of the public who do not want to see their local hospital closed down and do not believe one should have to travel 100 miles to visit the nearest accident and emergency department because some expert told the Minister doing so was a great idea when she was in the United States or Canada.

State control is to be exercised over the training of doctors, to which both patients and doctors will object strongly. If I were Minister for Health and Children, I would not like to have this power. I would like to believe I would be obliged to talk to those for whom I would be responsible, rather than having to issue a diktat to the Medical Council that would in some way restrict doctors' training, the knock-on effect of which would be that they would not be able to work in small hospitals. In this manner small hospitals could be closed, thus implementing Government policy by stealth.

What if the future Minister for Health and Children were Deputy Martin who seems to have a special interest in stem cell research? What would stop him if he decided to implement general Government policy to the effect that stem cell research could go ahead in Ireland? Where does this leave the Medical Council in terms of medical guidelines and doctors' rights? I will not stretch my point further and refer to the introduction of termination by ministerial directive.

Ms Harney

The Deputy is losing the run of himself. He is obsessed with Deputy Martin.

Dr. Twomey

Would the Minister blame me after watching him for four years?

Ms Harney

Deputy Twomey said Deputy Martin would introduce termination. Termination of what? The Deputy should be fair.

Dr. Twomey

I am talking about a Minister introducing termination of pregnancies.

Ms Harney

Does the Deputy believe Deputy Martin would do that?

Dr. Twomey

If in the future a Minister issued such a directive to the Medical Council, what would be the position in terms of general policy? The Minister is including many such provisions.

Ms Harney

A Minister cannot do anything he or she wants; ethical issues must be considered.

Dr. Twomey

We will wait and see because the Minister might believe she could override them.

A more important and immediate issue, on which the Minister has not touched, is that of competence assurance, about which I have asked her on many occasions in parliamentary questions before this Bill was drafted but she has never indicated her position. How will it work? The Minister stated she would provide funding for competence assurance and that the HSE would look after it. From my experience, I note that competence assurance is a massive undertaking. The 9,000 doctors in the country, including the neurosurgeons in Beaumont Hospital and general practitioners in County Wexford, are to be competence-assured to determine whether they can do their jobs. One cannot make wild statements that one will do this without demonstrating how.

The logistics of competence assurance are unbelievable and the cost could also be such. Who competence-assures the cardiothorastic surgeons in the Mater Hospital to determine they are doing their jobs properly? Will representatives from a consultant organisation or external experts be sent to do so? Will the assessees be asked to fill out a form or answer multiple-choice questions? These are the questions the Minister should be answering when she is telling patients she will protect them.

Competence assurance will have a great impact on the health care profession. If we are to find the 20 or 30 doctors we do not want working with patients, we need to know what we are doing. We do not want to collapse the health service completely; neither do we want to relieve doctors of their clinical duties to examine other doctors, thus exacerbating the existing problems in the health service. There are 29,000 patients waiting to see a consultant and 40,000 procedures are cancelled every year, mostly because the resources are lacking rather than because doctors are not available.

The worst step we could take would be to introduce a system of competence assurance that would not work and which would simply be more farce and window-dressing and have nothing to do with protecting patients. The Minister must answer my questions. We will address some of the points I am raising in more detail on Committee Stage but, now that we are talking about the overall thrust of the legislation, we must be clear on what we are discussing.

It is very easy to include in the explanatory memorandum a reference to "a new statutory framework for the maintenance of professional standards of registered medical practitioners". That is relatively straightforward and can be set up quickly. The Medical Council is working on the matter. The explanatory memorandum also states fitness to practise inquiries will generally be held in public. As the Minister knows, there is a doctor who did no justice to patients engaged in proceedings in the High Court to try to have his fitness to practise inquiry held in public. The complainants want it held in camera but he wants it held in public in order that he might intimidate them. If held in public, the complainants might not want to talk about their experiences with the doctor concerned 20 years after the event.

One must remember that it is not always positive to push for public fitness to practise inquiries. They are beneficial most of the time but one must be careful in deciding what complaints should be heard by a fitness to practise committee. I want incompetent and dangerous doctors and those who significantly abuse their patients to appear before it. A number of complaints have been made about medical practitioners and there were even some about significant sexual assaults. I am all for exposing the doctors involved, if this needs to be done, but we must be careful about how we proceed. We need to discuss the matter in much greater detail and not play to the gallery by claiming patients are being protected when nothing of the sort is being done.

I have asked the Minister about competence assurance five or six times in the past 12 months and would like her to outline her position thereon.

Ms Harney

Is the Deputy familiar with the voluntary scheme under way? It has to be voluntary because it cannot be statutory.

Dr. Twomey

It cannot be voluntary.

Ms Harney

The scheme in place is voluntary.

Dr. Twomey

It is but the only people who engage in voluntary schemes——

Ms Harney

It cannot be statutory because the law is not in place.

Dr. Twomey

There is no point in the Minister talking about what she intends because she should know exactly how she will proceed.

Ms Harney

I do. I will not be doing it because it will be done by——

Dr. Twomey

The scheme in operation is the simplest in the world because it only applies to general practitioners. It is relatively easy to competence-assure them. How will one competence-assure neurosurgeons, cardiothorastic surgeons, haematologists, pathologists and orthopaedic surgeons? How can I be assured the Minister is protecting patients? She should set up a patient safety authority, as Fine Gael and the Labour Party have recommended.

Ms McManus

I welcome the publication of this Bill which represents an important and long overdue reform of the system of regulation and standard setting for doctors. Medical practice is rapidly becoming more complex and challenging. It is important, therefore, that the structures to protect patients and support doctors are up to date and appropriate to meet those changes. However, it is not clear that the Minister has found the correct balance to protect the public good, while retaining the confidence of medical practitioners in the ability of the system to regulate and police their profession.

It would be a great pity if the changes proposed led to a deterioration in either confidence or competence in health care. We should remember this is the Minister who forced through the establishment of the HSE without proper planning, preparation or accountability, with the result that the management structure of the health service lost the public's confidence and alienated those working within it to the point where a major trade union representing health workers recently passed a motion of no confidence in the executive. We cannot allow the same alienation to be extended to the Medical Council. A streamlined, effective, modern and accountable system is required to regulate and assure competence in best medical practice.

For the most part, we are fortunate to have in Ireland a high level of professionalism and ethical standards in our doctors, although there are rare and frightening exceptions. For almost 20 years women in the north east were left at risk of extreme trauma and injury because no system was in place to protect them. The most striking element about that case is that it took a young midwife to speak out bravely and end this reign of terror. To this day that midwife has maintained her anonymity. The praise heaped on her by the Minister sounded hollow because words of praise are no substitute for robust protection of whistleblowers legislation. Unfortunately, the Government has run away from that important reform. The Labour Party published a Bill to protect whistleblowers which the Government accepted before behaving dishonourably by abandoning it quietly instead of putting it into law. This has meant that other health workers within the health service who see a wrong being done are prevented by fear of retribution from speaking out. It would have been a better tribute to the aforementioned midwife had the Minister introduced a protection of whistleblowers Bill instead of offering empty words of praise.

This Bill to reform the Medical Council has been long awaited. The 1978 Act has outlived its usefulness. It has been obvious for many years that new legislation is required. It is a great pity, however, that the debate on this long awaited Bill is being cut short. Two and a half hours is simply not good enough and shows the cavalier attitude which, regrettably, is the hallmark of the Government's tenure. In the past decade the main driving force for change has not come from the Government but from within the Medical Council. Under the presidency of Professor Gerard Bury, there was a distinct shift of policy towards reform and, in particular, the principle of competence assurance. That work has been continued during the tenure of Dr. John Hillery. Given these efforts, it is a pity that the Bill being presented to the House has led to much contention and anxiety among doctors.

The reasons for the controversy are obvious and have been analysed thoroughly by the various medical organisations, including the IMO. Critical positions have been presented and supported with evidence. It is not clear, however, why the Minister has chosen to insert certain provisions in the Bill. She needs to justify these provisions, with evidence to support her case. Evidence based practice is embedded in medical practice and provides a robust and accurate methodology for arriving at conclusions. It is not clear why she is choosing to give herself and future Ministers for Health and Children such extraordinary powers over the Medical Council. It seems she is confusing ministerial authority with democratic accountability but the two are not necessarily the same. Her proposals are an invitation for ministerial meddling, which is neither healthy nor necessary. I fully support the principle of democratic accountability but a safer and more accountable balance could be achieved by having a formalised link to the Oireachtas rather than the Minister.

It is clear that the concerns expressed by the public relate largely to the protection of patient safety and the right to seek redress and be heard when something goes wrong. I have described the inadequate response from the Government to the whistleblower legislation introduced by the Labour Party.

The Neary case exposed the limitations of current structures, showed a terrible failure to monitor and expose malpractice and revealed an urgent and pressing need to reform and improve the way medical professionals work. The Harding Clark report which outlined in detail the road map for the future stated in regard to the Medical Council:

The Inquiry is acutely aware of the sense of frustration felt by members of the Medical Council and the medical professional bodies at the lack of a new Statute giving the Council statutory powers to oblige doctors to engage in continuous medical education and to present for skills assessment. The Medical Council needs these powers urgently so that it can delegate those duties to those professional bodies to regulate the training and continuous assessment of their members.

The needs of the general public require that the professional bodies have the power and effective means at their disposal to monitor the competence of their members in order to ensure optimum patient care. In the past and perhaps at this present some doctors are engaging in procedures beyond their skills and some are failing to apply current practice. There is currently no legal obligation to keep their skills updated. This must change.

Competence assurance is not met solely by attendance at continuing professional development courses. Skills must be certified or validated. The public must have faith in an independent regulating body within the State.

At no stage does the report recommend ministerial authority over an independent regulating body; neither does it argue for a lay majority on the Medical Council. These issues seem immaterial to the concerns which arose in the Neary case.

We are dealing with issues of public concern. Most people will sooner or later fall ill, at which time they are entitled to protection from malpractice and, as far as is practicable, errors in their treatment. While oversight over those who regulate practitioners is needed, it must to be exercised at the highest level of authority, that is, the Oireachtas. I do not believe an individual Minister should be able to act at will over the Medical Council. The independence of the council is an important protection from political interference or direction for reasons other than patient safety but it is clear that there must be accountability. It is a better and safer option, for example, to vest the supreme power to close down the council solely in the Oireachtas. Such a decision would have extremely serious implications for the medical profession and patients and would have to be subject to rigorous and open scrutiny before being taken. Only the Oireachtas could guarantee the necessary safeguards. While I do not think the Minister would be culpable in this regard, leaving that power in the hands of a Minister is an invitation to occlude instead of expose. As the Minister says, she will not always be here.

Since the Minister for Health and Children, Deputy Harney, took office, Members have witnessed a worrying withdrawal of openness and accountability throughout the health service. The establishment of the Health Service Executive, HSE, has led to a loss of access to information to a disturbing degree. The Minister's legacy will be that there are no health boards, no media access, no effective system of parliamentary questions and no justification for the clamp down on accountability. Members' experience must make them deeply uneasy regarding the failure to provide the important checks and balances that only can be guaranteed by open scrutiny in these Chambers.

Members must recall, as the Minister never does, that the most significant adviser employed by the Government on health care reform, Professor Niamh Brennan, actually argued against getting rid of health boards. While she argued for their reformation, she came to the conclusion that they should not be abandoned. She acknowledged with some reluctance that accountability could be maintained only by including public representatives at a local level. However, her wise words were ignored and, consequently, we now have the most bureaucratic and impenetrable system of health care management imaginable. The public has no faith in the HSE structures as set up by the Minister and even those who work in it have declared a vote of no confidence in the organisation.

Yesterday, I met some front line workers who were completely frustrated by the difficulties they confront in their work. After hearing their myriad of complaints, I suggested they should make a presentation on their concerns to the overall director of the relevant directorate within the HSE. I was staggered to discover that not one of these highly qualified people was able to name the director of the directorate in which they operate. Their inability to name their departmental head constituted a telling indication to me of the HSE's poor state.

Ms Harney

Was the Deputy able to tell them who it was?

Dr. Twomey

It changes too often.

Ms McManus

While I was able to tell them, the name did not ring any bells. In fairness, the appointment was recent.

Ms Harney

Very well.

Ms McManus

However, I felt for them. It is not good political management or governance to leave in that position people who work in extremely stressful conditions with children who have suffered considerable abuse. People will not perform such stressful duties unless they believe they have the support of the organisation in which they work. The people I met had no sense of such support or of engagement or understanding from within. This is a form of atomisation and demoralisation that leads to vacancies and to people leaving their jobs because they cannot take any more.

The fact that this state of affairs is the direct result of ministerial and Government decisions as to how to manage the health service must inform Members in respect of the Bill under discussion. Members should learn from experience. While there is a view that experience merely constitutes the repetition of the same mistake with ever-increasing certainty, I hope Members can change and improve the Bill during its passage and that the Minister will learn from experience, rather than simply repeating previous mistakes.

Partnership is the key to a good working relationship. This applies within the HSE and between the Government and the Medical Council. It is important to recognise that, within the confines of existing legislation, in general the Medical Council has done its job well. It has the support of doctors and has regulated the profession in a way that, in general, has lived up to its task. Undoubtedly, however, the processes are both slow and secretive. The law is archaic and the manner in which the system operates is alienating to the public who may wish to complain to the Medical Council.

Recent events have undermined confidence in the Medical Council. To its credit, it published the reports relating to the so-called investigation by three consultant obstetricians. However, to its discredit, no explanation has been given as to why the Medical Council chose not to discipline the consultants for their failure to act properly in respect of their role in investigating the work of Dr. Neary. Although the fitness to practise committee recommended that sanctions be imposed, the medical council rejected this recommendation without any explanation, which simply is unacceptable. I support the Minister in asserting that transparency should be as fully enforced as possible. The Labour Party wants such enforcement to be included in this Bill.

Members must consider the issue of the lay majority. The Minister's argument has not been explained fully and I intend to table amendments on Committee Stage because the issues raised deserve to be considered. It is important to have a good debate on such issues.

There is a logic to separating the fitness to practise committee from the Medical Council itself. Fitness to practise is of direct concern to patients and it is appropriate to have a strong lay presence on that committee. However, one must recognise that this tends to slow down matters. While the process in courts with juries is slower than would otherwise be the case, such a step is logical and I welcome the openness of inquires, when appropriate. However, I am not yet convinced as to the necessity for, or desirability of, having a dominance of lay people on the Medical Council itself. Regulation, training, education and competence assurance all require expertise to make the correct decisions.

I read with great interest an article in The Irish Times on the experience of one lay person, namely, the journalist Ms Mary Raftery. She has concerns regarding the Government’s approach, which is to view a lay majority as a panacea and wrote about how it is vital that clinical audits and peer review should become mandatory for all doctors. However, she then makes the point:

While there is a role here for non-medical people, particularly in ensuring complete transparency, this process is more appropriately driven by doctors themselves. Lay people, by definition, lack the detailed knowledge necessary to judge the increasingly specialised nature of medical practice.

The second strand, which is currently also the responsibility of the Medical Council, is the investigation of complaints against doctors [in respect of fitness to practise]. It is here that the process of self-regulation has been exposed as being most seriously flawed.

She then noted she has heard complaints about the Medical Council and went on to state:

I have some small experience in this area. For five years during the 1990s, I was one of two lay members appointed to the board of the Dublin Dental Hospital. With no specialist knowledge of dentistry, I felt that my ability to have any significant impact was extremely limited.

This is not to criticise either the board or the hospital — far from it. It is merely to point out that it has been my direct experience that the influence of lay people, serving in a voluntary capacity in complex areas of which they have no expert knowledge, is in danger of being seriously exaggerated.

Other jurisdictions have confronted this problem. New Zealand, for [example], has split the two strands mentioned above.

She refers to that country's separation of clinical order and competence assurance from fitness to practise

. . . under the aegis of its medical council, which remains doctor-dominated. However, the investigation of complaints and concerns was removed from the council in 1994. It is now the responsibility of the Health and Disability Commissioner. His office is [fully] independent and is staffed by professional investigators who are not doctors, but can call on specialist knowledge as required.

There is active encouragement of complaints being made. She continues:

The commissioner also has the power himself to initiate an investigation into any matter of public concern in the health area. This ability to be proactive, rather than simply waiting for complaints to come in, is a key strength. Another is the entire separation from the medical profession.

New Zealand established this independent, stand-alone complaints body after a number of serious scandals

She goes on to observe:

It is simply not enough to throw a few more lay volunteers onto a medical council board. This kind of tinkering around the edges of a system which is fundamentally flawed will do nothing to restore our seriously shaken confidence in the medical profession. Neither will it provide an adequate remedy for those who are damaged by doctors' errors.

It is interesting to hear about the experience and case made by somebody who was a lay member of the board of a medical facility. We must listen to it. She made an extremely strong case for the establishment of a patient safety authority, the position both the Labour Party and Fine Gael fleshed out in detail. We have not heard from the Minister the case for lay people having a majority. As I understand it, none of the training schools is represented on the Medical Council. This raises issues——

Ms Harney

Under the Bill, they will be.

Ms McManus

I beg the Minister's pardon. I thought there was a problem but I will double-check it.

This shift has been an issue and shows a rejection of self-regulation. I do not complain about this. I complain about the idea that somehow lay people on the Medical Council will make a real difference. The case has not been proved; the evidence has not been brought forward and it is important to have it, given the import of the Bill.

I wish to raise an issue which was not raised by Deputy Twomey but about which I am concerned. The Minister is in love with the private model. Privatisation is the way by which she operates. It has infused the health service in a way we must examine cautiously and carefully. There can easily be conflict of interest, particularly when large amounts of money are made out of the health care system. "For profit" is a new phenomenon recently introduced. We must be careful and consider how we can secure protections against conflicts of interest arising.

I will give the example of a general practitioner who was an adviser to Professor Drumm in the HSE. This man was engaged with a company called Touchstone, a private company developing general practice clinics. He advised Professor Drumm and was a driving force in the promotion of approximately 500 primary care teams and centres. He left that important post and went straight onto the board of directors of Touchstone. In another country this would not be permitted. In the United States, much beloved by the Minister, it would not be permitted.

Concerns are raised about people sniffing around the health service because the Minister opened the door to them to make money from health provision in a way that is new to us. We do not have the protections, safeguards, guidelines or rigorous protocols to ensure people do not use their positions to promote privatisation or private business because lots of loot can accrue as a result of such a change. We must examine this matter in the context of the ethical behaviour of medical professionals and others.

In this country we know that no matter what scandals have occurred the basic relationship between patient and doctor is based generally on trust. We should not let go of this. It is important that we examine all aspects of this trust to secure and protect it.

Mr. Sherlock

I will not discuss the fitness to practise aspect of the Bill. I will discuss administration. I am glad the Minister is present.

Section 13 provides for the council to prepare a statement of strategy for its term of office. The Minister may return it if it does not comply with specific provisions. I wish to speak on this issue because the area I represent is located in the southern region. What is happening there under the HSE is appalling.

Under section 17, in Part 4 of the Bill, 25 members will be appointed by the Minister to do what Deputy Twomey spoke about, namely, to implement the recommendations of the Hanly report. That is what this is all about. Let there be no doubt that it will not go through without one hell of a fight. I am here to speak strongly on the matter of the €15 billion of taxpayer's money handed over to the HSE, some of which will be used to pay massive salaries to administrators with no affect on the business of the people. Under section 17, the Minister is determined to remove the control of the Medical Council, the regulatory body. According to the Bill, regulatory power will remain with a council, the majority of whose members will be nominated by the Minister. We know it is an absolute failure. The IMO suggests the Bill should be amended to state the Minister will have no role in the operational management of the council which must be accountable to the Oireachtas and free from political interference. This issue must be fought out when amendments are proposed.

I attended a meeting in Cork where a letter to an individual was discussed. The letter stated the World Medical Association was made aware of the Medical Practitioners Bill 2007 and indicated that, if it understood it correctly, the Bill, when it came into effect, would remove the control of the Medical Council, the regulatory and self-governing body of the profession, and that, apparently, regulatory power would then lay with a council, the majority of whose members would be nominated by the Minister. The Minister spoke——

Ms Harney

I think the Deputy got that letter from a fellow Corkman.

Mr. Sherlock

That may be the case——

Ms Harney

I know who the Deputy got it from.

Mr. Sherlock

——but it is a fact.

Ms Harney

It is wrong.

Mr. Sherlock

It comes from the world medical council and it does not have any doubt about it. Whereas the Minister was always deemed to be a person who spoke the truth honestly, she is not doing so now. The health service is appalling.

Mr. Durkan

Hear, hear.

Mr. Sherlock

I wish to state clearly and distinctly why I speak on this issue. The health advisory committees were abolished because the opportunity arose for public representatives and medical people to raise issues. Following a case in the north Cork area, a move was made to abolish the committees. Later, the Southern Health Board was abolished. The Minister and others stated that because of expenditure by the Southern Health Board, it had to be changed to the HSE. The health boards met only once every month but on those occasions one could ask questions of the CEO or senior members and receive replies. This is no longer the case. I hope the amendments proposed will be debated.

Acting Chairman (Mr. Kirk)

A number of speakers from the Technical Group will speak. They are Deputies Gormley, Crowe, Finian McGrath and Catherine Murphy.

Mr. Gormley

As the Acting Chairman stated, I will share my time with the other speakers from the Technical Group.

I have not seen Deputy Sherlock so animated in some time.

Ms Harney

I suspect it has something to do with a matter other than the Medical Council.

Mr. Gormley

The Minister might be correct. I suspect there may well be an election coming up.

Mr. Durkan

Deputy Sherlock might be right.

Mr. Gormley

Nevertheless, what he stated about the HSE was absolutely correct. Perhaps we should start there as that was, like the Bill before us today, very important legislation. I vividly recall stating at the time that the HSE was being set up, in a sense, to protect the Minister and would result in less accountability and transparency. I have been proved right.

We have heard delegations speaking about this legislation and the one factor everyone has in common, be they consultants, nurses, patient groups or members of the IMO, is a dissatisfaction with the HSE. Deputies are not happy with the role of the executive either as we cannot get answers to parliamentary questions. I repeatedly indicated on Committee Stage of that Bill that questions would be referred to the HSE. What has happened and do we get any reply? We get a reply from the Minister stating the question is being referred to the HSE and months later we might get a letter.

Ms Harney

Professor Drumm was in for five hours last week and the Deputy did not even appear. If the Deputy wishes to ask questions, he should go to the man himself when he is here for five hours.

Mr. Gormley

I cannot be in 100 places at one time. I have attended Joint Committee on Health and Children meetings speaking on fluoridation at length and I could have been the only person there.

Ms Harney

I agree with that.

Mr. Gormley

Even when we try to get answers at those meetings, the delegates have to get back to us with the information. I raised questions on alcohol consumption and how we will implement a strategy. Representatives of the HSE told me they would get back to me but that has not happened.

Acting Chairman

I remind the Deputy we are discussing the Medical Practitioners Bill.

Mr. Gormley

I know, but the Minister has managed to provoke me so I have to answer.

Ms Harney

I am very sorry for provoking the Deputy but it does not take much to do so.

Mr. Durkan

It is a serious case of provocation.

Mr. F. McGrath

The Minister has upset him.

Mr. Gormley

We must be careful in dealing with legislation. Listening to Deputy Twomey's contribution sent a shiver down my spine. He confirmed our worst fears and suspicions when he described the task he was given as a junior doctor, something that will not be covered in this legislation.

I have come across cases involving junior doctors. One was sent to apply a drip to a patient who had been on a Buxton chair for days in a hospital. The junior doctor was so tired that while he was treating the patient, he fell asleep. I have been told that a lady went to be treated and was misdiagnosed by a junior doctor before being sent home with a perforated bowel. Unfortunately and tragically, the woman died because of the misdiagnosis.

We have a serious problem where the workload of junior doctors is far too high. One aspect of the Hanly report is that we need more consultants. We need properly trained personnel in hospitals rather than having overworked junior doctors trying to deal with these very complex issues. Deputy Twomey's comments should send shivers down everybody's spine, including the Minister's. It is not acceptable for this to happen in our hospitals.

It is often said that the professions are a conspiracy against the laity. According to some people, this Bill is seen as a conspiracy of the laity against the profession. I fully understand the reasoning behind the composition of the Irish Medical Council. We can take into account malpractice, the horror stories from Our Lady of Lourdes Hospital and the Neary case. In that instance, there was quite clearly too cosy a relationship between Dr. Neary and his colleagues, sitting down for a cup of tea to discuss the case. That collegiality resulted in Dr. Neary getting away with it.

That is clearly unacceptable. From a political point of view, it makes sense to have a lay majority and it looks good. However, we should consider the facts. In future, all 25 people will be appointed by the Minister. I have been informed that the General Medical Council of England and Wales has the highest lay membership in Europe with 40% non-medical members. Perhaps the Minister could correct these facts, and I am open to correction, but no other country in the developed world has a lay majority.

Considering these factors, I wonder if it is wise, as Deputy McManus stated, to proceed down this road? Will the Minister be open to suggestions on Committee Stage? The Independent Hospitals' Association of Ireland will have one member and I have been told that this body is related to IBEC in some shape or form. I am sure the Minister will correct me at some stage.

Ms Harney

The IMO is part of the Irish Congress of Trade Unions. Is there anything significant in that?

Mr. Gormley

Those who have made representations to us feel there is an imbalance and people with clinical expertise are not being represented to the extent they ought to be.

A number of other issues have come to our attention, including one regarding confidentiality. I will come back to the way doctors are approached, while the issue of MRSA has already been mentioned. The Minister mentioned education programmes among GPs and in our hospitals.

The over-prescription of antibiotics is a major issue which must be tackled in the context of MRSA. We must have the highest hygiene and cleanliness standards but there is a great inconsistency. Some GPs and doctors in hospitals are conscientious about the issue but others are wholly irresponsible.

The Minister mentioned the Oireachtas Joint Committee on Health and Children. When I raised this issue in that forum, a member of a delegation stated that customers will vote with their feet. In other words, if antibiotics are not handed out, people will go to another doctor. How can this be regulated? This gets to the core of the issue. In the context of negligence, behaviour and conduct, surely we should be including issues such as this and indicating that doctors should prescribe in a responsible way.

I do not believe this legislation will cover that, nor do I believe that the programmes spoken about by the Minister will tackle this very serious problem. How many people in hospitals are doing the basics, such as washing hands? We believe that 40% or more of the people working in hospitals could have MRSA but we do not know the number for sure because we have not conducted detailed tests.

With regard to freedom of information, the Lourdes Hospital inquiry report states on page 345:

The Department of Health and Children should introduce legislation to protect clinical governance records and risk management clinical incident report forms from the application of the Freedom of Information Act. Unless these documents are protected from FOI or discovery, they are unlikely to be created and opportunities for learning from mistakes will be lost.

Is that particular recommendation in conflict with section 104 of the legislation? The Minister is texting but perhaps she could make a note of that point.

Ms Harney

I am listening to everything the Deputy is saying.

Mr. Gormley

The Minister can multitask. Fair play.

Ms Harney

I can.

Mr. Gormley

That is an important——

Ms Harney

My colleagues have the luxury of making press statements, but I must be able to respond.

Mr. Gormley

I will not make any press statement.

Mr. Durkan

The Tánaiste may be making a statement. The Minister should check on him.

Mr. Crowe

I must agree with the Minister's introduction to the Bill when she referred to the fundamental ties that bind people together in a modern society, the deference to institutions and the deference to authority.

Mr. F. McGrath

Is Sinn Féin backing the Progressive Democrats?

Mr. Crowe

What the Minister said is correct. There has been a sea change in people's attitudes towards authority and institutions, which is healthy for any modern society. I also agree with other speakers who spoke of the importance of the legislation.

Mr. Gormley

On a point of order, my microphone is on, but Deputy Crowe's is not.

Mr. Crowe

I am sure that no one is listening anyway.

Mr. Durkan

It is like e-voting. One can never trust it.

Mr. F. McGrath

That technology is from MI5.

Mr. Crowe

One of the most significant matters affecting the health services in recent years concerns the accountability and training of health professionals. Such legislation should be designed to protect patients and to help ensure that they receive care of the highest standard, but I am as disappointed as others by the guillotining of this debate after three hours. It is equally unacceptable that we needed to wait so long for the Bill. Those commitments in the Government's 2001 health strategy that have not been abandoned altogether have been repeatedly delayed, such as this Bill.

The core of the Bill is the reform of the Irish Medical Council, the main regulating body for the medical profession. Section 6 describes the objective of the Medical Council as "to protect the public by promoting and better ensuring high standards of professional conduct and professional education, training and competence among registered medical practitioners". The Medical Council as established has failed to protect the public, as seen in the scandal concerning the obstetrics and gynaecology unit at Our Lady of Lourdes Hospital in Drogheda where dozens of women were mutilated by Dr. Michael Neary. The Neary scandal is the background to the Bill and one of the main purposes of the legislation should be to ensure that such appalling treatment of vulnerable people within our health service is not allowed to recur.

The victims of Michael Neary were betrayed by the Our Lady of Lourdes Hospital authorities, which turned a blind eye to what was happening, Neary's professional body, the Irish Hospital Consultants Association, which carried out a bogus investigation that actually praised Neary, a surgeon who butchered women, and the Irish Medical Council, which proved incapable of dealing with this outrage speedily, openly and fairly. These betrayals reinforced the opinion held by many that when it comes to the crunch, some doctors and consultants will not report the inadequacies of their colleagues.

The report of Judge Maureen Harding Clark into the obstetrics and gynaecology unit of Our Lady of Lourdes Hospital was a damning indictment not just of one consultant, but of a conspiracy involving a number of people who participated in gross medical malpractice, turned a blind eye or took part in a cover-up involving the unlawful removal of the charts and birth registers of many of the victims with a view to concealing the details of the operations performed and the treatment given. In other words, this was theft to facilitate a cover-up, which was allowed to happen in a climate where consultants were seen to be above reproach and where elitism led to a total lack of accountability.

We are still waiting for a scheme of redress to deal with all claims of medical negligence made by the women who were in the care of the consultants and staff of the maternity unit of Our Lady of Lourdes Hospital between 1974 and 1998. The Minister for Health and Children owes a solemn obligation to the victims to establish a scheme of redress to provide them with a forum to state their cases and recompense, if possible, for the physical injury and personal grief and trauma they have suffered. The Government also needs to clarify the position of the Garda investigation and whether prosecutions will be pursued in respect of those who stole medical records.

The purpose of the Bill is to address the profound questions about the regulation of the medical profession raised by the Harding Clark report. The sad reality is that self-regulation by the professionals in this case did not work and led to a grave injustice being done to patients. Its failure showed up major weaknesses in the system.

The explanatory memorandum to the Bill states that the balance between self-regulation and public accountability needs to be adjusted. That is definitely the case in the wake of the Neary scandal. One of the main ways the Bill seeks to redress the balance is through changing the composition of the Medical Council to give it a lay majority. Both the IMO and the IHCA object to this measure, as they want to maintain a majority of medical professional representatives on the council. This argument will go back and forth during Committee and Report Stages, but self-regulation failed miserably in the Neary case and other cases. That has weakened the argument for maintaining the council as it is.

The Bill gives extensive powers to the Minister regarding the council. She will appoint the members nominated by professional bodies and statutory agencies and the lay members who have such qualifications, expertise, interests or experience as, in the opinion of the Minister, would enable them to make a contribution to the performance of the Council's functions. The key question for us as public representatives is who in the new Medical Council will represent the interests of patients, the users of the services provided by medical professions. The answer is far from clear in the Bill. Citizens will be more interested in the answer to that question than in arguments about how many representatives from which professional bodies should be on the council. The public has the right to know whether the council will serve it better.

Section 7 states that the Medical Council shall "perform its functions in the public interest", which is the key point of the Bill. The council has to act not in the interest of the Government of the day or of this or that professional body, but in the public interest. The majority of medical professionals act in the public interest and carry out health-giving and life-saving work everyday and often against the odds in our health services, which are crippled by the disastrous policies of this and previous Governments.

The Government's policies are undermining the ethos of public service, which should guide everyone working in our health service. The Government is pursuing a policy of privatisation that puts profit before people. It is providing land on public hospital sites and significant tax breaks to developers and speculators who see health care as a lucrative business. Once these private for-profit hospitals are in place, they will suck the life-blood out of the public health service. As the public system deteriorates, health professionals will be drawn into the private for-profit system. It is already happening. This week, a primary care specialist hired on a large salary to advise the HSE CEO, Professor Brendan Drumm, left for a top post and a seat on the board of directors of the private primary care company, Touchstone.

For years, the public service ethos has been undermined by contracts that allow hospital consultants to profit simultaneously from the public system and private practices. The Government claims to be trying to change that in the negotiations with the consultants, but the Minister has undermined her case. She claims to be serving the public system while bringing in the privateers. The Government is reinforcing the two-tier system. Public service is playing second fiddle to private profit.

The large bureaucratic backlog in the filling of posts and the appointment of health professionals in our public health services must be addressed. I am told by people working in the health services that since the establishment of the HSE, the bureaucracy has worsened. It is a nightmare and the massive bureaucratic bottleneck is denying patients the professional care they need, which must be addressed as a matter of urgency.

Mr. F. McGrath

I welcome the opportunity to speak on the Medical Practitioners Bill 2007 because it is an important element of the wide-ranging debate on health. This area has been a major issue over several years and one of grave concern to many of our citizens. It is something about which we all care passionately. However, if we confine ourselves just to this section of the debate we will not get anywhere, particularly if we fail to examine the broader issues also. I emphasise that in order to resolve the current crisis in the health service we need reform, investment and extra beds. Anyone who says the opposite has his or her head stuck in the sand. That is the way forward and it is very important.

The significant personnel in the context of the health service are patients, doctors, nurses and ancillary staff. These are the key people and if we do not take their views on board and work with them, we will not resolve the issues. We must have professional standards and we must do something about the MRSA crisis. People have to take responsibility for their professionalism and levels of hygiene and cleanliness. However, we also have a responsibility to ensure everyone does so.

What happened at Beaumont Hospital in my constituency during the week was unacceptable. I do not accept, as the Taoiseach said, that it was a bad day. I strongly challenge the Taoiseach's flippant remark about people chasing ambulances, and this was reported to me this morning when I was out and about in the constituency. Many people on the northside of Dublin were hopping mad in the past three or four days about the Taoiseach's remarks in this regard. There was a major crisis the other day in Beaumont and the reality is that we need extra beds and extra facilities for the elderly. To say anything otherwise is to mislead the public. The public is extremely annoyed about those remarks and I point this out to the Minister for Health and Children as she is in the Chamber.

When we talk about the so-called row with the consultants, it should be borne in mind that they are major stakeholders in the health service. It might surprise people to hear me defending their interests. I strongly support the policy of consultants working in the public sector and it must be emphasised that they have made a major contribution to the development of the health services. Some of the best consultants in the world work in our hospitals and are saving lives every day. I do not believe having macho rows a few weeks before a general election will resolve the issue. I advise the Minister to sit down and talk to them, get on with the job and work with them on this issue. This is crucial because the consultants have played a valuable role, as have many GPs, in the health service and have made a massive contribution to this country and to saving lives. I will stand by those people, particularly those who have done a very professional job. Admittedly, we have had a few bad examples, but the vast majority work long hours, giving dedicated service to patients and saving lives. That is something we should appreciate.

The other major stakeholders, the nurses and midwives, are on a countdown to a work to rule in regional hospitals around the country in the coming weeks. It takes a good deal to force nurses and midwives to take such action. Even at this stage, their willingness to engage in negotiations to avoid this path is open. However, it appears the political system is not amenable to their legitimate concerns for equality and fairness. Theirs is the only administrative and technical grade in the public service working 39 hours a week. This is on foot of a 1980 Labour Court recommendation that nurses should be the first to benefit from a reduction in the working week, due to their difficult working environments. Benchmarking is not the only show in town. They have clearly been shown that this is not the case. Nurses are fully aware that many deals have been brokered while they have been left out in the cold.

In New Zealand, for example, 40% of nurses abandon the profession within three years. In Ireland, if the trend continues, some 70% of newly qualified nurses will leave within 18 months. America requires 1 million nurses by 2012 while Canada needs 331,000 by 2016. In the light of the global, urgent and increasing need for nurses and midwives, people should value, respect and reward them in Ireland. Shortages are particularly evident in the Dublin teaching hospitals, where the number of nurses and midwives is critical. International nurses must be constantly recruited and replaced in Ireland. Nurses do not have to be paid to decentralise. They simply cannot afford to live in Dublin.

The lack of nurses and midwives impacts on patients and the health care systems as well as on economic and social development. The challenge for the Government is to focus on the retention issues and related cost-effectiveness. Some 15,000 nurses and midwives are registered with An Bord Altranais, but often do not practise. This is absolutely appalling. Surveys confirm that improvements in salaries and working conditions would attract nurses and midwives back into active service. I urge the Minister and the Government to think outside the box. If there are 15,000 people available, let us do something to facilitate those who are not practising and get them back into the service again.

Some 42,000 INO and PNA members are on their way to a dispute. The majority of these general and psychiatric nurses want to have the issue resolved. They want a 39-hour week, a proper week's wages and appropriate working conditions, so let them get on with it.

Ms Harney

They have the 39-hour week.

Mr. F. McGrath

I beg the Minister's pardon.

Ms Harney

The Deputy said they want a 39-hour week.

Mr. F. McGrath

My mistake, I am sorry. They want to do something, radically, about the 39-hour week.

Ms Harney

I am happy to give them a 39-hour week.

Mr. Durkan

The Minister should not go there.

Mr. F. McGrath

It is important that we look seriously at a reduction in their working hours and try to facilitate them. We should think somewhat more creatively outside the box about employment as well. I find it amazing that we will lose so many top quality people and that we are spending so much money training people we will not use. We must look at the cost-effectiveness of this also.

The main objectives of the Medical Practitioners Bill are to provide for a modern, efficient, transparent and accountable system for the regulation of the medical profession, which will satisfy the public and the profession, and to ensure that all medical practitioners are appropriately qualified and competent to practise in a safe manner on an ongoing basis. The Bill's ethos is a very important statement because professionalism and competency are crucial. The view of the Irish Hospital Consultants' Association has been very positive in this regard, although it has some concerns about the Bill.

Despite some reservations, the medical profession has welcomed the Bill, as published. It supports the Minister in her desire to have the Medical Practitioners Act 1978 replaced by a more modern and comprehensive legislative framework. However, the profession, including hospital consultants, is united in its concern regarding a limited number of the Bill's aspects. I raise this on their behalf because I am due to meet some consultants on Monday. I do not know how many of the northside Deputies have been invited to the meeting. I repeat that it is important for the Minister to engage with the consultants and not just pick a row with them for the sake of hype in the run-up to the election.

Section 7 outlines the functions of the Medical Council, which relate to the registration of medical practitioners, the regulation of their education and training at all levels and matters relating to the recognition of their qualifications. That is a vitally important matter. As we consider the educational requirements of general practitioners, let us go after young people in secondary schools and colleges who want to be doctors and to work in the service, not necessarily people with 700 or 800 points in the leaving certificate. This is something that should be borne mind regarding teachers as well. I recall when the famous call to training was in practice that, as well as getting a significant number of honours in the leaving certificate, the applicant had to be interviewed by psychologists, child care personnel, etc, to see whether he or she was suitable to work with children. Now the criterion is points, so the Minister should ensure that the right people are going into the health professions, whether as nurses or GPs.

I welcome this opportunity for a broader debate on health. If the Minister really wants to do something about the health service, it requires three measures — reform, investment and extra beds.

Mr. Ó Fearghaíl

I wish to share my time with Deputy Fitzpatrick.

Acting Chairman

That is agreed.

Mr. Ó Fearghaíl

I am delighted to have this opportunity to contribute, albeit briefly, on this vital legislation which has been described by the Minister, echoed by Deputy Finian McGrath, as aiming to provide a modern, efficient, transparent and accountable system for the regulation of the medical profession.

To properly evaluate this legislation it must be seen as part, and in the context, of the raft of legislation that has been brought forward by the Minister and her predecessor aimed at delivering a medical service that is patient centred, effective in all its aspects and responsive to the ongoing change that is a feature of life in the world of medicine today.

The Bill focuses to a great extent on the operation and make up of the Medical Council, the profession's governing body. It is clear from reading the Bill that the emphasis is firmly placed on ensuring that the Medical Council operates with the public interest as its number one priority at all times.

Despite the controversy that continues to surround the ongoing reform of our health services, the public at large have great confidence, and justifiably so, in our medical professionals. Throughout the country our general practitioners provide a valued service in local communities and generally retain close and ongoing contacts with their patient group. The overwhelming majority of people report real satisfaction with the level of care and expertise they benefit from when they are admitted to our hospital system. If there is a weakness in the system, and we must all admit there is, it occurs most often in accident and emergency departments in not all but some of our hospitals. Many have had the experience, as have I, of waiting endlessly in an accident and emergency department that is obviously well staffed, with no apparent shortage of hospital doctors, yet has nothing like the rapid throughput of patients those waiting or on trolleys would expect.

The Donegal man, Gerry Robinson, held British and Irish TV viewers spellbound for a number of nights as he set out to transform an NHS hospital. I am sure the Minister, Deputy Harney, who has worked very hard in her portfolio can empathise, to say the least, with the level of frustration clearly experienced by Robinson in his TV documentary, as he set out to reform the system in just one hospital. Management, management, management, was the message coming from Sir Gerry and it is reasonable to assert that as we move here towards increasing the number of consultants working in our hospitals by 1,500, as indicated by the Minister, we have a right to expect a correspondingly significant improvement in the management of our services at every level, including accident and emergency. It may well be a mistake and an over-simplification of the challenge to see the difficulties in accident and emergency departments as the major problem, when these difficulties may be no more than symptoms of an overall lack of integrated management in some of our hospitals.

In the publicity that surrounded the publication of this Bill much attention was given to Part 8, which deals with the matter of complaints referred to the Fitness to Practise Committee of the Medical Council. This is not in any way surprising, coming as it did in the aftermath of the publication of the Lourdes Hospital Inquiry into the activities of Dr. Neary. "Horrific and shocking" are mild terms to describe the extent of patient abuse which this doctor was able to inflict over a protracted period. Clearly the system currently in place and in place then abysmally failed to protect the interests and wellbeing of the many women who were victims of Dr. Neary's professional misconduct.

It is essential that the public has confidence in the regulatory system and, therefore, the reforms contained in this Bill are timely and deserving of our support. However, given the old maxim that "hard cases make bad law" I wonder if we are adopting the right approach in section 65, which deals with fitness to practise hearings, which it proposes will normally be held in public. I would be concerned about the possible impact on a medical professional's career in the aftermath of a public hearing at which the practitioner had been found innocent of any misconduct, given the propensity of the Irish people to believe that there is no smoke without fire. Would it not be more reasonable to provide for public hearings in situations where there was a prima facie case of significant wrongdoing against a medical practitioner? Such an approach would help maintain the high level of public confidence, which currently exists in the medical profession, and would also ensure that a new and demonstrable level of accountability was put in place for the future.

I congratulate the Minister on the provisions included in sections 17 and 20, which provide for a lay majority in the membership of the council and the Fitness to Practise Committee. This was adversely commented upon by a number of Members today. As a matter of principle it is prudent that the regulatory body for any profession comprise a majority of members who represent the most important stakeholders, those whom the profession aims to serve.

Section 86 deals with education and training and it brings me back to the point made earlier about the recruitment of up to 1,500 consultants. These positions are pivotal to the delivery of improved services on many fronts. Their arrival on the scene should significantly improve outcomes for patients and, through more effective management, deliver greater hospital throughput. In addition, these new consultants will be a major resource for the education and training of our postgraduate doctors who will benefit from the resulting, as it were, lower pupil teacher ratio. However, the key to the success of the recruitment project surely will lie in ensuring that the new consultants meet the same rigorous standards upheld by our current accreditation system.

Section 86 places the responsibility on the HSE to assess the number of intern and specialist training posts required by the health service on an annual basis. I noted again today the number of criticisms and direct attacks on the HSE made by Members. While it is politically expedient at this time to attack the HSE, it certainly does not serve the public interest to do so. It behoves us all to support this new initiative in a drive towards ensuring better delivery of service to the public at large.

I pay tribute to the Minister for Health and Children, Deputy Harney, and the Minister for Education and Science, Deputy Hanafin, for their joint initiative announced in February 2006, whereby €200 million will be invested in a major reform of medical education and training from undergraduate level through to post-graduate specialist training. In particular, I acknowledge the positive development that involves the introduction of a new graduate entry programme for medicine as part of the overall expansion of places from 305 to 725 by 2010. Traditionally, straight As were the prerequisite for entry to undergraduate medicine. However, academic excellence alone does not a doctor make.

Mr. Durkan

It does not.

Mr. Ó Fearghaíl

I echo Deputy Finian McGrath's view that we should consider not only those who have the academic ability but those who have the personal predisposition and vocation to work in this area. The introduction of a new aptitude test for selection for graduate entry to medicine is a worthwhile initiative.

I again welcome this Bill and commend it the House. I will hand over to my colleague, Deputy Fitzpatrick.

Dr. Fitzpatrick

I should first declare an interest in this area. I have practised as a GP in the north inner city for many years and have seen amazing changes over the years from the time I studied as a medical student in the Mater Hospital and did my training in Dr. Steven's Hospital, a hospital alas that is no longer with us. It was one of the tragedies of medicine in Dublin that Dr. Steven's Hospital was closed for the want of £600,000, which even at that time was not a major deficit. However, the powers that be at the time thought they would close it and walk away with the Worth library. I note Deputy Durkan is nodding in agreement. That was a scandal at the time.

Mr. Durkan

It was absolutely.

Dr. Fitzpatrick

I will not go any further than that other than to point out that the matter ended up in the High Court where a very learned judge castigated the perpetrators in no uncertain fashion. However, that is in the past.

I wish to make a few points about the position in the north inner city. I accept there are problems in accident and emergency departments but during the years I have seen an expansion of services to children, the opening of rapid access units for elderly patients who need quick assessment and treatment and the exponential expansion of the psychiatry of old age service which does an excellent job. It must be one of the few consultant-led services where the consultant goes to see patients in their own home or elsewhere. We could go down that road with many other services.

I join Deputies Ó Fearghaíl and Finian McGrath in welcoming the graduate entry programme. Speaking as a doctor, I would not have made it into medical school under the current system. Gaining 800 points in the leaving certificate examination should not be a prerequisite to being a doctor but it was left in place for so long because nobody could come up with an alternative system that would be open, accountable and transparent. Students with a very high number of points got into medical school whether they were suitable to practise as doctors. To be a doctor one must be able to empathise with patients and get on with them. A student who has achieved 800 points may be more suited to dealing with rocket science, which is not the same as dealing with patients on a daily basis. It will be interesting to see what the graduate entry programme does for the quality of medical professionals.

I congratulate the Minister and her Ministers of State. She has a most unenviable job. In many ways her position is similar to being a captain on a large crude oil carrier. We are familiar with 500,000 tonne carriers. It takes a considerable effort to make one change direction.

Mr. Durkan

Correct.

Dr. Fitzpatrick

The massive inertia embedded in the system is unbelievable. It is difficult to know how to address the problem. Gerry Robinson was involved in a three-part series on the BBC and was interviewed on "The Late Late Show" about his experience. It is easy to make such a programme. I agree with much of what he said but if he had to run a hospital on a daily basis, he would come up against a range of problems, including personal, managerial and clinical, that he would end up tearing his hair out.

The Minister's aim is to have patients' problems dealt with by consultants from the initial point of entry in hospital. Accordingly, she has proposed the appointment of an extra 1,500 consultants. This should make a difference to the delivery of health services. It will also make a big difference to the Irish Hospital Consultants Association. As a result, the people with whom we are dealing today may not be there in the future. These younger consultants will have different problems and demands. Many of them are adequately qualified to become consultants and frustrated because their ambitions are blocked by lack of entry to consultant grade.

The Minister is maintaining the membership of the Medical Council at 25. However, leaving the council unchanged is not an option in view of the Drogheda debacle, for example, which has helped to focus minds. I am surprised to learn that it is 30 years since Dáil Éireann took an interest in the council. Sometimes it takes a tsunami-like event to focus our minds. The council, as currently constituted, failed in dealing with what had happened in Drogheda. I hope members of the new council will be taken from outside the medical, paramedical and nursing professions. Neither should they work for the HSE. They should come from different walks of life to bring the views of the ordinary Seán citizen to the council in dealing with the problems which come before it.

Mr. Durkan

Like the health boards.

Dr. Fitzpatrick

Exactly. The old health board system worked because of its make-up. Deputy Durkan will remember that when we changed the health board system, many people with medical or paramedical expertise were appointed but they were not prepared to take responsibility. On one famous occasion they would not pass the estimates. It was left to the publicly elected representatives to do so. We shouldered our responsibility but they could not. That is why outsiders are needed. I hope the Minister will request the appointment of one or two local councillors, not Members of the Oireachtas who would have a vested interest or be too close to the action. They would bring an outsider's viewpoint and would not be caught up in the day-to-day business of running health authorities.

A number of medical practitioners have grave concerns about the Bill. However, the Minister must be seen to act for the common good. The membership of the fitness to practise sub-committee of the Medical Council is of the utmost importance. Many believe the council is the fitness to practise committee but that is not the case. Lay people are required to sit on this body also, as they would have a more detached view of matters coming before them.

I am inclined to agree with Deputy ÓFearghaíl's imní about the way it is proposed the fitness to practise committee will go about its business. I agree that if its meetings are to be held in public, there should be an initial screening of complaints coming before it. We have seen how people called before tribunals have been deemed to be guilty of some wrongdoing by the public. We should examine this issue in more detail on Committee Stage and see whether we can devise a screening process. I accept cases should be heard in the public domain. Doctors who transgress and are seen to so do should be examined in public. The information should be in the public arena.

Most appointments to statutory bodies are made by Ministers but in this case the recommendations of the nominating groups will be rubber-stamped by the Minister. He or she would take it that those nominated were people of ability and honour and would have time to do the job. The change in the remit of the Medical Council in regard to education, examining practices and peer reviews will ensure its members will be very busy. They must be able to guarantee that they will have time to give to the business of the council. We should demand no less than this because they will be acting on behalf of the public, not the medical profession. They are there to protect the public, ensure the members of the medical profession keep up to date, are well educated, caring and of high quality.

I fully support the Minister and commend the Bill to the House.

Mr. Durkan

I am glad to have an opportunity to speak on the Medical Practitioners Bill 2007. Like Deputy Fitzpatrick, I should declare an interest — I was a member of a local health committee and the local health board for many years. As I listen to this debate, I have to compare the problems the House is considering with the problems it used to have to manage. In the bad old days when this country had no money, patients could go into hospital and be attended to immediately, without having to wait for beds to become available. Nowadays, patients have to wait for the triage group to meet, assess them and pick out the must urgent cases. While I accept the need to prioritise, it is not right that patients with less important problems are pushed to one side, or onto hospital trolleys, when people with more urgent cases arrive. Such a description of what is happening may seem like a simplification, but that is not the case.

Unlike other Members of the House, I think the Health Service Executive cannot and will not work. The HSE is incapable of dealing with the needs of this country's health service. It is the brainchild of people who spent years comparing the requirements of this country's system with those of the system in the greater Manchester area. The two areas should not be equated in any way because of the colossal differences in terrain and distances. While the greater Manchester area has virtually the same population as Ireland, it is compressed into a much smaller area. A further mistake was made when people started to run the health service as a business. Some officials are more concerned with ensuring the service is running than catering for the needs of patients.

When I was first elected to this House, I heard Members giving many reasons for the closure of hospitals. Medical personnel and health service experts from all over the world argued that there were too many hospitals in the country. They proposed that we should concentrate our services in big hospitals. It was absolute rubbish. I do not care who the experts were — their ideas have not worked and will not work. They wrongly believed that adjustments in economies of scale would lead to benefits all round. Such changes have led to congestion and bedlam, however. People are stepping over each other because too many patients are concentrated in the same place at the same time. These problems have resulted from stupid planning over many years on the part of so-called experts who seem to know about everything other than the subject they should know about.

This is a social issue, rather than an economic one. Services need to be delivered as they are needed because it is a matter of life and death. We must use modern technology to upgrade the system, which needs to be more responsive. I do not think the Health Service Executive will do that, however. Given that the HSE covers the public and private sectors, its establishment represented the privatisation of the management of the health services. It was presumed that the new structures would work, even though they have not worked previously. One of the first mistakes it made was to place an emphasis on focus groups, which are needed now that nobody is in a position to tell HSE management what is going on. They dumped the red-necked, red-nosed politicians when they abolished the health boards. They thought we were too expensive and did not know anything anyway.

Ms McManus

Exactly.

Mr. Durkan

We knew precisely what was going on, including some things we were not supposed to know. The abolition of the health boards was promised before the last general election as a panacea that would save huge amounts of money. That was absolute rubbish because it had the opposite effect. It brought to an end the supervision of the health service by the blue-suited, brown-shoed, hard-nosed, red-necked politicians who used to watch what was going on. We often made ourselves unpopular by asking hard questions. We were removed from the arena because we were a nuisance to Ministers. It was tough, but that was the way it was.

There have been a number of scandals over recent years in areas like the political arena, financial services, banking, the environmental sector and the churches. It is good that members of all professions have been investigated and scandals have been uncovered. It indicates that the public has become more perceptive and demanding. I have no problem with it because it should lead to higher standards. This process applies to the medical and health sectors as much as it does to the sectors I have mentioned. I cannot understand why there is a need to provide in this Bill for a more rapid investigative system. Such a system would not be needed if the current systems were operating properly, as they were intended.

We are familiar with a number of instances of highly questionable medical practices in respect of which no action was taken for some unknown reason. Some such cases have been mentioned during this debate by other Members of the House. It is not sufficient to argue that the necessary procedures were not in place. If the normal procedures in any business, including the medical profession, had been followed and the normal comparisons had been made, alarm bells would surely have started to ring in all directions. I cannot understand why people did not ask what in heaven's name was going on. I recall the exacting performances which were demanded when politicians sat on health boards. Hard questions were asked of medical practitioners at health board meetings and in public. We may have been resented for asking such questions, but we asked them nevertheless. Some patients have tragically died after failing to be admitted to hospital, to be treated or to be referred to the right place at the right time. Is it good enough to investigate such cases? Will that bring such people back? Will it ease the tragedy or the hurt and loss for the immediate families? I do not think so.

Deputy Ó Fearghaíl spoke about the need for a vocational commitment in modern professions, which is important in the political arena and in every other sector in which services are delivered to the public. Those who have a genuine vocational commitment have an aptitude for what they are doing and a willingness and desire to serve the greater good. While such a spirit might seem anathema to some modern thinkers, it continues to exist, although it is disappearing. This quality, which is important because it adds significantly to the quality of service that is delivered to the public, seems to have been forgotten in this debate. I was not in favour of the introduction of degree courses for nurses, for example, because I thought it would lead to division within the system. I said at the time that young people who want to get involved in patient care would be excluded. They can work as nurses' assistants, etc, but that is not the same thing. The degree courses have excluded many people. The point made by Deputies Ó Fearghaíl and Fitzpatrick in this regard is correct. One can get 800 or 900 points in the leaving certificate, but it does not prove one has the ability or the aptitude to serve well in this area.

I have the greatest admiration for many medical practitioners, including local general practitioners and consultants, throughout the country. They work extremely long hours — above and beyond the call of duty — day in, day out. They have very little regard for their own health and personal circumstances. However, they do not all behave in such a manner, sadly.

The decision that patient focus groups are needed to deal with fitness to practise problems, etc, is part of the depoliticisation of what used to be a very political area. There was a time when there was an instant uproar if somebody did or said something wrong. Before the issue came into the public domain, questions were asked within the system and therefore the tendency for something to go wrong was averted. The circumstances were questioned. The emphasis now is on treating the issue after the event. We are putting the cart before the horse.

Modern technology could be utilised more effectively. It is possible with the use of modern technology to have video case conferences on a regular basis and to link hospitals. This would ensure standardisation of all aspects of the delivery of the services, whether it be at consultant, doctor or nursing level. This should be a simple task but it is not happening. It is common-place all over the world but for some unknown reason it cannot happen here. It is relatively inexpensive and there should be no difficulty with it. These matters require the attention of the Minister, the Minister of State and the Government.

Other speakers have referred to pay and conditions in the health service. The Government will say that pay and conditions in the health service absorb significant resources and this is especially true because of the way the system is managed. Reference has been made to an administrator from Northern Ireland who highlighted the issues.

I was a member of a health board at one time and I remember a visit to an institution. I will not name the institution but I spoke about it on another occasion in the House. The conditions applicable within that institution were appalling and shocking. An internal dispute was the reason for the conditions but it was the patients who suffered. This situation was uncovered during the course of an inspection by the visiting committee and within 12 hours the issue was addressed in full, otherwise the institution would have been closed down. If the standards and rules do not apply it is quite in order to close an institution.

I have been advised by some people that MRSA is very difficult to control. I disagree and remind the House that simple procedures of hygiene which are enforced around the clock will control it. However, there is no longer an emphasis on hygiene procedures because nobody wants to get involved as it is not an area of expertise.

Deputy Twomey has referred to the work practices expected of junior hospital doctors. I agree that operating theatres should be used on a 24-hour basis but I hope it is not suggested that the same consultant or surgeon should spend the whole day operating in the theatre. I hope it is recognised that the theatres will need to be staffed. No consultant can work from 7 a.m. until 12 midnight as the quality of work would suffer. The same applies to their attendance in wards and theatres all over the country. There are simple issues which could be attended to if practices are put in place. This might have helped to avoid some of the recent problems.

Public servants have a tendency to be defensive when their work is questioned and this is understandable. However, this may not be desirable in the case of life or death situations or in the delivery of health services. I recently telephoned a hospital about a patient who had attended there. I am bound to pass on information that had been brought to my attention because I would be to blame if I did not do so and something happened. I explained my interest in the case and I presume the matter was dealt with but I will revisit the matter if needs be.

In the past five years I have had occasion to bring a situation to the attention of the Minister of State's colleague by way of parliamentary question. This concerned the family of a patient and I decided it was necessary to explain what had happened. However, six or seven months went by with no reply to either the parliamentary question or the letter. It was the new system of answering parliamentary questions whereby a reply is issued a year later if one is lucky. Nothing happened until I insisted, with a series of parliamentary questions, that the matter be taken further. It should be sufficient to write one parliamentary question and receive an immediate response. That is the way it used to be when I was first elected but sadly, things have changed everywhere and not always for the better. In matters of that nature it does not necessarily mean that a public representative has a hidden agenda or is looking for publicity; it may mean that a genuine issue needs to be addressed. It should not automatically follow that every possible means is found to make excuses for not providing the information.

This Bill may be beneficial in protecting patients and patients expect to receive a service from the health system. They are supposed to receive an efficient, fast and effective service. Those providing the service are also supposed to be treated fairly and to be paid. Reference was made by other speakers to the fact that almost 70% of Irish-trained nurses leave the service. This must be addressed as a matter of urgency. They go to agencies and come back to work within the service with the result that the agency is the main beneficiary. Something crazy is happening. That is why Mr. Robinson was able to identify measures that were counterproductive. I would love to have more time to speak on this subject, in which I have taken an interest for many years. I hope I will be around for a few more in order to continue to take more than a passing interest in it.

Dr. Devins

I am delighted to have an opportunity to speak on this Bill. I wish to refer briefly to an issue Deputy Durkan raised in the course of his contribution. He mentioned the fact that doctors, particularly consultants, worked very long hours. It is the Government's objective to provide a consultant-provided rather than a consultant-led service. Unfortunately, as the Deputy and I are well aware, there are some regional or general hospitals in which consultants are on call for up to 48 hours at a time. That is certainly not conducive to good patient care. Therefore, the Government is to be commended for moving as quickly as possible to increase consultant numbers.

The need for the current arrangements to be updated is obvious, particularly when we consider that the existing legislation has been on the Statute Book for over 30 years. A new, modern, efficient and accountable system of regulation is patently required. It is agreed by all that changes to the 1978 Act are not enough — we need new legislation such as that before the House. In that regard, I welcome the input by the Medical Council which has made it clear that it supports the Bill. The council, together with other interested bodies, made numerous submissions to the Minister while the Bill was in gestation. From what the Minister said, I understand a total of 58 submissions were received. I was glad to hear that patients and patient advocacy groups were among those who had made submissions. As is patently obvious, the Government is committed to ensuring patient safety in legislation. That is the purpose of the Bill.

The main purpose of the Medical Council is to regulate the medical profession to ensure the public interest is safeguarded. This can be done in many ways: from ensuring the training of medical students is of the right quality to supervising ongoing education and training of doctors once they have qualified. If there is a problem with a doctor concerning health or fitness to practise, the appropriate committees of the council are utilised. Recently, we all saw the investigation by the council of Dr. Neary and the subsequent report by Judge Harding Clark. While for many this type of case may be their only source of knowledge of the council's workings, it is only fair to state an enormous amount of the council's time is taken up in supervising the training and subsequent qualifications of doctors.

The Medical Council is entrusted with maintaining the highest possible standards of medical care. It is an onerous task and one for which we need a modern, well resourced council which must be fully equipped to do such work. If enough resources are made available to the council to maintain the highest possible standards in training and supervision of qualifications, one hopes the need for fitness to practise investigations will be kept to a minimum. We must be realistic, however, and realise that even with the best standards applied, there will always be cases where the level of care by a doctor will not meet the requisite standard.

One of the remarkable facts about medicine in this and many other countries is that once doctors have qualified, they do not need to undergo any further training or education if they do not want to. Medicine is a complex and, thanks to the explosion of knowledge, rapidly changing profession. It is constantly evolving and new investigations and treatments are becoming available all the time. Speaking as a former practising general practitioner in Sligo, it is obvious that to practise safely and to the highest possible standards continuing education is essential. Most medics of whom I am aware do this either by further study, attending lectures or courses, or keeping up to date by reading medical journals. All these activities are part and parcel of continuing medical education.

At this juncture, I pay tribute to the County Sligo GP Society which can lay claim to being the first clinical society in Ireland to be devoted solely to general practice. It is run by GPs for GPs and engages in a wide spectrum of medical education activities. It also hosts a successful annual seminar which is attended by doctors, not just from Ireland but also from abroad, who discuss the latest investigations, treatments and ideas. In recent years this group of GPs in the north west has established connections with doctors in many European countries to the mutual benefit of all. Last weekend I had occasion to visit the society's annual seminar which was a stimulating experience. I have mentioned this society because it is an example of a body which promotes continuing medical education of which I am personally aware. All over the country doctors in hospitals or general practice are engaging in similar educational programmes. The fact remains, however, that there is no compulsion for any doctor to undertake further study. Unfortunately, I am sure there are some doctors who have not engaged in any such further education programmes from the time they qualified from medical school.

The Medical Council has an important role to play in this regard, as prevention is infinitely better than cure. I welcome the steps the council is taking in terms of continuous medical assessment and competence assurance. For the public to have faith in doctors, it must know that there is continuous assessment of a doctor's knowledge and skills. I welcome the fact that the Health Service Executive and other employers are required to facilitate competence assurance but I am aware of some concern that too much time may have to be spent on form filling. At a recent meeting of world medical regulators in New Zealand the issue of competence assurance was discussed. It was suggested the average doctor would have to spend between six and nine hours per week dealing with such issues, which in many cases could account for 20% of their working week. It is essential that competence assurance and continuing medical education are developed. We must also ensure the system does not develop in such a way that it becomes an end in itself, rather than a means to an end. I hope the new Medical Council will take these concerns on board because nobody wants to see a situation where perhaps 25% of a doctor's working week is devoted to competence assurance to the detriment of patient care.

On a separate issue, I note that the Our Lady of Lourdes Hospital inquiry report by Judge Harding Clark states, at page 345:

The Department of Health and Children should introduce legislation to protect clinical governance records and risk management clinical incident forms from the application of the FoI Act. Unless these documents are protected from FoI or discovery they are unlikely to be created and opportunities for learning from mistakes will be lost.

The absence of such an exemption will undermine any prospect of creating an open environment in which adverse incidents will be reported and, I hope, lessons learned. A balance should be stuck on this issue.

Until now, the Medical Council has had a majority of medical members but under the proposed legislation, there will be a majority of lay members. This is a huge step forward and constitutes a first for any medical council or its equivalent in Europe. There has been much discussion concerning this change in the council's composition and it is an issue which I am sure will be debated more fully on Committee Stage. Suffice it to say that some of the nominating bodies could potentially have a conflict of interest. For example, the HSE is the employing body of most doctors and the body which runs all our public hospitals. Is it an appropriate body to have the right to nominate somebody or, under this legislation, two persons who may have to adjudicate on an employee, or visit or report on the facilities of a hospital under its care? Concern has been expressed to me and other Members of the Oireachtas that the independence of the Medical Council and, more importantly, the perception of its independence may be compromised by having council members nominated by such a body. There are also some concerns with regard to the relevance of some of the other nominating bodies, specifically the Royal Irish Academy. These are issues which can be discussed more fully on Committee Stage.

Competence assurance and regulation of training facilities will take up an increasing amount of the work of the new council. The workload of all members will increase dramatically, but the workload of medical members, in particular those from an academic background, will be enormous. This issue will be dissected and analysed on Committee Stage. Having heard the Minister's speech, I am sure she is well aware of this issue and I welcome the fact that members may be co-opted to various committees to help carry out the work.

I would like to discuss one of the most important aspects of the council's work, namely, the composition and workings of its fitness to practise committee. This committee hears allegations, conducts inquiries and makes judgments as to whether a doctor's conduct falls below the appropriate standard. This is the aspect of the Medical Council's work with which the public is most familiar, but it takes up relatively little of the overall work of the council.

There has been much discussion on the composition of this important body which operates in a quasi-judicial way. There is a strong case to be made for its having a chairperson from a non-medical background. Such is the importance of the committee's work that having a person with a legal background as chair, whether senior counsel or an established solicitor, might be the best way forward. It is also worth discussing whether such hearings should be in public or private. That decision is difficult because of the sensitive nature of the issues. Some patients might prefer to have their complaint held in camera. There is a case to be made for allowing people the right to decide whether to opt for public or private hearing.

I welcome the Bill which has been a long time in coming. I look forward to discussing the issues in more detail on Committee Stage. I congratulate the Minister and the Government for driving forward this much needed change in the regulation of the medical profession. As the Minister stated, patient safety is at the heart of the health reform agenda. The Bill has patient safety as its raison d’être.

Mr. English

I welcome the opportunity to make some comments on the Bill which is welcome. I welcome the initiative behind the Bill and I welcome discussion on the area, but there are some problems. I will not go through the debate on Navan hospital again as we had that debate yesterday. There has been much talk about the Medical Practitioners Bill prior to its arrival in the House and there has been significant correspondence on it. I am glad we finally have the opportunity to debate it.

As the Minister stated, the main concern of the Bill is trust. We live in an era where trust is absent. It is absent not just in the medical profession, but in various organisations, the church, politics, etc. People have doubts, often with good reason. Life experience and reports of what takes place in hospitals have created fear and people no longer believe and trust in our systems, not just the medical system.

It is our duty to try to restore confidence, faith and trust in the systems for which we are responsible, whether social welfare, health, justice or whatever. We must all face that challenge over the coming years and try to give people a belief in what we do in this House and in Government. We do not always do a great job in this regard, yet we expect and demand other organisations to reform and take new initiatives.

I spoke about this with regard to justice. We have had many Bills in the House on the issue of reform of the Garda, etc., yet we have never had a proper debate about reforming ourselves or the House and how it works. We demand and expect every other organisation to reform and change the way they do business, but we have not done it here. This issue is separate to the Bill under discussion, but it is something we must face up to at some stage. We must modernise the way we do business and be accountable to Government, the Opposition and the public. I believe the House does not represent a real democracy in the way it works. If I, as a Deputy, say that, what does the public think? The issue of trust arises across the board and is all about restoring faith in our systems.

With regard to the medical profession, we have a major role in restoring belief in the service to the people. It is not all about money and hours of work but about providing a service. The desire to serve is an essential requirement for those who want to work in the public health service. Those working in the service are meant to be there for the good of patients and must believe they are there to serve. Politicians also serve.

The country seems to have lost belief in the idea that we are here to serve. This leads to abuses in the system, for example, the abuse of power, patients not getting the treatment they deserve or proper recognition, or patients' rights being abused. Many of our public servants no longer believe in public service. We have a role in trying to restore belief in the service. We can have all the rules, guidelines and councils we want, but if the people working in the system do not believe in what they are doing or do not do it for the right reasons, they will find a way to abuse the system, breach rules or break guidelines. There are bad eggs everywhere.

We must put legislation like this in place to monitor and control, but we must also work at restoring the desire to serve the community and patients and to deliver on results. It is not all about personal agendas. When we succeed in restoring this desire, it will help restore faith because people will get a different reaction from frontline staff. This aspiration is not just for the medical profession. We must deliver on service in this House and set a good example.

Many of the abuses in the medical and other professions are a result of the practice of deference and submission to authority. People bowed to authority and thought they did not have the right to question or be informed. I welcome the new initiative to ensure people are better informed and are not afraid to ask questions. Legislation such as this gives people confidence to ask questions and to know they have a say and are important.

There are, however, many people of various ages and with various levels of education who feel they cannot ask questions or who are afraid to ask them. We often meet these people because they come to us for advice or to ask us to ask questions on their behalf. We are not doctors and do not work full-time in the Department of Health and Children, but we try to give them advice and let them know they can push for information and ask questions. They must do so. Often, a sick hospital patient depends on a relative to push his or her case because he or she does not have the energy to do it or is afraid to offend the doctor.

We must let the word out that people can ask questions and seek information. They can demand and expect that. It is important to make a person available in all hospitals to link with the public and to tell patients in their own language exactly what is going on. They must be let know they have the right to push and expect more from their doctors.

Some people are still afraid to ask doctors a question, to challenge them or to advise them of what a second doctor has told them. I know of many experiences where people told doctors about advice or opinions received from somebody else and the attitude was how dare one offer an opinion, as if the opinion of the doctor in question was the only one that counted. We have seen, from the experience in Our Lady of Lourdes Hospital and other hospitals, that to accept just one person's opinion is a dangerous route to take. There should be greater openness in this regard.

The Bill removes self-regulation from the profession, which is a help. It is wrong for any profession to have the members of that profession responsible for regulation. I welcome any initiative to try to give Joe Soap a real say in a council such as this. There were many submissions in this regard and I am glad the Minister took them on board. I would still share my colleague's concerns that the Minister might have too much power in it. It is all about perception. We are supposed to believe this is a new way forward, safe from political interference. When one is explaining one is losing. The Minister went to great lengths today to explain that there would be no political interference in this system and that it was straightforward, but the fact that she had to say so proves to me that there is room for interference on this. We are supposed to close that door off so that interference is not possible.

One of the reasons there is a need for the Bill is what happened in the past, especially following publication of the Our Lady of Lourdes Hospital inquiry and other reports. We are fortunate to have good reports which document the hurt, trauma and abuse that went on in some of these hospitals. Our Lady of Lourdes Hospital inquiry is one with which I regularly have dealings and the hurt of the parents involved is very real. They are still suffering, yet the State did not act for a long time. The systems failed those people and it was only eventually — the same old story of a just-in-time policy — that the Government did anything to ease that pain, get information, get answers and punish those involved.

Sadly, there are other scandals still left unaddressed. What the Parents for Justice campaign is going through in the organ retention scandal is appalling. We are debating a Bill to restore faith, trust and justice in the system when they are still looking for information and answers. Those parents are going through absolute hell every day and the Minister is not doing enough to get the answers the families need to bring closure to their cases. The families are bitter about that and we really must go further to help them.

I went with parents to a hospital when they were to receive their child's organs and it was one of the most traumatic experiences I have ever had. Although I am young, I have witnessed a great deal but that certainly was one experience that went right to the heart. Their child, in their eyes, arrived out in one small white box. Their baby's organs were a set of slab slides, the size of microchips, out of the science laboratory. What they got back, in three or four different boxes in packages, was their child's organs. It was extremely traumatic.

They sat there that day and I sat with them. During the meeting of approximately an hour the parents asked questions of the relevant doctor. He could not give any answers or he could not give opinion, or there were legal reasons he could not give it. They did not get the answers they needed. They did not get all the parts of their child back. This occurred years later, following a cover-up. The parents thought they had buried their child's remains only to discover they had not, and they are still looking for parts of their child. That is an absolute disgrace and we have not done enough to get the answers.

I feel strongly about debating this Bill and speaking of the future when we have not done enough to correct the problems of the past. As Minister for Health and Children, Deputy Harney has a major role in getting those answers and bringing closure. What those parents are going through is appalling. By the grace of God, most of us here will never have that experience, especially because of change in legislation. However, we must correct what has happened in the past and end this saga once and for all.

The Bill is also about patients believing that doctors are adhering to best practice, that they have access to proper follow-up and that they can investigate the system. We are told that patients deserve best practice, but they need to know what best practice is. It is not clearly explained to everybody. While I accept best practice amounts to adherence to international standards, it seems to change quite a bit to suit the argument and it is not enough to merely use the words. One sees "best practice" referred to in health reports. Often it seems an excuse to bring about changes that will save money or to rearrange services. The perception among the general public is that best practice means the best system to suit the everyday lives of the doctors and the consultants, including golfing requirements, and that needs to be changed.

There has been talk for years of a new regional hospital in the north east to replace existing hospitals. After the HSE was formed, one of the new officials who was given the task to wrap up the matters in the north east, close as many hospitals as possible and get a new one opened explained to us that a catchment of 250,000 people was needed for a top-class regional hospital to give best service. We were told that was best practice according to international standards and that was the buzz line approximately two years ago. Then, seven or eight months ago, when the Teamwork document was published, another group of consultants brought in so-called experts from the UK to produce a report on the future needs of the north east and, lo and behold, we are told that the magic figure according to international best practice is now 350,000. It has changed by 100,000 in a year. I would say the main reason that figure changed is that the population in the north east has increased to over 350,000, heading towards 400,000 plus. The magical figure of best practice suits the new argument for one new hospital for the north east. In fact, if that Teamwork document is to be believed and if 350,000 is the new figure, we should be looking at building two regional hospitals in the north east, especially as that document is a plan for the next 20 or 30 years. The population of County Meath alone is over 170,000 and heading for 200,000 within the next couple of years. The population of County Louth is 150,000 plus. The populations of counties Cavan and Monaghan are both between 60,000 and 70,000. If the population of the north east is well above that magical figure of 350,000 and heading rapidly towards a second 350,000, should we not be discussing two regional hospitals for the area?

While the Minister is present I take this opportunity to raise another matter which is slightly outside the scope of this Bill, but it all comes back to patients' safety and patients' service. Recently on "Question and Answers" the Minister stated that in the future we will build this new regional hospital, a project we all support. In the meantime, however, we must retain services to the highest standard in our hospitals, but we in Navan are being told that the emergency surgery service is to be withdrawn — in fact, it is nearly gone. We are told this is best for patients.

The Minister stated that there must be investment in certain hospitals, even during this ten-year period until the new hospital is built, and she mentioned Our Lady of Lourdes Hospital and Cavan General Hospital in that regard. She did not mention any investment in the hospitals of Navan, Louth or Monaghan. While I accept she cannot put money into them all, the Navan case is worth looking at because its population has nearly trebled in the past couple of years. The population of Meath has increased by over 50%. The journey from the further parts of Meath such as Enfield, Ballivor and Oldcastle to Our Lady of Lourdes Hospital in Drogheda takes well over an hour, yet we are being told that it is best for the people of Meath to withdraw emergency surgery facilities, which has a knock-on effect in reducing the service provided by casualty and accident and emergency. We are being told to accept that in the next couple of months, yet the completion of a new regional hospital could be ten years away at best, if not 15 or 20 years.

I have asked Professor Drumm about this. He has been on radio telling us all that we should accept this, he knows his stuff and he will challenge any of us to debate it with him. Nobody has come down to explain to the people how it is best for them to remove this service. I accept, as we all do, that the emergency surgery service in the hospital is not ideal, but that is because of a failure of Governments over the years which did not provide the hospital with the resources and staff to keep functioning to a high standard.

Navan hospital provides a great service but we are told, by a crowd from the UK who wrote Teamwork, that it is best to withdraw that service now before anything better is provided. It is hard to accept. In my humble opinion, and in the opinion of the average Joe Soap, it would be best to keep the service where the people can get to it in time after a serious accident. Would it not make sense to improve the service? We are trying to operate a surgical department which should have at least three consultant surgeons with one and a half whole-time equivalents and expect them to perform miracles, and yet the Bill is about ensuring best practice is adhered to. It is not best practice to have half the number of staff necessary running a surgical department. It is certainly not best practice to withdraw the service. Best practice would be to put additional staff in place to ensure a top-class service.

When the new hospital is built we will accept the withdrawal of services in Navan hospital and in other hospitals. When the new hospital is large enough to cater for all the patients and the population concerned that would make sense, but at present we are being shoved into Our Lady of Lourdes Hospital which cannot cope. It has not increased in size in the past ten to 15 years, yet the population in its own county has increased dramatically, never mind all the Meath patients. Lumping a catchment area of 170,000 on top of an existing hospital does not make sense, has not been explained properly and certainly could not mean best practice.

The Bill is about ensuring people can trust and believe in the system but it is hard to envisage this happening in the current environment. It is to put people first and give patients greater influence. They must also be respected by health service staff. That is not always the case. The Minister cannot wave a magic wand to solve the problem, but she must try to instil a sense of respect into all medical staff, both at the front line and in offices. Patients do not deserve to be treated like nobodies and should be given complete information. They should not be kept in the dark and fed like mushrooms, which often happens.

Doctors are working in a much more demanding environment than heretofore because of population trends, new initiatives, best practice guidelines and modern advice. They require new guidelines and watchdogs to keep an eye on them, but we still expect them to work savage hours. Some junior doctors are working unbelievable hours. There is no point saying life is bad and that they are under pressure. Government decisions resulting in the failure to provide enough doctors and resources are putting them under undue pressure in the first place. In this regard, I have already mentioned the surgical department in Navan hospital but it applies in other hospitals as well.

I welcome the idea behind the Bill, especially the view that the public interest must come first. However, the public does not believe it. The Bill is a step in this direction although it requires amendment. I want to believe the public and patients come first, yet I deal closely with people who say they do not.

Reports such as the Teamwork report recommend changes that do not make sense and appear to have been drawn up to suit the HSE's plans, the Government's agenda and resources rather than to implement what is best for the patient. I have said to consultants, Professor Drumm and others that they should explain to the people why the reports' recommendations are best for them, but nobody is doing this. Decisions are made and services are withdrawn without consultation and people are left in limbo, with longer journeys to make if they need to go to a properly staffed accident and emergency unit. This is certainly not good enough.

Consultants were paid taxpayers' money to produce the Teamwork report. When they arrived in Buswells Hotel to present it to all the Deputies from the north east, we listened and accepted the need for change. However, when I went to Navan hospital, where I was told services would be withdrawn, and asked the chief member of staff if he knew there was a mine employing over 700 people under the hospital, he could not answer my question. He and the staff around him had a look on their faces that confirmed to me that they did not realise it. The mine has an ambulance on its premises, not for fun but because it is quite possible that a serious accident could happen at any given time in which many persons, even 50 or 60, could require emergency treatment. Although it is very important that a top-class accident and emergency unit be retained at Navan hospital, the consultants reporting on its future did not realise and were probably not even told about the mine. Will the Minister check this out? If I am wrong, so be it, but I do not believe I am. If I am correct, the report must be fundamentally flawed and will have serious consequences for many people.

Minister for Health and Children (Ms Harney)

I thank the Deputies who contributed to the debate. It is not unusual that they wandered somewhat beyond the remit of the proposed legislation. It is fair to say there is broad agreement on the need for new legislation to regulate the medical profession. The current Act is almost 30 years old and, as I acknowledged in my opening contribution, much has changed in the intervening years.

I refer in particular to the expectations of patients regarding regulation. This Bill provides for a modern framework for regulating the medical profession. Sometimes there is confusion between the regulatory body, which must act in the public interest, and representative organisations that represent doctors. This confusion is often evident in Members' contributions.

The council is a public body established by statute. In the first instance, it must inspire public confidence, and this is greatest when there is a lay majority. Yesterday a White Paper was published in the United Kingdom by the Secretary of State for Health and the chief medical officer. They make the point that doctors should not comprise the majority. To be fair, one must realise they are discussing parity between doctors and non-doctors. We have a 25-member council and have chosen a ratio of 13:12. The lay majority is not just for optics. If it were there would be no point to it. It is a question of reassuring patients and the public that the body that oversees the regulation of doctors is, above all else, concerned with the public interest and is not involved in the regulation of the profession by the profession.

Deputy McManus referred to the comments of Mary Raftery. She is a journalist with whom I do not always agree but for whom I have high regard because she is insightful. I have spoken to former lay members of the Medical Council and they take a very different view from hers. When we were legislating for the Health and Social Care Professionals Council, nobody made an issue of its lay majority. The Bar Council recently decided to have a lay majority. It did so purely on a voluntary basis because it is not a statutory body. It felt this decision would inspire greater public confidence in the regulation of the Bar. Before becoming Minister for Health and Children, I established an oversight group to supervise regulation by the different accounting bodies. This has a 60:40 lay majority. Most accountants I meet tell me it has worked extraordinarily well although there was much fear and worry when the ratio was proposed.

We are not talking about appointing just anyone to the Medical Council. A number of bodies are mentioned in this regard, one of which is An Bord Altranais. Nurses work very closely with doctors. The HSE will have two representatives and the independent hospital sector will have one because it is a large sector. This sector has featured since the latter part of the 18th century and it is appropriate that it have representation. There will be a representative from the Royal Irish Academy because the area of research is important.

Ms McManus

It is very mysterious that the Royal Irish Academy is represented.

Ms Harney

Research is important. Every day our criminal justice system operates by having 12 ordinary women and men sit as jurors to assess very technical information, sometimes medical information, and reach a decision thereon. Nobody has ever questioned the capacity of ordinary women and men to understand the relevant issues.

Ms McManus

I am questioning the representation of the Royal Irish Academy.

Ms Harney

It is a reputable body.

Ms McManus

Absolutely.

Ms Harney

It was suggested to me by doctors that it might be appropriate to consider it for representation. It has a great role to play in medical research.

On Committee Stage we can tease out these issues further but, as I stated, one of the first points made by the White Paper published in the United Kingdom is that doctors should not be in the majority on regulatory bodies. Many countries are examining this idea.

Let me address a point made by Deputy Twomey that I found rather bizarre and which I do not want to let go. He said that if a Minister such as Deputy Martin were again Minister for Health and Children, he might give a direction to the Medical Council on stem cell research and the termination of pregnancies. I do not understand this. Abortion is illegal under the Constitution.

Ms McManus

It is not illegal under the Constitution where a woman's life is in danger.

Ms Harney

That is true but it is not a matter for the Medical Council, as the Deputy well knows.

Ms McManus

Doctors, as the Minister well knows, are carrying out abortions to save women's lives. The Government ducked the issue.

Ms Harney

Deputies McManus and Twomey know well that the Medical Council has no role in respect of these kinds of issues. That is clearly stated in the legislation with regard to ministerial directives on general policy issues such as medical education and training, the numbers of people enrolled on courses and the length of time they spend in education.

As a result of this legislation, the Medical Council will receive public funding for the first time. The provisions do not exist in a vacuum because it is not unusual in legislation dealing with governance of the Central Bank, the Environmental Protection Agency and several other independent bodies that the Oireachtas provides for ministerial powers in respect of policy directives. Those who try to misrepresent that provision as ministerial interference in the operation of organisations could not be further from the truth. It is specifically stated in the legislation that Ministers cannot interfere in ethical, fitness to practise or other operational issues.

Dr. Twomey

Things can change.

Ms Harney

There is no question of giving a Minister inappropriate powers, nor should there be. We can discuss the issue further on Committee Stage but I do not want to see political interference with fitness to practise or other ethical issues.

The examples provided by Deputy Twomey from his experiences as a doctor were frightening. Our hospital system is overly dependant on juniors, although I did not realise that a junior doctor could be asked to carry out the complex procedures performed by the Deputy on his first day in the job. Until we reach the stage where we have sufficient consultants, I am certain that juniors will continue to do inappropriate work which should be supervised or carried out by consultants.

Although 15,000 doctors are registered in Ireland, of whom 12,000 are in the country, we need to switch the balance in hospitals between junior and senior doctors. Appropriate supervision is also needed, which will require competence assurance. I am not in a position to indicate the number of doctors in Ireland who are not competent to practise or the number of bad doctors, although I hope they are very few. However, if we do not continue to educate and keep apace of the rapid developments taking place in medicine, we will not be competent to do our jobs. De-skilling happens in medicine as well as other areas.

Competence assurance, which Deputy McManus claimed was initiated by the Medical Council, involves self-assessment and peer review on an ongoing basis. I am not the competent person to set out that process. Several months ago, I launched a voluntary scheme for general practitioners developed by the Medical Council and the Irish College of General Practitioners. I understand 350 doctors are participating in that scheme, along with their patients. The competence assurance model which the Medical Council wants to have introduced will be expensive and that is why we have enshrined a commitment to public funding.

Dr. Twomey

What is the cost of implementing the scheme?

Ms Harney

This week I spoke with Dr. Quigley, who is involved on the issue as vice president of the council, and he undertook to send me the costings.

Acting Chairman

The Minister could provide the information on Committee Stage.

Ms Harney

I am advised that the cost of administration is €2.4 million.

Dr. Twomey

That figure does not cover carrying out the competence assurance scheme.

Ms Harney

I will revert to the Deputy on the matter. I understand the Medical Council has submitted cost proposals but I have not studied them personally. I would be happy to make them available in advance of Committee Stage debate.

Ms McManus

I would also appreciate a copy of the information.

Ms Harney

I can arrange that. I will also send a copy to Deputy Gormley, in case he thinks I have some reason not to share the information with him. The scheme will be expensive but the doctors made a compelling case to me that expecting it to be financed from registration fees would greatly delay its implementation. We are therefore going to make public moneys available from the time of enactment of this Bill towards the cost of the scheme.

With regard to the education and training elements of this Bill, medical education in Ireland is changing. Several Deputies referred to the high number of points needed to enroll as a medical student. The points required will drop to 460 and we will take 60 graduate entries from this academic year. We increased the undergraduate places for the academic year beginning 2006 by 70 and we will increase the numbers of Irish and EU students from 325 to 725. That will clearly be expensive, requiring, for example, the appointment this year of an additional 17 academic clinicians, and we will have to provide the resources at third level to accommodate the huge expansion in the provision of medical education. We also have to find ways of retaining those who graduate from the Irish education system because, while it is good for people to go abroad for part of their training, I would like to think the Irish health care system can attract them back.

The legislation also makes provision for foreigners who come to work in Ireland and remain on the temporary register for considerable periods of time. The present process for allowing highly qualified people from the US and elsewhere to become specialists in this jurisdiction is very cumbersome. I note that today's news led on this provision, along with the refugee issue, which is being addressed on humanitarian grounds. It will be a matter for the Medical Council to assess the quality of refugee applicants and to assure itself they have the appropriate qualifications. It would be awful to think that a refugee with qualifications in medicine was not able to apply his or her training in the Irish health care system.

While many of the issues raised today are more appropriate to Committee Stage, I wish to speak about whistleblowing. The Bill provides that doctors who give evidence to inquiries or fitness to practise tribunals against colleagues are protected from being sued. A number of doctors have informed me that it is difficult for them under current legislation to speak their mind because they fear litigation. An amendment will be proposed on Committee Stage of the Health Information and Quality Authority Bill to protect all employees from victimisation in their places of employment and from being sued when they make complaints, provided they are not vexatious. That important provision will cover all health care settings. However, I believe the lack of such provisions at present is not the reason why people do not make complaints. Many complainants prefer anonymity to being identified even where they are not victimised.

Deputies raised a range of issues, from the nurses' strike to hospitals in the north east. This is not the forum to address such issues because the most fundamental change brought by the Bill is ensuring that we have the highest possible standards of patient safety and that competence assurance is at the heart of the regulation of medical practitioners. The provisions for a lay majority and protection for those who make complaints from being sued are important but it is most reassuring from a public and patient safety perspective that we will for the first time have a system for ensuring that doctors on the register are competent to practise. I commend this Bill to the House and look forward to Committee Stage.

Question put.

Dr. Twomey

I call a division.

Acting Chairman (Dr. Woods)

The division will be taken immediately after the Order of Business on Tuesday, 27 February, in accordance with the Order of the House of yesterday, 22 February 2007.

The Dáil adjourned at 2 p.m. until 2.30 a.m. on Tuesday, 27 February 2007.