Other Questions

General Practitioner Services

Thomas P. Broughan

Question:

6 Deputy Thomas P. Broughan asked the Minister for Health and Children her plans to make it easier for new general practitioners to provide services for patients who hold a medical card; and if she will make a statement on the matter. [41864/10]

I strongly support the view that access to General Medical Services, GMS, contracts should be opened up to all qualified and vocationally trained GPs who meet general suitability criteria. The Irish Medical Organisation, the HSE and my Department are parties to the terms of the GMS contract. A consultation group representing all parties to the contract have been reviewing the provisions relating to entry to the GMS scheme. Considerable progress has been made in this regard. An interim arrangement which applied up to 31 March 2010 allowed appropriately qualified and trained GPs to apply for access to the GMS scheme to provide a service to specific categories of patients such as those who become eligible for a medical card under the Health Act 2008 after 1 October 2009. A total of 178 GPs have been deemed eligible under this arrangement and a further 66 applicants are awaiting a decision pending the supply of further documentation or further clarification.

A further initiative which allowed a number of GPs who commenced working under the GP visit card scheme in 2005 to be allowed take on full GMS patients in 2010 was brought forward by one year and implemented from 1 July 2009. Approximately 50 GPs benefited from this measure. In addition, work is ongoing to identify a mechanism to up-skill long-term locums or assistants who are not currently eligible for GMS contracts. My Department and the HSE continue to explore further options to make it easier for new general practitioners to provide services for patients who hold a medical card.

I thank the Minister for her reply. That all sounds very good and progressive but the Competition Authority notes that before any decision is made regarding a new contract in an area, due regard must be given to the viability of existing GP practices. The marking system used for selecting who will be given a contract gives more points to GPs who already hold contracts. As the authority points out, this is not good for either competition, the patient or the service. Everyone will agree that having competition around the corner from another GP probably forces people to up-skill. Newly qualified GPs are being forced into practice in existing areas. It needs to be opened up.

I refer to a report by Dr. Ronan Boland whom I know quite well. He stated that criticism of the decision on payment agreements for GPs was no longer valid. He said that as part of the Croke Park deal, the most recent public service agreement, the Government said discussions would take place with the Irish Medical Organisation regarding commitments to make appropriate changes to the Competition Act 2002 to enable the IMO to represent its members in negotiations. I welcome this proposal but where does this leave the poor old Irish Pharmacy Union?

I agree with the Deputy's point about the marking system. Changes in that marking system are at an advanced stage in order that preference is not given to the individuals as she suggested, and that is only fair. I have been informed there could be 400 or 500 GPs. The data suggest it is probably close to 500. There are a total of 2,600 GPs in active practice, 300 doctors are working in a locum capacity and 2,100 have a GMS contract. This means there is a gap of 500 GPs and I want those individuals to have access to a GMS contract. There is an agreement between the Department of Health and Children, the IMO and the HSE — previously the health boards — which precludes that. I have sought the advice of the Attorney General. Under the Croke Park agreement we hope to be able to reach agreement on some of these issues. This would involve the change of the contract in this case.

The Competition Act is a matter for my colleague, the Minister for Enterprise, Trade and Innovation, Deputy Batt O'Keeffe. Any changes to competition law are a matter for him and not for my Department.

I welcome the Minister's indication that she hopes for a situation of universal access for GPs to the General Medical Services scheme. That is as it should be and I fully concur with Deputy Lynch's argument. As a backdrop, is there not also the issue of the real shortage of GPs per head of population? When a comparison is made between Ireland and Germany, it is noted that Germany has twice as many GPs per 100,000 of the population. In France the number is in excess of three times as many. The number of GPs in Ireland is 52 per 100,000 of the population and up to 164 GPs per 100,000 of the population in France. Is there not a major need to increase places to allow for a greater throughput of GPs into the system? In 2001, some 600 primary care units were promised but only 112 have been realised and there is a real need. Will the Minister comment on this aspect of the question posed?

I welcome the Deputy's comments regarding opening up the GMS scheme to all GPs. He is correct that there is a shortage of GPs. We have increased the number of training places this year from 120 to 157. We have also greatly increased the number of medical students. The big challenge will be to keep those students of medicine in Ireland or in medicine anywhere because a fair number of medical students do not subsequently stay in medicine. A large number also leave the country, some for reasons of training and others on a more permanent basis.

We have a number of challenges such as opening up access. It is not fair that not all GPs have access to the GMS scheme. The terms of the GMS contract require the parties to agree and to give notice of an intention to break the contract. I have sought the advice of the Attorney General because contracts cannot go against the law. A number of GPs do not have access to the GMS practice and are very agitated, and rightly so. Those issues need to be addressed in the interest of fairness and equity but also in the interests of having wider access to general practitioners with a GMS contract.

The primary care teams involve individuals working together in a different way. I accept there are deficits in the system. Even if all health professionals are working in the community and working better together on a team basis, that in itself has significant benefits for patients.

I concur with other speakers and I encourage the Minister to open up the GMS scheme to suitably qualified GPs. I echo the point made by Deputy Ó Caoláin about the shortage of GPs in the country. Certain areas such as Tallaght have no GP practice. If the contract is to be changed, I appeal to the Minister to ensure that in the opening of up the GMS scheme to GPs, they do not all end up in Grafton Street with no one out in Tallaght. The message is clear that we need to have a structure to encourage GPs into areas where they are needed to provide a service.

The Minister alluded to the fact that many GPs have been many years in practice but are not in the GMS system. Will they be given priority because they are being treated most unfairly?

The change must be made in the first instance. Anyone who is qualified should have access to a GMS contract if they have the necessary qualifications and vocational training. If this is the case there should be no barrier. It is in the interests of the HSE to provide supports for GPs based on volume of patients. It would not be acceptable for a small practice to be given the same level of support as a large practice with a large number of patients, especially in disadvantaged areas. This may not appeal to everyone but I favour distorting the way we pay GPs to favour those operating in more disadvantaged areas where the challenges are greater. This is the practice in other countries. In the context of any new contracts, we need to examine this policy.

Health Promotion

Mary Upton

Question:

7 Deputy Mary Upton asked the Minister for Health and Children the steps she is taking at national and European level to curtail or significantly reduce alcohol sponsorship of sport; and if she will make a statement on the matter. [36699/10]

I am concerned about the high level of alcohol consumption in Ireland, especially among younger people. One in four deaths in young men between the ages of 15 and 34 is due to alcohol, compared with one in 12 deaths due to cancers and one in 25 deaths due to circulatory disease. Suicide rates have doubled in Ireland in the past 20 years. Alcohol is a factor in nearly half of all young male suicides.

As Minister of State with responsibility for health promotion, protecting the health of our young people from alcohol related harm is one of my key priorities. Participation in sport is a key element of the health and social well-being of our children as well as the rest of the population and I want to promote this very positive relationship between sport and health.

Following a Government decision in 2008, a working group was established to deliver on the commitment in the programme for Government to discuss the question of the sponsorship of sporting events by the alcohol industry with a view to phasing it out.

This report was published in June 2010 and subsequently the Minister, Deputy Harney, referred it to the steering group developing the national substance misuse strategy to assist in its deliberations on the issues of alcohol marketing and sponsorship. The national substance misuse strategy is intended to incorporate alcohol policy with the already agreed drugs policy element. The steering group is examining a wide range of issues on alcohol policy such as pricing, availability, treatment, prevention, marketing and sponsorship and working towards completing its work before the end of the year. I look forward to receiving its report and considering its recommendations.

With regard to the specific matter of curtailing alcohol sponsorship of sports events at a European level, there is no legislative framework at a European level to control or regulate marketing or sponsorship by the alcohol industry. Member states have national competence in this area. It is a matter for individual member states to introduce and implement measures at national level if they wish to control sports event sponsorship in their own jurisdiction.

One of the most staggering figures I have seen in a long time is that 16 and 17 year olds in Ireland spend approximately €145 million a year on alcohol. We all know it is not possible to put an old head on young shoulders and that we need to divert young men and women away from alcohol-related activities. The only way they seek such diversion is through sport and community activity. However, we do not provide enough facilities in communities to allow that to happen. We have magnificent organisations, the IRFU and the GAA, etc., but some teenagers do not want to join these clubs and want alternatives. There was a very sad case in Cork recently.

I will be very brief. A young man in his first few weeks in college while with a small group of friends died from alcohol poisoning. It was not intentional; it was just something they did because they were celebrating.

Does the Deputy have a question?

When the Minister of State receives the report of the steering group, does she have a timeframe for implementing its recommendations? I am sure some of them will refer to activities within communities.

I do not have a timeframe at this point. However, the question is on sponsorship of sports events by alcohol companies, one of the issues the steering group is considering, but it has not yet reached a decision. Representatives of sports groups, including the FAI and the IRFU, recently met the Minister, Deputy Hanafin, to discuss the isssue of sports sponsorship. It is still being discussed, but I will certainly take the group's recommendations very seriously.

An article in The Lancet concluded that “aggressively targeting alcohol harms is a valid and necessary public health strategy”. Professor Joe Barry from Trinity College has commented on the matter.

Quotations are not allowed at Question Time.

I beg your pardon, a Leas-Cheann Comhairle. Is that the case, even if they inform the question?

I am sure the Deputy is just referring to them.

I am only alluding to them, Sir. There is obviously still a need to reduce demand for alcohol, address the availability of cheap alcohol and have fewer outlets and restricted sports event sponsorship. Will the Government make representations to the European Union in this regard? I accept the matter is within the remit of individual governments, but we need to start somewhere. Surely Ireland could give a lead and show we have a concern in this regard. While I know it is not within the remit of the Minister of State, perhaps she could discuss with her colleague in the Department of Education and Skills whether there should be school modules on the use and dangers of alcohol. As Deputy Kathleen Lynch pointed out, students arriving from secondary school in university find themselves with freedom and disposable income and we have heard what can happen.

The topic of alcohol and health is discussed at the Employment, Social Policy, Health and Consumer Affairs Council which agreed a set of conclusions at a meeting in December 2009, which indicates the importance of the issue across the European Union. As I said, member states may implement measures at national level. As there is no facility at European level, we implement our own measures within our own jurisdiction.

Regardless of the recommendations made in the forthcoming report, I have sympathy with the Minister of State and the Government in trying to address this issue which cannot be left to the Government alone to deal with because a major societal issue is involved. In trying to address it is the Minister of State cognisant that in the past week an editorial in a newspaper with a significant circulation figure totally excused the conduct of a radio presenter who had engaged in a lewd act on a flight into Ireland on the grounds that he was not able to remember the incident? It is incredible that an editorial would reflect such sympathy. How will we ever tackle the issue of alcohol abuse against such a backdrop where a newspaper actually excuses the conduct of an individual because he was not able to remember it?

As I said, I am concerned at the high level of alcohol consumption among younger people andlook forward to receiving the recommendations of the steering group which is working on the matter. I am taking some action.

Does the Minister of State agree that advertising has a significant impact on young people? We heard all of the arguments that sports would collapse without tobacco advertising and sponsorship but that did not happen. Does the Minister of State agree that we should consider the connection between alcohol advertising and sport?

We are reviewing the effect advertising and sponsorship have on young people. It is a major issue. Obviously, the sports organisations are concerned about the financial impact it would have. Their representatives recently met the relevant Minister.

Hospital Services

Willie Penrose

Question:

8 Deputy Willie Penrose asked the Minister for Health and Children the number of public hospital beds that are closed throughout the State; and if she will make a statement on the matter. [41868/10]

The most recent information on bed closures in the acute hospital system is for the week ending 7 November. At that point 892 inpatient beds and 19 day beds were closed for reasons of infection control, refurbishment or cost containment. This is from a complement of approximately 11,800 inpatient beds and 1,800 day beds in the public hospital system.

Access to appropriate care for patients is not about the number of beds in the hospital but about providing quality care and improving outcomes for patients. Previously many procedures such as varicose vein surgery and hernia procedures required patients to stay in hospital. These can now be provided, in the main, on a day-case basis. This is better for patients and a more efficient use of resources. The average cost of an inpatient bed is €889 per day or €324,485 per year.

There is a significant variation between hospitals on the length of stay of patients in hospital for similar procedures. Reducing the length of stay in hospitals whcih have above average lengths of stay will be good for patients, as well as being more cost-effective. Hospitals are also working to reduce admissions by, for example, identifying patients who may only need diagnostics and should not require an inpatient stay in hospital.

In 2009 the combined number of inpatient and day case discharges was 3% greater than in 2008. The HSE's national plan for 2010 maintains the focus on increased efficiency and is committed to delivering broadly the same level of overall hospital activity as in 2009. It is important that the clear focus of the health service is on the number of patients we treat, not on the number of beds. Increasingly our focus is on measuring patient outcomes. This will continue to be the focus in the coming years.

To a great extent, I agree with the philosophy that it is better for patients to spend as little time in hospital as possible. However, last night there were 31 patients on trolleys in Cork University Hospital. Regardless of how good we become or how speedy the procedure is, we will still need beds in hospitals for those who still need to be in hospital. We cannot continue to cut back on the numbers of beds.

A question please, Deputy.

If we continue in this vein, what point will we need to reach before the closing of beds will stop? Do we have 30,000 beds in the system? Can the Minister provide a figure? Clearly, we do not have sufficient beds to meet the needs of patients.

Over the past several years we have increasingly relied on day case activity rather than inpatient accommodation as a way of providing treatment. Last year, the HSE devised a basket of 24 procedures with the British Association of Day Surgery and set targets for hospitals to increase day activity on these procedures from 62% to 75%. There are huge variations in performance across the country. Tallaght hospital does best in the treatment of hernias, with 84% treated on a day case bases, whereas some hospitals have rates of as low as 37%. Mayo had 16% day rates and an average stay of three days for its 138 patients. Some hospitals are better than others at carrying out procedures on a day case basis.

I will not pretend some beds are not being closed for cost containment reasons. Next year will be even more challenging given the reductions required in public and health expenditure. The fiscal adjustment of €6 billion will have a major impact on the resources available for health services, which account for 27% of current Government spending. The quicker we move to best practice on day activity, the better. This year, the HSE committed in its service plan to carrying out 10,000 diagnostic tests on an outpatient basis and to moving 33,000 people from accident and emergency departments to day case diagnostic activity. I look forward to learning the outcome of these commitments and understand the HSE is on target in delivering on them.

In regard to the variation between Tallaght and Mayo, hernias are more common among older people and I do not doubt social isolation, age, lack of carers and remoteness play a large part in explaining why patients cannot be treated on a day case basis.

Will the Minister acknowledge that the number of beds in the system has decreased from 18,000 20 years ago to fewer than 11,000 today despite a population increase of 750,000 during the same period? There have been repeated calls from this side of the House to provide rehabilitation facilities so that people can move to the next phase of treatment after leaving hospital. Last night in Beaumont hospital, 47 patients were lying on trolleys. Another hospital in Dublin had 175 people in what it called delayed discharge situations for up to nine months. The CEO of this hospital advised me that 30 of the patients could avail of rehabilitation services but that the remaining 140 would need long-term care. When pressed as to whether they received appropriate care at the time of discharge, he admitted that at least 50% of them could have gone home with the support of rehabilitation. Not only are we costing the taxpayer money, but we are also doing a terrible disservice to patients. I ask the Minister why she does not provide additional rehabilitation beds for the greater Dublin area, where they are needed.

I accept what the Deputy said about the shortage of rehabilitation facilities. Acute rehabilitation could be provided in a more localised environment and an enormous amount of work has been done on requirements at both national and local levels. Fantastic rehabilitation facilities have been developed in the mid-west for stroke and other patients in order to bring them home and get them better more quickly. I accept that deficits remain to be addressed, however.

The fair deal scheme has reduced by 33% the number of delayed discharges in the Dublin area. I hope to see the scheme being expedited over the latter months of this year and early 2011. The system is up and running and over 12,000 people have availed of it because people who could be in long-term care continue to occupy hospital beds.

Can the Minister estimate the number of hospital beds that will be lost as a result of the cuts she has signalled to front line spending in the health services? In response to previous parliamentary questions she estimated these cuts at between €600 million and €1 billion. How will she explain the ongoing abuse and waste within our two tier system to patients who depend on public hospitals? Clinical directors and hospital managers have had to write to almost 300 consultants regarding blatant breaches of contractual obligations on the ratio of public to private practice. I could provide a list of issues which are causing tremendous vexation and deep anger in many quarters.

The Deputy is correct that the reductions in health spending next year will be a minimum of €600 million but, as the Government has not finalised the four year plan or the Estimates for next year, I am not in a position to confirm the exact figure. When I know the figure, I will sit down with the HSE to work out how the budgetary parameters can be implemented. I do not pretend it will be easy and it will be particularly challenging for the acute hospital system.

Consultants are obliged to meet the terms of their contracts and it is a matter for hospitals and the HSE to pursue breaches. As the Deputy will be aware, it is my ambition not to have private activity in public hospitals. The reason for the co-location model was to ensure beds currently being occupied by private patients who have alternatives can be used instead by public patients. I recognise the Deputy does not agree with that policy but in a country where half the population has private health insurance, we are going to have large numbers of private patients in public hospitals.

Is consideration being given to people who do not require hospitalisation for surgical procedures when stress tests are carried out? I have found that such people have to stay longer in hospital than other patients.

Cork University Hospital is probably at the higher end of the list of bed costs because it is that type of hospital. How many are occupying beds in the hospital who could instead be in rehabilitation and what is the position for HSE south?

Cork University Hospital is at the higher end because of the acuity and complexity of the work carried out there relative to other hospitals. I set out the average costs but they vary depending on staff levels and other factors.

We have been making advances on an agreed policy approach for the country as a whole. Heretofore the approach was to send everybody to a single national rehabilitation hospital for acute rehabilitation treatment. That is being rethought and there is more emphasis on developing a national tertiary facility and a hub and spoke pattern of outreach services in the regions.

Health Service Investigations

Aengus Ó Snodaigh

Question:

9 Deputy Aengus Ó Snodaigh asked the Minister for Health and Children the action she will take on foot of the Hayes Report on Tallaght hospital [41902/10]

I welcome the Hayes report into the management of radiology and GP referral letters at Tallaght hospital, which was published on 4 November. The report is thorough and clear in its conclusions.

The Tallaght hospital review identified serious concerns about the robustness of the governance structures at board and management level within the hospital. The particular problems with the board and management structure, culture and style must be addressed urgently. The report also points to the inadequacy of reporting systems; the lack of clear lines of responsibility; inadequate risk management; lack of written protocols and procedures; communications within the hospital and with the main stakeholders; and poorly developed relationships with GPs in the area. All of these problems are clearly inconsistent with a patient-centred approach. The report makes detailed constructive recommendations about the operation of specific services in the hospital and all of these will be implemented.

Tallaght hospital has 600 beds and employs nearly 3,000 staff. It operates on a budget of €245 million, of which €189 million is provided by the State. Within this resource allocation, the hospital should be able to provide patients with a safe and comprehensive service.

I met Dr. Hayes on 8 November to discuss the implications of his report and I met the chair of Tallaght hospital on 9 November. I have also had discussions with the CEO of the HSE about the report. The main focus will be on the initiatives that are needed in the hospital and in the wider health system to provide sustained improvements in services for patients. The HSE and Tallaght Hospital have accepted all the recommendations in the report and are committed to implementing them as quickly as possible. A number of key recommendations regarding the management of X-rays and GP referral letters have already been implemented. I understand changes have also been made by Tallaght Hospital to the operation of its board, which I mentioned earlier.

I welcome the Hayes report on Tallaght hospital. I urge the full and early implementation of all the recommendations in the report. Tallaght hospital is a fine hospital. Its staff and patients deserve full support. While I acknowledge that progress is being made in addressing administration and filing deficiencies, I must refer again to the cutbacks the Minister has signalled for 2011. What impact does the Minister expect those cutbacks to have on X-rays and GP referrals? How can a significant increase in the amount of time people have to wait to secure treatments be avoided?

I remind the Deputy that this question relates to the Hayes report.

This is a real concern not only in Tallaght but in all hospital sites at this time. The Minister has said we have a challenging time ahead. The reality is that it will be a serious time, or worse, in the lives of the many patients who present themselves at our hospitals.

It is clear that when next year's reductions are being made, the priority will be to maintain services for patients. I will deal with that in my discussions with the HSE when I am aware of what the exact figure will be.

I remind the Minister that this question relates to the Hayes report.

The HSE procures €3.2 billion worth of goods and services each year. I want that figure to be reduced in line with what is happening in the economy. In addition, almost €2 billion is spent on drugs. A further €1 billion is spent on non-core pay, such as premium, overtime and on-call pay. The bulk of the reductions need to be found in that basket so that services to the public are not adversely affected. There is a major job to be done in Tallaght Hospital to address the deficiencies that have been identified in this report; in the PricewaterhouseCoopers report, which the hospital commissioned; and in the Teamwork report. The recommendations in the various reports that have examined the operation of Tallaght Hospital need to be implemented as soon as possible. I have received a commitment from the chairman that that will happen.

Yesterday, there were 32 people lying on trolleys in Tallaght Hospital. If the Chair will indulge me, I would like to correct something I said on the record last week. I mentioned that a Government backbencher was given an appointment date for a CT scan that is 13 months away. In fact, he was given an appointment date that is four and a half months away for a simple X-ray. I should have said he has several constituents who are waiting 13 and a half months for CT scans. I would like to raise an aspect of the workings of Tallaght Hospital with the Minister. Does she intend to put any particular structures in place? Has she identified the problems that have led to such a high turnover of CEOs? Can she assure the House that the matter is under——

I remind the Deputy that this question relates to the Hayes report.

It relates to Tallaght Hospital. I am asking about the management of the hospital.

Deputies cannot raise everything to do with Tallaght Hospital. It is not open season on Tallaght Hospital, in terms of questions.

It is open season on the patients, unfortunately.

I am not an expert in this area. It seems from the various reflections and reports we have been given since Tallaght Hospital was established, particularly the Hayes report, that insufficient homework was done in advance of the merging into one big entity of three small hospitals that had very different perspectives. When one goes into Tallaght Hospital, one will see evidence of the involvement of the Adelaide Foundation, the Meath Foundation and the Children's Foundation. We have to learn lessons from that. That is why so much work is being done in advance of the development of the new children's hospital. We are trying to tease out some of these issues.

Since the publication of the Hayes report, has the Minister had any direct engagement with the management at Tallaght Hospital on the potential for the full implementation of the report's recommendations? I appealed earlier for the deficiencies identified at Tallaght to be rectified at the earliest opportunity. Can the Minister indicate what steps she has taken to ensure the recommendations will be implemented in full at the earliest opportunity?

In the first instance, I have spoken to Dr. Hayes. I have read his report. It is always important to speak to the authors of these reports. I did not meet him until he completed his report because I did not think it would be appropriate for me to do so. He did not ask to meet me. I had a long meeting with him on Monday. I got his insights, in addition to what he had said in the report. I met the chairman on Tuesday morning, with Mr. William McKee, who has come from Northern Ireland at the behest of the chairman and the board to assist the new acting manager, Mr. O'Connell, in the implementation of the key recommendations. I have every confidence that the chairman, Mr. McCann, and the board of the hospital are taking this matter seriously and will put into effect the recommendations in the Hayes report and the other changes that are needed if there is to be a modern and functioning hospital in the south-west part of Dublin. I have every confidence that that will happen.

Hospital Laboratories

Caoimhghín Ó Caoláin

Question:

10 Deputy Caoimhghín Ó Caoláin asked the Minister for Health and Children the future of the hospital laboratory sector; and if she will make a statement on the matter. [41900/10]

Approximately 77 million laboratory tests are undertaken across 44 public hospitals each year. The HSE announced plans last year to modernise laboratory services and achieve significant efficiencies in the configuration and operation of such services. As part of this initiative, the HSE is in discussions with the National Development Finance Agency about the capital financing of a small number of dedicated cold laboratories which would process the large volumes of routine patient tests currently processed in hospital laboratories. An outline business case, including a cost-benefit analysis, has been developed. It identifies and analyses a number of options for financing the various cold laboratory site configurations. The options include direct public provision, direct private provision and public private partnership. These options are being considered by the HSE. The Croke Park agreement acknowledges the advanced level of engagement of the relevant stakeholders in the delivery of major changes to medical laboratory services. We would like to see early progress in this area. Discussions between the HSE and the relevant trade unions on the introduction of revised work practices in existing laboratories, in the context of the Croke Park agreement, are under way. I understand good progress is being made in this regard. This process will quickly help to inform decisions on the modernisation of medical laboratory services within the cost, efficiency and quality parameters that need to be met.

I asked the Minister a couple of questions on 22 April last. The answer I received to one question, which was particularly detailed, was incomplete. I have to say, with respect, that the answer the Minister has given me this afternoon is also incomplete. I will persist, however. The Minister claimed in response to Questions Nos. 84 and 85 of 22 April last that the Association of Clinical Biochemists in Ireland was consulted when the Teamwork report was being drawn up. I have the parliamentary replies in question if the Minister wishes to refer to them. The association has assured me that it was not consulted, contrary to what the Minister said. I am aware that the association has also contacted other Deputies. Have the Minister and the HSE examined the danger that this service will become fragmented, for example when the testing that is done in primary and secondary cases is separated? Do they agree it is possible that clinical liaison and input will be weakened under the proposed privatised and centralised model? The Minister did not reply to that important part of the question I asked on that occasion. Will a cost-benefit analysis be carried out on the aspect of this approach that would see many tests being done externally, and possibly overseas? Is any effort being made to establish the real cost of this approach?

I said in my reply that there is good engagement on this issue, through the Croke Park agreement, between the staff representatives and the HSE. There has been some rationalisation and reconfiguration in this area since the Teamwork report was published. Work practices have changed and more laboratories have been accredited. That is the good news. We need to achieve efficiencies in this area. The more efficiencies we achieve, the more money we have for patient services. It is intended to roll out the changed work practices in a number of key hospitals, including St. James's Hospital and Beaumont Hospital, quite soon. That will inform that decisions that will be made. It is clear that a cost-benefit analysis will be carried out. The Teamwork report gave us a great deal of food for thought on how we can offer a safer and higher quality service that is more cost-effective. That is what we have to do.

We know what happened when changes were made to the system of reading smear tests. The outsourcing of that service created difficulties.

I need a question from the Deputy.

How much is the Minister hoping to save from the restructuring of this laboratory service? How will this saving be made predominantly? Will it be made through cuts in staff or overtime? When will this begin?

Those discussions are taking place with the staff representatives but my understanding is they will start in December on a number of key sites. The sites chosen are St. James's, Beaumont, Waterford, Galway and Cork. They are having discussions with staff representatives regarding those sites and I understand they are at an advanced stage.

Is the Minister concerned that she gave false information in a parliamentary reply to this Deputy on this issue, as I have indicated to her?

With regard to the certification and proper standards of the laboratories to be employed, what assurances do we have the laboratories that will be outsourced domestically or to foreign locations will reach the standards we hope for? Is she aware that her policy of essentially ending the role of hospital laboratories is resulting in the flight of highly trained, highly qualified people who would ordinarily have taken up employment in laboratories on a number of hospital sites across the State? We are losing them and we are witnessing a brain drain. How does she square that with the Government's so-called commitment to a knowledge economy?

There will be a huge need for highly qualified medical scientists in Ireland. This is about how we organise the service and whether we continue to provide it all in house or whether we outsource it or combine the public and private sectors. Above all, we have to ensure quality in as efficient a way as possible. That is what will guide the response of the HSE and the Government in this area. I understand the discussions with staff representatives are leading to a fair agreement between both sides and I hope that can be the case.

How is it hoped to make the savings? Will it be predominantly through cuts in overtime or staff cuts?

I do not have all the detail but it is generally about providing the service in a more cost-effective fashion.

Does the Minister agree what while she seeks efficiencies — which is important and we all support her in that — it is equally important to retain our indigenous ability to do these tests and not to outsource them outside the country?

We would never outsource everything outside the country. One cannot run a hospital system without a laboratory system and, therefore, there is no question of that. Clearly, we have to provide these quality services in the most cost-effective way we can for all our patients and that is what will happen.

Written Answers follow Adjournment Debate.