Medical Practitioners (Amendment) Bill 2011: Second Stage

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

I wish to start by thanking Opposition Members for their support for this urgent legislation to address the shortfall we are currently experiencing in non-consultant hospital doctors who are essential to the running of hospitals and the safe delivery of care to patients.

The provisions of the Bill before the House enable the Medical Council to register doctors in a newly created supervised register where those doctors registered will be assigned for a defined period of time not exceeding two years to identifiable, supervised posts to which specific criteria will be attached. Given the seriousness of the shortage of non-consultant hospital doctors, NCHDs, in our hospitals this legislation is being debated against certain time constraints and I appreciate the co-operation of the House in this regard.

The shortage of NCHDs in Ireland is not related to funding, any recruitment embargo, moratorium or reorganisation of hospitals but to an inability to attract enough doctors to work in our hospitals. In this regard, we are not unique, as much of Europe, including the United Kingdom, is encountering the same problems. Some 450 posts, including approximately 180 non-consultant hospital doctor vacancies, mostly in service rather than training posts, are due to be filled from 11 July when the next rotation takes place. The number of vacancies is decreasing on an ongoing basis as doctors are appointed via the HSE centralised recruitment process. Following an intensive recruitment drive by the HSE, more than 200 doctors from India and Pakistan have applied to fill these vacancies, but it is unlikely they will all be in a position to meet by 11 July the new registration requirements of the Medical Council provided for in the Bill, resulting in take up of duty being phased over a period of weeks.

I have previously stated in the House and take the opportunity to reiterate that I will not oversee any process that results in the employment of non-consultant hospital doctors who are not capable of safely providing the services required. Certain specialties such as emergency medicine will be most affected by non-consultant hospital doctor vacancies. I am working with my Department and the HSE to devise arrangements which can be implemented in hospitals if and as required to ensure any resulting impact on services is minimised and that patient safety is maintained. Patient safety must be at the top of our agenda and our utmost priority.

Current legislative provisions under the Medical Practitioners Act 2007 do not facilitate the registration by the Medical Council of the doctors from Pakistan and India who have applied to work in Ireland. This relates to the requirement to sit the pre-registration examination system, PRES, which is best suited to those recently qualified rather than those qualified for some years who have worked in specialty specific posts for the greater part of their career. The task that I, as Minister for Health, have been dedicated to in recent weeks is to see how best to secure these doctors to work in Ireland in a manner that will give complete assurance regarding the safety of patients and compliance with the regulatory standards required. The Medical Practitioners Act 2007 which provides the current statutory framework for the regulation of the profession is very robust legislation in terms of the protection of the public and great care has been taken in the preparation of the Bill to ensure it not be undermined in any way.

I have been working intensively with the HSE, my Department, the Medical Council and the Forum of Irish Postgraduate Medical Training Bodies to introduce regulatory arrangements that will facilitate recruitment of suitably qualified doctors, in particular, those from India and Pakistan, without delay. All involved have shown great willingness and ability in working towards a resolution of this matter. I am confident that all involved will embrace and support the changes proposed in the Bill. I take the opportunity to express my appreciation and gratitude to the Medical Council and colleges for their co-operation in this regard and their speedy attention to the matter.

The Medical Practitioners Act 2007 provides for the registration and regulation of medical practitioners in four divisions of the register which include the general division, the specialist division, the trainee specialist division and the visiting EEA practitioner division . The Bill provides a legislative basis to establish a fifth division to be known as the supervised division. This new division will allow the Medical Council to assess applicants under a range of headings and link a doctor’s registration with an identifiable supervised post in a specific specialty and for a contract specific period not exceeding two years in aggregate. This will enable the council to fulfil its core statutory responsibility as the regulatory body accountable for the protection of the public. It will also support the HSE in putting in place arrangements to facilitate recruitment on a basis that meets the objectives of service delivery and the provision of safe high quality care. To further strengthen the role of both agencies in safeguarding the public, the council is finalising statutory rules to underpin the operation of the new supervised division.

I am acutely aware of the need to ensure any doctor from India or Pakistan seeking registration by the Medical Council is proficient in the English language. I have sought and received written assurance from the HSE that with regard to those selected for recruitment, the entirety of their medical education has been conducted in English and that many have also acquired postgraduate qualifications through the English language. They were interviewed through English using the standard HSE interview, marking and scoring process, but in this case the pass mark was raised from 40% to 60% in each domain, including language and communication skills. We have set these doctors an even higher target. In addition, language and communication skills will also be assessed in the course of the new knowledge and clinical skills assessment process particular to the new supervised division. When in post, the ongoing supervision criteria attaching to each post will facilitate ongoing monitoring of language and communication skills. It is important to note that this supervision will include training in order that doctors who come to this country will leave here enhanced and suitably upskilled.

Part of the solution in addressing the underlying problem of sourcing and retaining doctors in the health service is being addressed by the HSE which in recent years has created a significant number of additional consultant posts and will continue to build on this in parallel with reducing the number of non-consultant hospital doctor posts in the system, particularly non-training posts. It has also taken steps to improve the quality of all NCHD posts and continues to do so. As of 11 July, 80%, 3,750, of the 4,660 NCHD posts will be part of structured training schemes run by the postgraduate training bodies and funded by the HSE. This contrasts with the situation in 2007 when 53%, 2,248, were in structured training, 31% were in stand-alone training, while 16%, 763, received no training at all. As I said, this is only part of the solution. As Minister for Health, I am committed to addressing the wider issues which have contributed to the situation confronting us. These issues include a requirement for a better skills mix, new and more flexible rostering arrangements and the reorganisation of health services, all of which form part of the ongoing reform of how we access and deliver health services.

Deputies have been provided with an explanatory memorandum which sets out in detail the contents of the Bill. However, I will briefly outline the Bill's provisions. In summary, it provides for a new division of the medical practitioners register, to be known as the supervised division. Registration in this division will be limited to two years and is linked to employment in a post and the medical practitioners will be supervised by their employer. Medical practitioners who apply to be registered in this division will undergo an assessment and examination which differs from that for registration in the other divisions of the register. The assessment will be specific to their medical specialty and the fact that the post is supervised.

Section 1 sets out the definitions used in the Bill. It provides that any reference to the Act of 2007 means a reference to the Medical Practitioners Act 2007. Section 2 amends definitions used in the Medical Practitioners Act 2007. The provision amends the definition of "registered" to include a reference to the new supervised division. It also amends the definition of "registered medical practitioner" to provide for the new section 56A and that medical practitioners cease to be on the register after a period. A definition for the new division is also included.

Section 3 amends the functions of the Medical Council to allow it approve posts for the purposes of the supervised division. Section 4 amends the council's power to make rules to provide that it can set criteria for assessing applications for registration in this new division and to allow it to specify the examinations and assessments for registration in the new supervised division. It is envisaged that this will comprise a two stage process. The first stage will involve providing documentary evidence of medical education, etc, with the second being a specialty specific knowledge and clinical assessment.

Section 5 amends the Medical Practitioners Act 2007 to provide that the Medical Council can charge a fee for registration and retention in this new supervised division.

Section 6 provides that the register will now have five rather than four divisions, that the new division will be called the supervised division and registration will include the identifiable post to which each registration applies.

Section 7 amends references in the Medical Practitioners Act to include a reference to the new division.

Section 8 is a key section in the legislation. It details how medical practitioners register in the new supervised division. It provides that a medical practitioner must meet the requirements specified in the legislation and the criteria outlined in the rules. It also provides that a person cannot be registered in this division if he or she is able to be registered in another division of the register.

A medical practitioner may only be registered for a maximum of two years in this division. The registration is linked to identifiable posts which have been approved by the Medical Council. Posts must be certified as being publicly funded. The HSE will not certify that a post is publicly funded unless the post is funded substantially by the HSE. The council will only approve posts where it is satisfied that adequate arrangements are in place for the supervision of the medical practitioner and will take into account the experience of the medical practitioner, the seniority of the post and the duties to be performed. The medical practitioner ceases to be registered when he or she leaves the post and the employer must notify the Medical Council within five days of the person leaving. These provisions have been included for the safety of the public by ensuring these medical practitioners are supervised and can only work in specific posts. If a person is found to be unsuitable despite all the due diligence, he or she cannot leave a surgical post in Naas and go to work in psychiatry in Cork, presenting a danger to the public.

Section 9 provides that a medical practitioner who removes himself or herself from the register cannot seek to have the registration restored under the provisions of section 52 of the Medical Practitioners Act 2007.

Section 10 relates to fitness to practise. As the medical practitioners on the supervised division are only registered for two years or until they leave a post, the Bill provides that, unlike other divisions of the register, the Medical Council can investigate complaints made against these medical practitioners, even if they are no longer registered. This is to provide due process for both the medical practitioner and the person who makes the complaint. This means that fitness to practise procedures will apply to the medical practitioners on the supervised division both when they are registered in the supervised division and when they are no longer on the register.

Section 11 is another measure for the protection of the public. It provides that the Medical Council can apply to the court for an order to prohibit a medical practitioner, who was registered on the supervised division but is no longer registered, from applying for registration in any division of the register. This is only done where it is considered necessary to protect the public. The court can make any order it considers appropriate.

Section 12 provides that section 70 of the Medical Practitioners Act, which provides for the steps to be taken by the Medical Council following a fitness to practise report, will include a reference to a new section which is inserted by section 14 of this Bill.

Section 13 inserts a new section into the Medical Practitioners Act to provide that the sanctions provided for in sections 71 and 72 of that Act do not apply where the medical practitioner is no longer registered in the supervised division or in another division. This is because the next section, section 14, provides for the sanctions in these cases. Section 14 inserts a new section into the Medical Practitioners Act to provide for sanctions in cases where the medical practitioner is no longer registered in the supervised division. These sanctions include advice or admonishment, censure or a fine not exceeding €5,000, the attachment of conditions which would apply if the medical practitioner applied for registration, and a prohibition on the medical practitioner from applying for registration in a division or divisions for a specified period.

Section 15 inserts another new section into the Medical Practitioners Act. This new section is linked to the previous section and provides for the council to decide on the amount of the fine, the nature of conditions and the period a practitioner is prohibited from applying for registration.

Sections 16 to 19, inclusive, provide for amendments to sections 73 to 76, inclusive, of the Medical Practitioners Act 2007 which relate to sanctions and the right of appeal. The amended sections now include a reference to the new section 71A which is inserted by section 14 of this Bill and relates to sanctions for those who were registered on the supervised division but are no longer registered.

Section 20, the final section of this Bill, provides for the Short Title and the commencement of the Act. Some sections of the Act will commence on enactment while more will require a commencement order. The sections that require a commencement order cannot be commenced immediately as these sections rely on rules or criteria to be set by the Medical Council prior to commencement.

The Bill will form a major part of the arrangement being put in place to attract doctors to Ireland not just now but in the coming years as we continue with the ongoing reform of the health system and the arrangements governing medical manpower planning and medical education and training. I am seeking the co-operation of the House in the speedy passing and enactment of the Bill and I am grateful for the co-operation to date. Arising from this, the co-operation we have found between the colleges and the council will allow us establish a manpower forum to plan our manpower requirements properly into the future and create clear career paths for non-consultant hospital doctors, both Irish and non-Irish, to avoid us reaching such a situation again. I commend the Bill to the House.

I welcome the opportunity to speak on the Bill. I thank the Minister's officials for their offer to brief us on the Bill owing to the timeframe between publication and today's debate. The shortage of non-consultant hospital doctors has been a problem for some years because of structural issues with the provision of health care here. We have been slow to address the issue over the years. Those doctors have been the workhorses in the provision of health care for many years. Obviously the problem has been exacerbated by changes in economic circumstances, new opportunities, and people willing to travel outside the country for career purposes and self-advancement in their profession, resulting in the problems we face on 11 July.

The Bill will obviously assist in recruitment efforts. I know the Minister and the HSE are making tremendous recruitment efforts in India and Pakistan, which it is hoped will bring enough non-consultant hospital doctors into the system to address the deficiencies that exist. The Minister referred to the importance of proficiency in the English language. When we pass the legislation, it is important that there is confidence and integrity in the system of registration of doctors under the supervised division. The last thing we need is a perception permeating that somehow these people, who are registered for two years, are yellow pack, so to speak, non-consultant hospital doctors. It is critical the public and other medical practitioners have confidence in these non-consultant hospital doctors. We all know there is quite a hierarchical structure in the higher echelons of health care and we do not want to be seen to have different grades and standards. I am satisfied the Bill makes sufficient provision for assessments prior to registration, registration itself and supervision thereafter to ensure the public and their peers will have confidence that the people who arrive here to provide much needed services are people of high quality.

In most societies there can be a sinister undertone of racism. In previous general elections I contested in my constituency of Cork North-Central it has been something that has cropped up now and again. The last thing we need is the perception that a doctor of a different skin colour is somehow less qualified than other doctors, which can have a very damaging impact on those who come here to provide the services we badly need. I hope the Bill will give everyone the confidence that the people who come here are here because of their ability, knowledge and expertise as opposed to people filling posts because of a shortage here.

The shortage of non-consultant hospital doctors is a structural issue that needs to be addressed. Given the Minister's knowledge of the health services, I know he will make strides in this area. Non-consultant hospital doctors need to have career paths and training opportunities and need to be able to see they can advance their knowledge, skills, expertise and career. I would welcome any changes to allow specified training programmes in order that when they leave, they do so after both giving and gaining. It would be positive to have a movement of doctors into the country and some of our own going outside, gathering experience and coming back again. That would be welcome provided we have the legislative basis to ensure the registration system has the confidence of the applicants' peers and the public.

Surveys have been carried out by various organisations and health representatives into the lack of non-consultant hospital doctors in accident and emergency units. There is disquiet and concern in many communities that they might lose accident and emergency services come 11 July. I would like to get clarity on the issue. For example, there is grave concern that the accident and emergency unit in the Mid-Western Regional Hospital will operate from 8 a.m. to 8 p.m. and close at night-time, requiring patients to be transferred to Galway or Cork. We need clarity as to how many non-consultant hospital doctors the Minister expects to have in place on 11 July. Where there are deficiencies, we will need continued recruitment in the months ahead to fill those posts. In the meantime, if services must be withdrawn on a temporary basis to ensure quality of care and that professionalism remains high, we need an assurance that these services will be reinstated when the non-consultant hospital doctors required are recruited in the months ahead.

There is a concern, perhaps even a suspicion, that the HIQA report is one element being used to downgrade services throughout the country and, equally, that the shortage of non-consultant hospital doctors will be used as a mechanism to temporarily withdraw services and, by stealth, to announce in the months ahead that they are to be withdrawn on a permanent basis. We need clarity as to the hospitals which may have services withdrawn temporarily in the weeks ahead because of the shortage of non-consultant hospital doctors and when the HSE anticipates the services to be reinstated as non-consultant hospital doctors are recruited.

On the broader issue, the Bill is welcome and will have a major impact on recruitment. There is no doubt that the two-year provision and the putting in place of training programmes for self-advancement and career advancement will attract many doctors from India and Pakistan to come here.

Section 11 reads, "In the case of a medical practitioner whose name was previously registered in the Supervised Division and that practitioner's name is not registered in any other division of the register, the Council may make an ex parte application to the Court for an order prohibiting that practitioner from applying for registration in any of the divisions of the register”. To clarify, I presume the purpose of this provision is that if a non-consultant hospital doctor arrives and is registered in the supervised division and a complaint is brought against him or her which is followed by an investigation that takes place after the expiry of the two-year period, that doctor will not be free to apply for full registration. This is a very safe and significant mechanism to include in the Bill, as it provides for clarity that doctors coming to Ireland will have the required qualifications, expertise, capabilities and language proficiency. In the event of anyone slipping through the examination process net, it is good that there will be a mechanism in place to deal with the matter.

The Minister knows as well as I do that the primary concern is the provision of services in local hospitals. It is a bone of contention, in particular, given the situation at Roscommon County Hospital in recent days, where people believed the Government had made a commitment which was breached. They had supported political parties in good faith, assuming that the services would be retained and even upgraded, as stated. While I do not want to make a strong political point in the context of the Bill, it is critical that we do not arrive at a situation where in the coming weeks communities will accept in good faith the withdrawal of services as being only a temporary measure, while an attempt is made to fill non-consultant hospital doctor posts, only to find in the coming months that a decision has been made to withdraw the services completely. The Minister must state clearly in the House that this will not happen, which will put many communities at ease in the coming months when they hear about the temporary suspension of services.

There were many people outside the gates of this Parliament yesterday protesting on behalf of Roscommon County Hospital and there is genuine disquiet throughout the country on the issue. Hearing that one of the largest hospitals in the country may have to suspend accident and emergency services on a 24-hour basis puts fear into people in smaller communities and hospitals. The Minister said some time ago on the "The Frontline" programme that he could not guarantee that all services would be maintained and that there could be temporary closure of services in smaller hospitals. However, when we hear there could be temporary closure of services in larger hospitals, this causes much disquiet.

Will the Minister outline the hospitals which will have a full complement of non-consultant hospital doctors on 11 July, the hospitals which will have enough non-consultant hospital doctors to retain all services but at a reduced capacity, and the hospitals which will have to suspend accident and emergency services and other specialties in the coming weeks? If there was clarity on this question, we could take in good faith that the Minister, with the HSE and those recruiting doctors, were making every effort to fill these posts quickly as applicants were assessed, deemed suitable and registered in the supervised division.

With regard to the hierarchical structure in the medical profession, there is no doubt non-consultant hospital doctors are the backbone of front-line services. At times, they are overworked and work exceptionally long hours, with strange rostering times that put huge pressure on an individual. This issue was debated some years ago in the context of exemptions to the EU working time directive. It is critical that not only there be opportunities in the context of training and career advancement but that we try to change the attitude that has permeated the health system, namely, that non-consultant hospital doctors and junior doctors can be worked for excessively long hours and treated badly or with disdain in some cases, as I witnessed as a hospital patient. It will take a long time to change attitudes and the perceptions some consultants may have of other medical professionals. I know this causes difficulties in hospitals, even in trying to recruit non-consultant hospital doctors, because they hear through the system that certain hospitals may not be a great place in which to work. If there is that perception, it will obviously be more difficult to attract non-consultant hospital doctors to these posts.

I wish the recruitment process well. The Bill's focus on the Medical Council, the recruitment process and the registration process will help to instil the confidence the public should have in the quality and professionalism of the doctors who come to work in this country. Equally, whatever happens, we must not end up in a situation where there is a perception that the people concerned are in some way less qualified. The issue of racism can be used in very sinister ways at times, as I have witnessed in my area. When doctors have a different skin colour or speak with a different tone, there can be an idea that somehow they are less qualified and less capable of providing the good quality care we expect from those who have taken the oath. I hope it will become clear in the course of the debate that this legislation will ensure no one will slip through the net and that the integrity of the process will be retained.

This Bill should not be necessary, as the Minister and I both agree. It arises from the inappropriate way in which medical staffing, training and practice are configured in the State. It has been known and widely recognised for years that the hospital system is totally over-reliant on junior doctors. Successive Governments have failed to address this over-reliance and inappropriate staffing, with the result that a crisis has arisen this year. Emergency departments in hospitals across the State have come under renewed threat. I say "renewed threat" advisedly. These departments have been under threat in recent years because of the long-standing and ill-conceived hospital centralisation strategy pursued by former Governments led by Fianna Fáil, Progressive Democrats and the Green Party, successive Fianna Fáil and Progressive Democrats Ministers for Health and Children, including the former Minister, Mary Harney, and their creation, the HSE. Sadly, that policy is now being continued by the Fine Gael-Labour Party coalition and the current Minister for Health.

I stated during the Sinn Féin Private Members' debate on accident and emergency services that the junior doctors crisis is being used as a smokescreen for the advancement of the centralisation strategy. The first victim in this episode was the emergency department in Roscommon. Last night we saw people from Roscommon and surrounding counties, as well as other communities where hospital services are coming under threat, protesting in their hundreds outside the gates of Leinster House. It was a huge turnout on an evening of pouring rain. That is the bigger picture and we will continue to fight to defend the right to safe and accessible hospital services for all our citizens. A cornerstone of my approach as health spokesperson is that citizens throughout the length and breadth of the State are entitled to access quality acute hospital services on the basis of need rather than their ability to pay or geographic location. That is an absolute demand not only for Sinn Féin, but also for the increasing numbers of people who realise that the critical services which they depend on in times of need have come under the threat.

The Bill before us concerns the immediate crisis of the non-consultant hospital doctors shortage. It is a stop-gap measure and Sinn Féin will not oppose it given that it is designed to avert the widespread shutdown of services. Let us be clear, however, that our position is in no way an endorsement of the manner in which hospital staffing is configured. Still less is it an endorsement of the HSE's plans to implement a so-called reconfiguration of hospital services. The junior doctors crisis has led to the hasty drafting of this Bill. It was published only yesterday, a matter which I raised in the House in the presence of the Minister for Health, and it is being rushed through all Stages in both Houses of the Oireachtas over today and tomorrow in order to meet the 11 July deadline for the non-consultant hospital doctor turnaround. This is no way to deal with important legislation and it is certainly no way to plan health services. I listened carefully to the Minister's remarks and I hope we will not have to face a repeat of this situation in the future.

It is ludicrous that we should have to send teams of people to India and Pakistan to find doctors to staff hospitals across this State. Recruiting sufficient additional junior doctors is required in the immediate term and the substance of the Bill provides the means to do that by changing the system of registration. The Minister has assured us these incoming non-consultant hospital doctors will be properly qualified, assessed and supervised. It is vital for patients that his commitments are met because skilled professionals are required in these posts. By no means the least important of the skills required are good language and communications skills to deal with patients and other staff. This is an issue which is repeatedly raised by the patients who go through our hospital system.

This Bill facilitates the continuation for the time being of the current system or, I should say, prevents its collapse and the consequent loss of services. How long will this ramshackle structure stand before it is replaced by a proper system of medical training and hospital staffing? What is the Minister's plan, if any, to end the reliance on junior doctors and get better value for patients from consultants?

Sinn Féin has put forward a range of proposals to address this issue. Irish hospital consultants earn €250,000 per annum for a nominal 33 hour week. The implementation of the consultants' contract cost the Government more than €140 million in 2009. Consultants who practice privately in public hospitals are being paid twice to treat the same patient, once by the taxpayer and a second time by the patient or the patient's health insurer. Some consultants have been reported to spend 40% of their working time on private practice, part of which is reimbursed by the National Treatment Purchase Fund. This is a serious matter which has been highlighted by the Comptroller and Auditor General. Hospital managers have been obliged to write to a significant minority of consultants who consistently breached their contracted duties of public acute hospital service provision. That must be met head-on. Furthermore, the cap of 25% on time spent by publicly employed consultants in private practice is effectively in dispute, with medical unions taking issue with HSE monitoring mechanisms. Questions arise over the reported provision of public care in addition to the known extent of private practice.

In 2009 the Comptroller and Auditor General stated:

As part of contractual arrangements agreed in 2008, consultants undertook to limit private practice to set levels.

There has been limited progress in implementing this provision in that

private practice levels in many hospitals continue to exceed permitted levels, in some cases significantly so

monitoring is very much in arrears being reported up to nine months after the work was done

Although an implicit objective of Consultants Contract 2008 was to remove any financial incentive on the part of consultants to engage in private practice above an agreed level, no financial adjustment has yet been effected.

That is a serious and damning statement on the oversight and management of consultants' time.

Sinn Féin takes the view that no monitoring mechanism can adequately deal with a perverse and absurd system which we can no longer afford. The perverse incentives that currently apply to the selection and treatment of patients should be removed. This is necessary so that we can afford to train and employ the medical consultants and general practitioners we so badly need to meet the needs of patients and bring the country up to the OECD average.

We also advocate the introduction of a new public-only consultant contract, capping the salaries of medical consultants. Let us be clear about it; €150,000 is not a petty return. Although we have to go to the people in a referendum to deal with the judges' issue, we do not have to do that with consultants, yet this is not being addressed as it should. It is still unclear how the Government's proposed model of insurance-based health care funding would work in this respect. We need clarity and detail about its health care reform plans, which is something the Fine Gael Party promised but has yet to deliver.

Little attention has been paid in this debate to the constructive contribution of nurses. I want to commend the INMO, whose considered intervention on junior doctors is very worthy of the Minister's consideration. The INMO has stated that it is an exaggeration to say that a unit should close because of a shortage in one profession. I disagree with the earlier contributor who put such strong emphasis on the NCHDs as the back bone of the system. We agree with the INMO view that up to 70% of the care given in emergency departments is provided by nurses. Under medical supervision and protocol, they may be in a position to carry the bulk of the services in many of the departments facing a shortage of NCHDs. The INMO stated the following:

We should have nurse led units, for example, minor injury units, walk in chest pain clinics, stroke units etc. There should be direct referral to nurses and other health professionals e.g. physiotherapists, occupational therapists and others.

Nurses are on duty 24/7 and they are best placed to deliver high quality care around the clock. We need to use the expanded role of the nurse to do procedures previously done by NCHDs. There are nurses already trained to do so.

I will not continue with the rest of the quotation because time is going to beat me.

You have two minutes remaining.

I urge the Minister to take on board the arguments of the INMO, to give them serious consideration and to view them in a positive light.

I want to take this opportunity to flesh out our view on the role of small and medium-sized public hospitals. We reject the policy of centralisation of public hospitals. Centralisation provides a fig leaf for cutting public hospital services. We believe that, given the highly dispersed nature of our population, small and medium sized public hospitals must continue to provide the maximum possible range of services for their communities. In ensuring that second-level care is provided at the most local level, we have called for the development of funding mechanisms designed to address geographic inequality in public hospitals; the retention and development of acute or emergency services in second-level public hospitals; the provision of cancer care on a truly nationwide basis, with access to radiation oncology and other cancer services in all the regions; and the deployment of medical staff and configuration of medical training in a way that facilitates the continuation of services to patients. All of this is achievable.

Let us be very clear on this. The bottom line for the deployment of hospital services, the configuration of medical staffing and the organisation of professional training and registration must be the best interests of patients. That must always come first, before the vested interests of training colleges and professional bodies.

This Bill is a stop gap measure. It is not real reform. It is an expedient. For that reason, and to help ensure the safe and successful roll-out of its intent, we are calling for the implementation of this Act to be under review from day one. I urge the Minister to accept my amendment on Committee Stage. I trust the Minister and those acting on his behalf are successful and I wish success to his exercise in recruiting the full complement of NCHDs required to maintain the continuation of all of the accident and emergency services we need. I conclude by putting on record Sinn Féin's decision to support the passage of this Bill through all Stages today, for the reasons already stated.

A Cheann Comhairle, I thank you for allowing me to speak on this Bill.

All of the citizens of this State are entitled to a decent, quality health service as a right and we should never turn our backs on that core principle. This is very important. It costs money and we will have to pay for it. We have ignored this in the broader debate on our health services. This is why I support the core value of a universal health service. If they can do it in countries like Cuba, blockaded by the US for over 40 years, we certainly can do it in Ireland. I urge the Minister to look at the health service in Cuba and look at the example of a country that is being hammered economically but still has a top quality health service. There are strong links between Beaumont hospital in my constituency and many of the health services in Cuba.

I feel very strongly that there is too much talk about reform and change, and not enough action on providing a quality health service. However, today's Bill is part of that reform and I welcome the constructive proposals in it. The Medical Practitioners (Amendment) Bill 2011 is intended urgently to assist in addressing the current difficulty with vacancies for non-consultant hospital doctors. The current level of vacancies at NCHD level has significant implications for the maintenance of acute services, particularly in the smaller hospitals and in certain locations where vacancies are concentrated. The reasons for the shortage of junior doctors are quite complex, and include the fact that the posts in question are mainly non-training posts and therefore not attractive to doctors. There is a general international shortage of junior doctors. That is the reality on the ground.

When we examine the details of this issue and when we talk about acute services and certain smaller hospitals, we have debates like that yesterday about Roscommon. It is misleading for people to say that TDs and the public want hospitals at every crossroads. We all accept that some hospitals have to specialise and be centres of excellence for serious illness. However, the debate about Roscommon is that the people there have a right to accident and emergency services, just like the people I represent in Coolock, Artane, Beaumont and Marino.

The centres of excellence are also a real issue and must be examined. However, the other issue is that false promises were made to the people before the last general election. If the Minister had not made these promises, he would not have had half the hassle he had yesterday. Politicians should not go out during election campaigns and make promises they cannot deliver. The common comment to me on the doorsteps was to go in there and try to fix the mess that is going on. If we are straight with people, they will be straight with us and will be very respectful.

It is also important to say that we have some examples of where the health service is working, and I commend those directly involved. I strongly campaigned for and supported the introduction of a new cystic fibrosis unit in Beaumont hospital, which cost €3.8 million and which is an excellent service. It deals with young children across the north side. Many of us have been fighting for a unit in St. Vincent's hospital, and the Minister supported it in Opposition, but the good news is that this unit is now being built and will hopefully be finished in a matter of months. We had experiences of delays and bureaucracy between the Department and the HSE, and this is the problem with our health services.

Another example of good practice in my constituency is the orthopaedic hospital in Clontarf. We campaigned for that locally and the €16.6 million required was delivered four years ago, and it is now providing an excellent service. It is a centre of excellence for many people in the orthopaedic area. We have many examples of good practice and good services, so let us try to implement them right across our health service.

There is an issue in respect of the registration of doctors from countries outside the European Union. I commend those doctors who come from non-EU countries and who have made a massive contribution to the health service here. There are also language issues which we must face up to and which are raised regularly with me.

I urge reform and change and call for a top quality public health service. Our people need a quality service based on equality of access. This Bill is another part of that process. I strongly support Deputy Ó Caoláin's point that we need a review of this legislation in the future.

The first sight I had of this legislation was yesterday. None of us is happy with that nor I am quite certain is the Minister. I support the Bill because it is necessary for us to fill this gap next week and I recognise this Government is in office for a very short time and that it will take time to deliver change. However, there is nothing more certain than we will be back here with amendments. One cannot rush things and anticipate every eventuality. Issues will arise which are unintended.

We have been told in recent weeks that it will take more than one Dáil term to implement fully a new health care system. Will we see a turnover of junior hospital doctors throughout the term of this Dáil? Is this an emergency and a temporary measure or is it an emergency measure which will become permanent? We have been told the majority of doctors are likely to come from India and Pakistan. Reading the Minister's speech, I note they may well be more qualified than some of the people who have just trained here and may well have some specialties. Those countries can probably ill-afford to lose these doctors.

These doctors will not arrive alone and they will have families. Has any provision been made for their families because people coming to work here must be treated humanely? I echo the point Deputy Finian McGrath made that these doctors keep our hospitals going. Anyone who has had a family member in and out of hospital will know it simply would not function without foreign nationals, including many people from outside the European Union. Foreign doctors working in our hospitals is nothing new.

I am concerned that when we close a small hospital, the feeder hospital to which people go is not, in some cases, receiving additional supports. Last week I received a telephone call from a man who was diagnosed with early prostate cancer. For administrative reasons, his operation in a large teaching hospital in Dublin did not proceed in the middle of June and was rescheduled for the middle of July. I contacted the admissions nurse to find out whether it was likely to proceed on that date. The man was told to telephone the day before or the morning of the operation. That man is really worried about his cancer progressing. I was quite shocked by what the nurse said. She said she was cancelling operations on a daily basis, that people were arriving in ambulances and that there was an obvious need for their surgery to proceed on a particular day because they could see blood in urine and so on.

This is not just about Roscommon, Navan and Loughlinstown; it is about the whole system. If we transfer services from one hospital to a centre of excellence, it is essential that it is able to cope with the additional capacity, otherwise our health care system will fail. I am very concerned that it will fail this man who is one of a very large number of people. It is only one story but it is the most important thing that has ever happened to him and it is a story that is repeated. I have major concerns about the lack of integration.

The backdrop to this problem is the peculiar and probably very lopsided situation that exists in this country. On the one hand, we invest a phenomenal amount of time and resources in training doctors whom we export while on the other hand, we are resorting to panic measures to import doctors frantically to deal with the chaos and crisis. That situation reflects deep-rooted problems in our health service and in the area of medical training which need to be addressed.

Obviously, I am happy to see any measure which will address the crisis but I echo the concerns of other Deputies that the speed with which this legislation is being pushed through may cause us problems in future. As Deputy Catherine Murphy said, we only received the Bill yesterday. We need to be cautious.

As we are discussing recruiting doctors from other countries, it would be remiss not to mention the situation of Irish-trained doctors imprisoned in Bahrain and the very inadequate response in standing up for those doctors. If we want doctors to work in our service, we should be prepared to stand by them when they take humanitarian actions and are penalised for so doing. There was a very poor response and a lack of support for them by the Royal College of Surgeons and the Royal College of Physicians.

The nub of the problem is the shortage of junior doctors. There is a 25% deficit of junior doctors in 32 of our 24-7 accident and emergency departments along with a shortfall in middle grade doctors. The loss of these doctors to the system is causing major problems and has major implications for the future. We need to deal with that but instead we seem to be just plugging the hole by importing hundreds of primarily Indian and Pakistani doctors to do a narrow range of duties and for a narrow timeframe. Will the Minister explain why it is only for two years and why their activity is being restricted? Does he envisage this being repeated after the two years? Presumably, many of these people will be really able and experienced and will make a valuable contribution, so why is it being limited to two years?

The position of non-consultant hospital doctor is not attractive because it is non-training. It does not contribute to the career prospects or the educational advancement of the doctors concerned, so they are not inclined to take up those posts. Therefore, we need to look at measures which will overcome that. One of the ways to make the position more attractive would be to count hours worked as training hours to incentivise more doctors to take up that position. It is noteworthy that the five accident and emergency departments which are not experiencing problems are those which are fully resourced and have dealt with the overcrowding issues. There is a link between the shortage of these doctors and overcrowding.

We need to take a holistic approach and address the other issues in regard to the crisis in the health service if we are to overcome some of the difficulties doctors have. I do not believe we can divorce this from the overcrowding issue. The most important point is that the whole system needs to be looked at.

We must look at measures which will incentivise and encourage doctors trained in Ireland to stay and use their skills here. That is really the nub of this issue. We could do that in a number of ways. Irish-trained doctors should be required to work in Irish hospitals for a certain period after their training and that if they do not do that, there could be some form of pay back to the State of the subsidy provided for their education. Some measures should be adopted in that regard but it should be balanced with enhanced resources and training opportunities which would encourage doctors to stay. Unless we address the issue we will increasingly resort to panic measures which are not the ultimate solution.

Deputy Ó Caoláin and I were in this House prior to the 2007 election, when the Medical Practitioners Bill went through, and I am surprised to be back so soon with amending legislation as a result of a crisis involving the junior doctors in our hospital service. At the same time it is to be expected because of the way we run the health service. There is a crisis in the daily running of our service and in the manner in which we plan and look to reform it. People have seen what happened outside the gate last night and Deputy Ó Caoláin and I have experienced the haphazard changes to the way health services are delivered. One would be surprised at how far back is the genesis of this crisis.

The last Government received praise for changes to cancer services and the cancer treatment reform programme it initiated. The baseline of that change to the delivery of cancer services goes back to 1994 when Deputy Michael Noonan, then Minister responsible for health, published a cancer strategy. It took over ten years for that strategy to have an impact on health services. When we ask why we are here and how quickly we can change the issue, we must realise who is responsible for making changes in the health services and how their decisions can have an impact for such a long time. We must be radical in our thinking if we are to achieve solutions for the current crisis.

Manpower planning in the health services goes back to the Hanly report published in 2003. It was not concerned with closing small hospitals but rather the planning of manpower, and it is still being used by the HSE and the Department of Health to this day. Changes implemented over the past ten years have to some degree contributed to our current position.

The last Government failed to take on board the problems in our public health care system. The former Minister for Health and Children, Mary Harney, abandoned any sort of change within the health system and tried to find a political solution in the co-location project, which was built on the idea that the Celtic tiger would never die. That is another Government policy lying in tatters while still affecting how health services are delivered.

There are many good individuals within the health services but the administration is chaotic, with no grand strategy concerning what we want from the services. Percolating through the system to hospital and regional management, there are many problems which are not being dealt with by people we are paying well to do so. There is a need for us as politicians to highlight such matters and discuss them in an open, frank and transparent manner in order to deal with the issue.

There is another group within the health service, the hospital consultants, that must take some of the blame for our current position. I spoke about the cancer care policy document published by Deputy Michael Noonan in 1994, the same year I became a senior house officer in Mallow General Hospital. I went through a large number of hospitals in Munster before I went into general practice, and I earnestly believe the same carry-on in training is happening today. There has been little or no change and the group of people responsible is hospital consultants. It would be generous of me to say my training was only haphazard. I can honestly say disaster was averted not because of excellent training or my expertise but because I was lucky and I had a good nurse beside me. That is not the way to train junior doctors.

I am also concerned about supervision within our health services. We must place responsibility not just with some faceless bureaucrats within the HSE who can then hang out a junior doctor when a mistake is made. We must make the people who are delivering the health services responsible for what is happening. We should also wake up and consider what changes can be made. As far back as the late 1990s a programme was being run in Donegal where heart attack patients received thrombolysis in the back of an ambulance under the supervision of trained emergency medical technicians and the local GP. That programme disappeared. In Paris and many parts of France there are now ambulances being driven around with fully trained doctors and cardiologists who can deal with heart attacks and strokes in the back of the vehicle. We have not implemented such radical proposals within our health services.

Innovative pilot projects have been run on a piecemeal basis across the health service in the past 15 years, with some showing potential to work in primary and emergency care, but they have not been progressed or implemented. We are not thinking radically enough about the solutions to the problems.

This legislation is a sticking plaster and it is a bad policy for a country, after 25 years, to rely on 80% to 90% of junior doctors in non-teaching hospitals coming from countries like Pakistan and India. That is the case in this country and we have essentially been relying on countries which need doctors as much as we do, taking their qualified doctors and putting them into our health system. Our doctors are leaving our health care system to go to America, England, France and Germany because the quality of the training in those countries is better, as is the experience they will garner. Some of the doctors will return but many do not. We are acting as a parasite on Third World countries in order to shore up our health service.

As other Members have stated, this policy is ingrained in our health services and we see it as normal that up to 90% of junior doctors are from outside the jurisdiction, which is wrong. There should be opportunities for people from outside the country, such as Pakistan or India, to come to the country for extra training and to improve their skills before returning home. That is not what is happening and we are using these doctors just to shore up our services. Many of those doctors must be just lucky like I was in order to avoid crises in the health service. We have not drilled down into how we train junior doctors within our health services or taken the issue seriously.

I commend the Minister, Deputy James Reilly, as he understands these issues perfectly. His problem is we are dealing with an economic and not just a policy mess. That is having a massive impact on how we deal with the policy disasters in our health service now. I wish the Minister for Health the best of luck in trying to work through these issues.

We should submit our own solutions while being realistic about what can be achieved. Deputy Ó Caoláin and I have seen all this happen very close to home, and we know some issues could have been averted. Radical solutions could have been used but were not. As I noted, pilot projects were promoted but left to fall apart. The health service is chaotic by its nature and includes emergency services, such as Dublin fire brigades, ambulances in Connemara, the emergency care nurse in a small hospital or a junior doctor with limited experience. Nevertheless, we must ensure to maintain the proper standards, protocols and procedures to limit the damage done to patients we are expected to care for within the emergency services.

We must focus on patient safety as it is only through luck that there have not been more disasters in the health service over the past number of years.

We need to make sure there is good training and expertise. Proper procedures, rather than luck, will ensure people get good outcomes from our health services.

I welcome the chance to speak on this legislation. When I read some background information on the Bill, it struck me that it is accepted this problem is not just found in Ireland — it is a Europe-wide problem. I understand it is particularly acute in the UK. Is it time to examine this issue at EU level? Why are the health systems in Ireland, the UK and Europe as a whole insufficiently attractive to the graduates who, as taxpayers, we have put through our education systems? Many medical professionals from this country are going to New Zealand and Australia. It seems to be a Europe-wide problem. Rather than accept it as the norm that this challenge will arise here, in the UK or across Europe every six months, perhaps it is time for us to examine the matter collectively at EU level.

When the results of the leaving certificate and the points race are published in four or five weeks, we will find once again that there is a huge demand for medicine degrees. Those who are maintaining that level of demand are being lost to our system at some point along the way. We are being forced to pass rushed legislation of this nature to deal with that problem. Deputy Twomey — it is relevant to note he is a doctor — said that as users of the health service, we have accepted being dealt with by international doctors while at the same time wondering where the Irish graduates have gone. Perhaps patients accept that things often happen to junior doctors. I might return to the question of whether many incidents are not being reported or dealt with.

We need to be careful about a couple of aspects of this legislation. I understand Cathal Magee told the Committee of Public Accounts this morning that 158 junior doctor posts are vacant. In the rush to fill those vacancies, we have to make sure we retain the checks and balances that are normally in place when medical personnel are being recruited. They need to be as robust as ever. As a professional, Deputy Twomey understands the sanctity of the doctor-patient relationship. We do not need to start reciting examples of that sanctity being broken. If that were to happen under the new approach proposed in this legislation, it would undermine the whole system. We need to make sure, in the rush that is under way, that the requisite standards are maintained.

It is probably a given, subject to what Deputy Twomey was saying, that those being recruited should have proficiency in their medical skills. They need to have proficiency in many other areas as well. I am not just talking about non-consultant hospital doctors — this applies right across the system. In recent years, I have had personal experience of dealing with consultants on behalf of family members. Some of them are absolutely fantastic at treating patients and communicating messages to patients. Others are just horrendous, frankly. Some consultants in the system want to have a lord-tenant relationship with their patients. They treat people who are paying to use their services with utter disgust. They see patients as something to get out of the way very quickly. A patient with a range of conditions is fragile enough without having to deal with such a scenario.

As we review educational standards, we also need to consider standards of civility and treatment. I am reluctant to use the term "customer service" because I hate looking at the health service as if it were a business with customer relationships. I am sure every Member of this House has experienced a difficult relationship with a consultant. Thousands of people have had similar experiences. It can be difficult to get some consultants to understand messages or to show respect. Perhaps the process of opening the examination of standards of education will give us a chance to examine these problems formally.

Deputy Twomey spoke about the approaches of general practitioners. We do not use our GPs enough. They are contacted when things go wrong but they should also have a role in health promotion and illness prevention. The Deputy has spoken previously about such matters, which are absolutely crucial. We tend to rush to accident and emergency departments when minor problems develop. If we had a primary care system that was properly managed, resourced and facilitated throughout the country — such a system is beginning to take hold — it would take much of the pressure from accident and emergency units.

I was intrigued to hear Deputy Twomey refer to geographical models within the health system. The House debated that matter last night in the context of the hospital network, which is a huge issue. I often wonder whether the bean counters and accountants in the HSE fully understand the insecurity people can feel when hospital services are geographically distant from them. It is grand in this city because people can hop on a DART or get on the motorway and get to hospital relatively quickly. There is a necklace of hospitals around the city of Dublin. It is a big worry that people in rural areas who suffer heart attacks or strokes may be an hour away from the main hospital in Galway or elsewhere. It strikes me that we might need to examine the models to which Deputy Twomey referred. Not only do we need to use our GPs to a greater extent, but we also need to scale up on our local senior nurses. We need to ascertain what skills are held by district nurses and examine whether it is possible for them to use such skills in emergency situations as they arise. That would alleviate the pressure on accident and emergency units, which is driving the problem we are discussing.

I would like to speak about the recruitment of doctors by private clinics. I often wonder whether we are looking at a timebomb in that regard. In recent years, the Medical Council has taken cases against some private clinics. Deputy Twomey spoke about luck. Unfortunately, some patients in private clinics have not been lucky. Will the standards put in place by the Minister and enforced by the Health Information and Quality Authority apply in private clinics as well as HSE-run hospitals? I understand the Medial Council has dealt with cases in Galway in which patient care was compromised considerably. That is on the public record. We need to make sure such cases are not replicated.

I wish to refer to the approach of the HSE to hospital management and reconfiguration. The HSE's attitude to Members of this House was laid bare during last night's debate. Deputies were given assurances by the HSE only for it to sanction a complete reversal within minutes. Those who are involved in hospital reconfiguration and in the running and management of the HSE need to understand we have a mandate. We have put ourselves in front of the people. We try to present problems, cases and scenarios to the HSE and many other bodies. We are talking about the HSE in this instance. I ask Minister to instil within the HSE a culture of respect for Deputies and Senators, and public representatives in general, as part of the process of reforming that organisation. These processes need to be improved so we can carry messages and make representations on behalf of people.

I understand the Minister is committed to the introduction of the Dutch model of care. I have not had a chance to check whether the problem we are discussing arises in the Netherlands. As I have said, it is a Europe-wide problem. How does the Dutch equivalent of our six-month training rotation work? Our system has probably not changed since the Minister's time and that of Deputy Twomey. One does six months and then one moves on. Although our training mechanism has served the country well, is it the proper one for these times? I am sure Deputy Twomey will agree that the parts of the health service that work — quite a number of them do — are working well. At a time when we are examining everything, it is time to examine whether our training system works for 21st century Ireland. Does it deliver a good experience for students who are becoming doctors? Does it help to make them as proficient as possible? Are we using it to cover gaps in our system? If so, it needs to be addressed.

I wish the Minister well in this portfolio. As a former Opposition spokesman on health and as a medical practitioner, he knows what he is taking on. This is a system. We do not want to have to return to deal with the same problem six or 12 months from now. We have to look at it now. The time has come, and perhaps the Minister can lead this effort in the context of Ireland's upcoming Presidency of the Council, for a European-wide effort to identify why there is a problem in Europe attracting medical practitioners into hospitals.

First, I welcome the Bill, and particularly the co-operation of the Opposition in facilitating its speedy passage through the House. Some reference has been made to the fact there is an element of emergency in this and a strong element of rush. I suppose that has been a factor across a broad range of Departments over the past number of months. However, the Bill must be welcomed and the Minister must be commended in bringing forward the Bill so quickly.

The Minister has gone through the main elements of the Bill but there are a couple of areas on which I want to touch. The first is the important area of confidence. There are measures in the Bill that give confidence to the people of the country, particularly in the area of the assessment, supervision and the potential for censure or removal, if required.

Yesterday, by coincidence, the Indian ambassador visited the Oireachtas Joint Committee on Foreign Affairs and Trade. He was supportive of, and indeed engaged with, the forthcoming arrival of doctors from his country. However, he made the observation — he stated he had met the Tánaiste and Minister for Foreign Affairs and Trade, Deputy Gilmore — that we need to engage more with the universities in securing more students to come to study medicine in the country and follow through as part of their training, rather than come here for a couple of years as a stop-gap measure. He pointed out there are only 1,000 Indian students in this country as compared to 80,000 studying across a broad range of subjects in our neighbour's, in the United Kingdom and he suggested that some work should continue to be done — he stated he had met the presidents of the universities — to try to encourage an increase in that. From speaking to the president of my university in Cork, no doubt there would be a significant degree of welcome in bringing more international students because of the revenue they can deliver for the universities.

While this is a European-wide problem as has been discussed — the spokesperson for Fianna Fáil, who is not now in the Chamber, made some reference to not being political and then proceeded to be quite political in his remarks — like so many other elements of this first number of months in government, such as our economic problem which is a world-wide problem, somehow we find ourselves with problems that are more serious than those being encountered anywhere else. It must be restated that the reason for that in terms of the health service has been the mismanagement of many areas of those services in this country for the past 14 years. It is unfortunate that a large element of work done by all Ministers in the first number of months has been to put out the fires but when these have been extinguished, one will see a proper structure that will deliver services, as was suggested, through universal care and other areas.

I support Deputy Calleary, who was much more constructive in his remarks, on the importance of using the existing structures. I note the two previous speakers for Fine Gael, including the Minister and Deputy Twomey, are medical doctors. There is a significant resource in the country in terms of the existing general practitioner network. It has been made clear by the Minister that he wants to see the provision of medical services as close as is possible to general practice. I held discussions last week with an accident and emergency consultant in a Cork hospital who told me that approximately 80% of the patients who attend his accident and emergency department are what he referred to as "ambulatory patients", in other words, they can walk in to receive services and they can walk out. He strongly believes — this is a premise supported not only by the Minister but by the general practitioner body in general — that we need to develop much more the primary care health system and to use the general practitioners. This consultant placed particular importance on using the training that his nursing staff have and stated the requirement on which we need to focus over the next number of years is to develop systems that allow general practitioners to engage more directly with specialists, therefore by-passing the requirement for patients to wait over long periods in trauma units. The reality, as the House will be aware, is that many patients are left waiting in accident and emergency departments because there are patients with more serious conditions being treated. In many cases the requirement for them to sit there could have been dealt with by their general practitioner and by units that could have by-passed the accident and emergency department.

It has been my experience that hospital managers seem to be a remarkably mixed group of people. In my time some of the best staff I have met in the health service have been hospital managers and some of the worst staff I have met have been hospital managers. It is welcome that the Minister is bringing the health services back under his control. It is far too easy, and, as happens frequently for us, dismissive, to speak about the failings of the health service without acknowledging some of the remarkable talents. This is, after all, a small country. It has a small number of hospitals and it has a small number of senior staff managing the hospitals. I suggest to the Minister — I am sure it is something of which he is aware already — that there needs to be more responsibility in the Department for identifying the better staff who have delivered in their hospitals and the professionals with the ambition and desire to continue to strive to improve the services that they can deliver; equally, to be ruthless enough to identify the professionals who cannot; and ensure we can deliver the best possible services for patients.

I welcome this opportunity to speak on this important legislation. The establishment of this new division of the register of medical practitioners to be called the supervised division with the intention of smoothing the way for the recruitment of non-consultant hospital doctors from abroad is timely and, indeed, necessary considering the current difficulties relating to the recruitment of NCHDs. I am conscious that the shortage of junior doctors is currently a problem in hospitals across the world.

I also recognise the efforts of the Minister to recruit doctors to fill the posts which will become vacant from 11 July. He has already succeeded in recruiting 200 potential candidates from Pakistan and India, thanks in part to an extensive recruitment drive abroad. I am also conscious that the Minister has patient safety uppermost in his mind and has made it clear that he must only employ NCHDs who are suitably qualified and proficient in the English language.

While the Minister is working hard to resolve the current shortage and the establishment of this new supervised division will bring new NCHDs into the system next week, we need to look at the bigger picture and examine the problem of the shortage of NCHDs generally to ensure this situation will not arise again.

Despite this being a worldwide issue, I make a brief point about one specific issue I believe could help to improve the situation in Ireland. I have a suggestion to make which would help to combat the current shortage of junior doctors. I suggest the Minister for Health consider the possibility of extending to two years the pre-registration period for all junior doctors. We need to keep young Irish-trained doctors in Ireland. Let us face it: there are enough people emigrating in other sectors. Extending the pre-registration period to two years would bring practice in Ireland into line with that in the United Kingdom where the system requires junior doctors to work in foundation years 1 and 2 before completing their internship. I submitted this idea in the form of a parliamentary question to the Minister on 24 June. In his response he indicated that he would examine the option, for which I am grateful. He stated, "The question of contracting doctors who were trained in Ireland to work for a certain period in our public health system is among the options which I intend to examine in the context of the healthcare workforce planning."

The shortage of junior doctors is most visible in accident and emergency units. Accordingly, I suggest that if we require junior doctors to work for a second year, it should be spent in an accident and emergency unit under the supervision of a consultant. This morning I spoke to a consultant anaesthetist who informed me that in several smaller hospitals doctors training to be anaesthetists were putting people to sleep under anaesthetic for operations and, often, the surgeons working with these trainee anaesthetists were also non-consultant surgeons, that is to say, not fully qualified either. The point is that when junior doctors are trained, the trainees should not be running hospital accident and emergency units. The provision of adequate training for junior doctors should also be addressed.

The explanatory memorandum notes that the reasons for the shortage of junior doctors are complex and include the fact that the posts in question are largely non-training posts. Changing the system to a two-year registration scheme could contribute to the efforts to retain junior doctors in Ireland. We are losing their services, since many of them leave the country after their one-year internship.

I acknowledge that the Minister supports the need to reduce the hours currently worked by non-consultant hospital doctors. He should consult junior doctors because they have a view also and often their voice is not heard because of various lobby groups among the medical organisations.

I welcome the Bill and applaud the efforts of the Minister to solve the crisis. I hope he will take my comments on board.

I call Deputy Healy.

I did not realise I was next to speak.

I understand the Deputy was to share time with Deputy Wallace who is not present.

I welcome the Bill and the opportunity to speak to it. I understand its importance and appreciate the necessity for its being fast-tracked through the Dáil. The Minister will be aware that all sides of the House understand the position and are keen to have the Bill passed today.

It appears we are in a situation similar to the one we were in some years ago with temporary registration which in my experience, having worked in hospital for years, worked rather well. I am not sure why that system was changed, but I imagine there were good reasons for it at the time.

It is important to acknowledge the contribution foreign or non-national doctors have made to the health service over a long period. In my experience, there has been a considerable number of excellent, well trained doctors and trainee doctors who have given excellent service throughout the years.

Given the problem with which the Minister has to deal, the Bill is both urgent and welcome. This measure should have been taken before now. It should have been introduced during the time of the previous Government.

I have wondered about the role of the HSE since the shortage of doctors was identified. The problem did not arise overnight; it was brewing for some time. Therefore, I would have expected the HSE to have dealt with it long before now.

I share the Minister's view on the HSE. I never believed its establishment was a good development. I opposed its formation in this House because I believed at the time — it has turned out to be true — that effectively it would be an unaccountable body. Certainly, it is unaccountable to this House. It has became centralised and is out of touch. With its establishment, local input and the input of locally elected members representing the public were curtailed. Local representation disappeared and, effectively, the HSE became an unaccountable body. In my experience, the idea of consultation is merely an afterthought for it. Effectively, it decides what it wants to do in a given case and the consultation process is either non-existent, incomplete or a rubber-stamping exercise in respect of a decision already made by senior HSE managers who have little or no knowledge of local circumstances.

The formation of the HSE allowed the Minister of the day to wash his or her hands of matters. There was such an occasion in the previous Dáil when parliamentary questions were refused on the basis that the Minister had no responsibility for the day-to-day running of services. I welcome the indication from the Minister that he will initiate reform in that regard. His initial dealings with the board and the appointment of new members are welcome.

Several speakers have raised the matter of language proficiency and the standard of doctors to be appointed using the new procedures. The detail set out by the Minister is welcome. He refers to proficiency in the English language. On occasion, this has presented a difficulty for patients, colleagues and other professionals in hospitals. What the Minister has said appears to cover the matter. One possible reason the HSE did not address this issue in the past is that it somehow thought the shortage of junior doctors might be used for the purposes of the forced reconfiguration of hospital services. While I hope I am wrong in this regard, one worries that everything the HSE does with regard to hospital services is motivated by its so-called goal of reconfiguration or, in other words, the stripping of services from local hospitals and their centralisation in larger regional hospitals. I absolutely oppose this process as the normal range of health services at hospital level should be available locally with easy access for local users.

While the shortage of non-consultant hospital doctors should not be used in such a manner, it also should not put at a disadvantage those hospitals which have built links during the years with medical schools both in Ireland and abroad. I refer to hospitals with proven records of provision of high quality care which have been able to attract doctors on this basis during the years and which continue to so do. Such hospitals which have good in-hospital training services for doctors and which through their links with medical schools in Ireland and elsewhere have been successful in recruiting non-consultant hospital doctors should not be placed at a disadvantage. I have heard suggestions from time to time that the HSE might wish to relocate doctors from such hospitals to regional hospitals. However, the point has been made in the media more than once that this problem affects both small hospitals and many of the regional hospitals.

I welcome the two-year registration period and believe there should be long-term manpower planning. New career paths and strategies, as well as planning on a long-term basis, should be put in place to ensure this problem does not recur every six or 12 months.

I commend the Minister for his introduction of this legislation in such a speedy fashion. In addition, I acknowledge his tenacity and determination to introduce a system that is both workable and provides for consistency for the future when the need for junior doctors will be critical, as they will act as vital cogs in the remoulding, rebuilding and restructuring of a broken system. I acknowledge the efforts of the team from Letterkenny General Hospital who travelled to India within the last month as part of the recruitment strategy. I hope the hospital will meet the quota requirements in respect of the imminent allocation of junior doctors.

As for the designation of Letterkenny General Hospital with regard to private patient charges, this morning I forwarded some literature to the Minister. The designation of the hospital might be revisited as a way towards meeting shortfalls in the budget this year, when a deficit of €8.9 million is expected.

Were Letterkenny General Hospital to be redesignated as a regional hospital to provide regional services, including oncology and cardiac services, for patients in counties Sligo and Leitrim, there would be an opportunity to save more than €2.2 million per annum. This is worth considering and I ask the Minister to examine the possibility.

Donegal is the county with the highest level of social deprivation and one of the highest levels of chronic disease in Ireland. It also has the lowest rate of private health insurance coverage at 13%. In the past five years Letterkenny General Hospital has developed its role as a major provider of acute services in the north west. In particular, it has developed its regional role in the provision of cancer, renal and cardiac services. In January the hospital initiated its undergraduate medical education programme, thereby attaining university hospital status, with its first intake of 20 undergraduate medical students who will spend one year of their clinical and academic training at the hospital. Moreover, the programme's scope will increase to 40 medical students in September.

In addition, during the first four months of the year, Letterkenny General Hospital reduced its expenditure by almost 4%, while simultaneously rising to the top of the HealthStat hospital rankings. I commend all staff at the hospital for achieving this recognition. Despite this combination of budgetary reductions which included pay reductions and difficulties in recruiting junior doctors, high consumable costs were incurred owing to the fact that 90% of the hospital's inpatient activity was non-elective. The number of emergency department presentations has risen by 5% in the year to date. Consequently, the possibility of having a deficit of €8.9 million by the end of the year remains. While the figure of €2.2 million will not be realised unless the designation for private health insurance is revisited, savings could be made in this regard.

As for the health system in general, there has been a regional campaign for radiotherapy services for a number of years at both grassroots campaign and political level. I acknowledge the personal attention the Minister has given to this agenda and his commitment to funding Altnagelvin Hospital on the basis of a commitment to admit 30% of patients from County Donegal. This has brought much welcome relief to many cancer sufferers who had been travelling to Galway or Dublin. Border geography should not be a barrier to access and I look forward to working closely with the Minister on the scheme. It also should be noted that if that type of radiotherapy service is to be provided, it augurs well for cancer services at Letterkenny General Hospital and it is important that one hospital does not detract from the services provided at another.

On the challenge faced by the Minister, while he possesses his own medical knowledge and experience, as a layman, my perception is that he must dismantle a broken bureaucratic monster and in tandem recalibrate the manner in which services are run. Obviously, this will bring pain and be a difficult time for many. I was warned about this on the canvas trail when I was told things would be tough and that people would not envy me for my task. While it is tough, the important point is that although some will harness it in an effort to use it as a political weapon, anger is not and never will be policy. I acknowledge there will be hurt, pain and anger, but to use anger as a political weapon will do no service to either the health service or the people of this country. I commend the Minister on his hard work.

I thank the Leas-Cheann Comhairle for the opportunity to speak on this Bill. I congratulate the Minister for putting together, under urgent and pressing conditions, legislation that answers the practical challenge of bringing the standard of service provision into the hospitals as quickly as possible.

The contributions to the debate have been very good, including from the Opposition speakers. They have put together a very thorough consideration of the Bill.

I thank the Deputy. We try to be constructive.

Deputy Liam Twomey is both a medical practitioner and a politician. I agree with him that it is regrettable there has been a long, drawn out mess for so long and that we have to face the situation under fire-fighting conditions, but nevertheless well-thought out fire-fighting conditions. I commend Deputy Ó Caoláin on a very measured consideration of the Bill. He points out the weaknesses in the framework of delivering medical education and converting that education into practical experience through the hospital system. I have two brothers who are general practitioners, who went through medical school followed by the junior hospital doctor system. In those days, 30 to 35 years ago, the titles of the medical posts in hospitals ranged from consultant down through registrar and senior houseman to junior houseman. These terms are no longer used but rather the titles now are consultants, non-consultant hospital doctors and pre-registration qualified doctors. Deputy Ó Caoláin pointed out that a public service consultant post has a salary of €250,000 a year and that there is a duty on such a person not to concentrate that much on private practice and only to take on a small level of such work. This example in a profession trickles down and it encourages loyalty, commitment, enthusiasm and support from the people who are newly qualified.

One of the other features of the system is the almost impossible challenge of the six-monthly and one-yearly contracts. Every 1 January and 1 July sees a rush to secure hospital posts. Unless there is a compensation for the unsocial demands on junior doctors, there is a great temptation for them to go abroad to avail of research facilities and other medical opportunities arising. It is a pity we cannot swing some of our economic resources into research and into making the schedules of junior hospital doctors more conducive to a balanced way of life. To work 80 and 90 hours a week on very anti-social rosters does not make sense. The challenge is to look at the whole framework from the classroom education through to clinical education, post-graduation experiences and the development of further experience. I congratulate the Minister and the Department staff on dealing with the emergency by means of this legislation.

I listened with interest to Deputy Mathews's contribution. This is an issue which has been ongoing for a long time. We must work with the Minister in a rational and reasonable way to ensure the junior doctors crisis which has arisen this year and in other years is finally resolved. If the truth be told, we should all get behind the Minister's efforts because I know he has given a commitment to try to resolve the very issue to which Deputy Mathews has referred. For my part, I believe the greater good of society is served by us working together and not making a political football out of this issue.

There are a number of issues to be considered. I refer to the issue of the training of doctors and the entrance requirements for medical school. Deputy Mathews alluded to the issue of how to attract our young qualified doctors to stay in this country. The third and most complex issue is also the issue that has failed to be dealt with over many years by many governments, namely, the grip which consultants have over the system. The danger is that consultants have the system in a certain way that suits them and this is not friendly to the young, aspiring, up and coming person within the system. In my view, if the Minister is genuinely working to resolve that issue, if he is prepared to do the slow, patient work rather than becoming the tool of vested interests who are trying to preserve the status quo, then the Opposition will support him in bringing about the radical change needed.

I refer to the genesis of the mother and child scheme dispute and the 1947 Fianna Fáil Bill that was eventually enacted by Fianna Fáil in 1951. Unfortunately, Dr. Noel Browne failed to have the scheme established and it was the cause of the collapse of a government. That scheme was more about consultants' interests than it was anything to do with the Catholic Church. The more one reads about it, the scheme was a football among the vested interests. In my view, where there is common cause, we should not play politics with it. Unfortunately, however, the record of this present Government when it was in Opposition was exactly as Deputy McHugh said. It was harnessing the anger and making promises it knew could not be delivered once it walked into government. Promises relating to Roscommon hospital were made as late as March of this year. I hope the Minister will give the House an assurance today that this issue of the shortage of junior hospital doctors will not be used on the so-called health and safety grounds to start closing accident and emergency units in smaller hospitals permanently. Sometimes what the system loves is an emergency in which to introduce measures for a temporary period but which are then made permanent. It is fair to say that income tax was first introduced in Britain to pay for the Napoleonic wars. That emergency measure has lasted a long time.

The Minister has clearly identified that the smaller hospitals will be the losers in this regard. I refer to a statement he made when he said that we may very well end up with some accident and emergency department that cannot be safely manned. He assured us it would not be any of the major hospitals but rather that it would be the small, rural hospitals where there would be a real difficulty. If this is caused purely by a temporary difficulty, I hope the Minister gives an undertaking that once that temporary difficulty is resolved, we will then revert to the status quo.

As regards the smaller hospitals, I have never believed that the status quo can go on forever. I have never been unrealistic. I know people criticise me on various issues for being, what I would call, analytical and realistic and not playing to the gallery. I have never joined the queues of people who say we are going to abolish special areas of conservation, SACs, for example, or that everything in the small hospitals will stay as they were. I defended and I will continue to defend the basic thesis of the cancer strategy. If there was an appreciably better chance, we would go a lot further than Galway or Dublin to get a diagnosis or operation.

I do not believe that we have examined enough the work that could be done to decentralise that which is currently done centrally but does not need to be. We could provide services on a much more local basis. If something is high-tech or very specialised and people's chances are better over a short duration, they are willing to travel. I know people who have gone to England and America to get what they thought was a better chance of life in an extreme situation.

People want continuous treatments which can be provided locally to be provided at local level. They could start in one's own home and involve things like tele-medicine. They could also include GP clinics, and primary care centres that should be able to provide more services than they currently do should obviate the necessity of travelling to major hospitals for treatment. The system can work up to smaller hospitals. Very good work practices have been developed in Galway and Portiunucla where outreach services are being provided and doctors go to hospitals because a high level of technology is not involved.

What should be the preserve of the big hospitals are expensive and specialised treatments which need critical numbers. Therefore, the process does not need to be a continuous one of drawing into the centre. As is the case with chemical reactions, the system could go in two directions at once. Lots of things that were traditionally done in the centre could be moved away from it to the most local level possible. Certain specialties that require ever greater levels of technology and specialisation should be centralised because they tend to involve short-term procedures such as operations and diagnosis.

We often get the impression that this is a one-way street and things can only be moved into the centre. I am not a doctor; the Minister is. If there is a problem with MRSA in hospitals, the more people who are brought in unnecessarily to huge conglomerations of people, the greater the risk of infection. Therefore, limiting the time people spend and need for them to come into large centres would be a rational approach. It is also convenient to provide services locally, in terms of reducing queues and so on. There is a lot we can do.

There is a great temptation to play the game that was played with us on the Government. There was cynicism in recent years in terms of promises made which were known could never be fulfilled. In the anxiety to get into Government, any promise could be made. The programme for Government is littered with promises that will never be fulfilled. The temptation is to respond in kind but we would be wrong. The Government was wrong in Opposition and we will not do it because it plays to the gallery.

I was amused to hear the comments of Deputy McHugh. Fine Gael Deputies have short memories. He was correct. When we know in our hearts and souls that change is inevitable, we should work to make change for the better and not pretend that the status quo is a perfect solution and no change will happen. I have always argued that if people set their faces against any change, it will take place without any influence or input. If one recognises that we are in a radically changing world with radically new technologies and try to direct the change to give the best output, even though it is not half as spectacular as trying to stop the flood, one will have a much greater chance of influencing change for the better and ensuring it is rational.

As I said on the Order of Business, we are anxious to facilitate this Bill. We accept it is an emergency Bill and it is important that we work with the Minister to ensure this type of emergency legislation is not needed in the future. We should resolve this issue and stop robbing the Third World of people it has trained at great expense and bringing them here because we have a flawed system. It is morally reprehensible that we have to do it. It is mainly a result of vested interests in the medical profession.

I am glad to have the opportunity to speak on this Bill. It is unfortunate we have to introduce it in the first place. I recognise the difficult position in which many Members of the House have been placed in recent times and no doubt will be in the future. One has to ask why we have to introduce this Bill at the current time. Sadly, the reason is because of the lack of procedures in place to ensure we did not arrive at our current junction.

The Bill is intended to assist urgently in the addressing of current difficulties relating to non-consultant hospital doctor vacancies. Forward planning in all institutions is supposed to be able to identify and plan for something long before the need arises and becomes urgent. I mean no disrespect to the main Opposition party. Sadly, it has to bear a huge amount of responsibility for the situation in which we find ourselves. For the past five or six years I have been listening to how the Minister has been doing a great job in the Department of Health. I am afraid if the Minister did a great job and this is the end result, I do not agree with that and did not at the time.

Needless to say, I did not agree with the setting up of the HSE. I was totally opposed to it when it was set up, as were a number of other people in the House. It created a duplication of services that already existed. The Houses of the Oireachtas and Government handed over to an independent autocratic body full policy-making responsibilities for which the House, its Members and Government became responsible. Decisions are taken by people who are not elected to public office or Ministers. They have taken over and now dictate to the Government and Parliament where we should be going in the future.

The thinking that has led to our current situation is out of date. We have listened to the mantra about centres of excellence. We have heard how they will be the answer to all our prayers and that we will have delivery of services all over the place in a way which was never seen before. It is rubbish. It was the theory in the UK ten or 15 years ago. It had to change its thinking and policy when it found out that big was not beautiful, did not deliver, was too bureaucratic and sprawling and access could not be gained to services in the manner in which the public wanted. Services are provided for the public and patients and should involve ease of access for them rather than internal administrators, consultants and those working in the system.

A great deal of the responsibility for the debacle we have seen in recent times must rest with those who had authority and presided over the situation over the past ten years. I will separate Sinn Féin from my comments on the Opposition because it did not have responsibility for health. I hope the Opposition recognises that it was a disaster and we have seen the results. The sad part is that we have a growing population with a growing demand for services but less access to them. More people are telling us how we should deal with the issue when the simple fact of the matter is that the solution was obvious to all and sundry.

I listened to Deputy Twomey with interest. He gave a very interesting account of the way the system works from the inside. Those of us, including the Minister, who were once members of health boards know full well that what he said was true. In the thrust for forward thinking, the amorphous mass said we must close down services throughout the country and asked what to do to achieve that.

We disrupt services and fail to address the issues before, or as and when, they arise. We refuse to have proper forward planning, so we have dysfunctional institutions. The sad part of it is that, one by one, in the various smaller hospitals around the country means and reasons will be found to remove some part of those services, leaving them incapable to standing alone and providing the services to which people are entitled.

That responsibility rests with the main Opposition party whether or not it wants to accept responsibility for it. I am not suggesting the Members sitting across the floor of the House were responsible. However, we heard all the time about how the previous Minister was doing a great job. I know that Minister was not a member of Fianna Fáil but that party had core responsibility, to use a commonly used phase. It was readily said that the Minister was doing a great job. I could not understand where they were getting their information from but now I know because the information was wrong. It was provided by spin-doctors to tell people they were feeling well. Even though some people might be dying, they were still being told by spin-doctors they should be feeling better. They were told services were in place and access was available. They were asked what the problem was with travelling 50 or 100 miles, if they were in danger of dying in the next the minutes.

What in God's name are we talking about as we move into the 21st century? How often have we seen situations in the recent past, in every branch of society, where modern science and technology cannot do a better or quicker job? Why are we going the other way? We are incapable of responding to people's needs when they arise, although it should be simple to do so. We could get simple things done years ago, but not now.

Not so long ago, matters such as we have discussed over the last 24 hours were raised at health board meetings. We were told, however, that health boards were bad but, ironically, the issues raised there received attention and were addressed. That was because the health board membership comprised medical professionals, such as doctors and nurses, as well as politicians and administrators. They foresaw what was happening in advance and could predict what was likely to happen next year, so we did not arrive at a crisis.

The Minister of the day — I will not say who he was, but he is still an Opposition Member — came forward with this brilliant idea to abolish the health boards. First of all, he said they were not working, so he increased their number from eight to 11, but that did not work. He then decided to abolish them altogether, which was a bright thing to do. He said he would hand them over to what effectively was a private organisation. It was a privatisation of the health service. He handed it over but we now have no service at all.

We have what appears to be a public and private health service but in fact we have two private health services. Therefore when the unfortunate public need access to health services, which would ordinarily be available to them through the public health service, they must now join waiting lists. If they want a hospital bed they will be told that no beds are available. If they wish to be seen by a consultant, they may find the consultant is in another hospital, or could be in two places in the one day — one public and one private clinic. It will depend how urgent a person's case is as to whether they are seen. Meanwhile, the patient's physical condition will not have changed at all, so I do not know how the urgency of a case can change as regards access between the public and private systems.

I understand the need for this legislation, but its provisions were required four or five years ago. That was obvious to all and sundry. In recent years, many of us tabled questions as to why provision was not made to meet such requirements long before it became a necessity. The Department of Health failed to exert its authority over the HSE. How many times were we told when in Opposition that the Minister had no responsibility to the House and that it was a matter for the HSE? What is the HSE and what does it do? Who elected or appointed its members?

The HSE has devolved responsibilities and this, without a shadow of a doubt, is the biggest single enemy of democracy in this country at present. It is the biggest single obstacle to the delivery of health services. As elected public representatives we are expected to deliver to the public, either through Parliament or Government, but we cannot do so. The public have a right to comment on us, but it is within our hands to change the system. I hope this is the last time we will have to take this kind of retrospective action as a result of the negligence of previous incumbents of various offices to do the job they were elected to do.

I welcome the Bill and appreciate that it requires a speedy passage through the House due to the lack of junior doctors at this juncture. The Bill must be passed and enacted before doctors from overseas can register with the Medical Council and fill the vacant non-consultant hospital doctor posts with effect from 11 July.

I commence by paying tribute to all the staff and doctors in our hospitals, not only in my constituency but throughout the country, who have always had their patients' welfare to the fore. Despite whatever difficulties there may be in the delivery and administration of health service facilities, I am always glad to hear when my constituents praise the level of care and professionalism afforded to them and their families when they have had to avail of them. It is only right and proper that we should acknowledge the huge commitment that has and continues to be given by everybody in the health service in these difficult times.

I still fear there may be a number of posts left unfilled next Monday and thereafter. I initially became aware of the impending difficulties concerning the anticipated shortage of junior doctors on 25 May, following receipt of correspondence from the HSE Dublin mid-Leinster region. I was told then that relevant parties were working on contingency plans in the event of such a shortage emerging. Consultative meetings had commenced with clinicians in the midlands, including my constituency. It was further stated that the HSE was putting a number of processes in place on a short, medium and long-term basis to address issues contributing to this difficulty. The communication finally stated that a recruitment drive had commenced and I understand that it is continuing. The Minister updated us last Thursday in this regard and will do so further in the coming hours.

My caution about accepting the assurances concerning hospitals in my constituency is based on the language used in that correspondence. The documentation spoke about contingency plans and various processes being put in place, in addition to various short, medium and long-term processes. That is what gave me cause to worry. Why was there a need to speak of medium or long-term processes being put in place when there was seemingly great confidence in achieving the quotas of doctors required throughout the country?

Yesterday, we saw an example of one such long-term plan in Roscommon. That debacle may not have been diverted had promises not been given by the then Leader of the Opposition, his spokesperson on health and the Fine Gael candidates in that election, but the manner in which people felt let down and betrayed by these personnel may have been allayed.

What about your own gang?

As I have been saying for a number of months, the promises made about guaranteeing hospital services were probably not necessary in order to achieve the electoral success that occurred. They also promised to overhaul completely the EU-IMF agreement but that promise had not been and cannot be kept either. They promised not to put one more cent into the banks but that promise cannot be kept. They promised to resist in Government many of the austerity measures in last year's budget, but that promise cannot be maintained either, apart from reversing the minimum wage cut.

The Deputy should speak to the previous Taoiseach.

All of this affects the credibility of Deputy Buttimer and others. It affects the trust placed in them by huge numbers of the electorate of this country in electing them to government. It affects their ability to bring the people with them in the context of the tough measures coming down the track.

Last year's budget contained €6.6 billion in cuts. The Government is required to find a further €3.6 billion this year. The Government has postponed until September discussions in regard to what areas or Departments may be affected. Meanwhile, the Taoiseach and Tánaiste say there will be no tax increases or changes in welfare rates. The Government should get a few more lifeboats ready, in terms of back benchers, considering what is coming down the tracks.

Fianna Fáil wrote the book on it.

This would indicate major spending cuts in various Departments will be announced and spoken about in greater detail come September. Is this to include the Department of Health? In what areas of health will there be further curtailments? Will there be further curtailments in accident and emergency departments and other disciplines in other hospitals throughout the country or will supplementary funding be provided for that Department before then?

During the past number of months Deputy Kelleher has on several occasions asked the Minister for Health if he will be introducing a supplementary budget to maintain the commitment given by him in relation to his Department, based on what has been said by many candidates in February. Perhaps the Minister will make an unambiguous statement in this regard. Last week, we asked the Minister, Deputy Reilly, to list in order of preference the hospitals that would get first call on junior doctors as appointments were ratified. This would allow for details of contingency plans in smaller hospitals to be published and scrutinised. Obviously, I am mindful of hospitals in my constituency of Portlaoise and Tullamore. The Minister did not accede to that request but said he would know more the following day and so on. This culminated in what happened yesterday in regard to Roscommon County Hospital.

Deputy Charles Flanagan eventually announced that the Midlands Regional Hospital, Portlaoise would not be affected. I have accepted his word in this regard and expect confirmation in that regard following the passing of this legislation and subsequent appointment of personnel to that hospital. I expect that the Bill will allow HSE personnel to confirm unambiguously that services in the midlands area will not be affected. We need confirmation and unambiguous commitments in this regard. On Tuesday last, the Dublin-Mid Leinster Regional Health Forum was told that the midland health group will maintain 24 hour emergency services from 11 July pending clarification of a number of issues. As late as last Tuesday, clarification was pending. When I contacted the HSE today and asked for clarification I was told in a communication that it is not envisaged that there will be any impact on midland regional hospitals.

I ask that the Minister put this issue to bed once and for all. The Minister told us last Thursday he would know more the following day and so on. At that stage 221 of the 475 appointments had been agreed. How many appointments have been agreed to date? If the Minister can tell us that, he can then put on the record and publish a list of hospitals that will not be affected, a list of hospitals that will be affected and a list of contingency plans for other hospitals, following which we can scrutinise those lists to see if they hold water and can let the public know what they are facing in this regard.

Like many other members of the Opposition, Fianna Fáil has no problem in supporting the passage of this Bill. We acknowledge the need for it and the Minister's commitment in bringing it forward as soon as available. It is hoped the Bill is water tight and that these appointments can be made following its passage. It is incumbent on the Minister to publish before this week is out a list of hospitals that will not be affected and hospitals that will be affected. In respect of those hospitals that will be affected, I want to see contingency plans. As a public representative, I am entitled to scrutinise those contingency plans on behalf of the people who elected me to this House.

I welcome the legislation and cross party support for it. It is regrettable we are in this position. We should never be in a position whereby patient safety and delivery of service is in crisis and it should not be allowed to happen again. I commend the Minister, Deputy Reilly, for his stewardship of this issue. The shortage of non-consultant hospital doctors did not arise overnight. This matter was not flagged on a Monday morning by people inquiring of one another how their weekend went discovering there would be no doctors from 11 July. This was known about for two years.

Many members opposite have been complaining about this matter. Where were members of the previous Government during the past two years in terms of delivery of service? Who was in charge? Who was steering the ship of State? I remain unconvinced that anyone was steering the ship in the area of health for the past 14 years. I will come back to that issue. The shortage of non-consultant hospital doctors is an urgent matter. The Minister and his officials have been proactive in dealing with it. I am confident the Minister, Deputy Reilly, will be a reforming and pioneering Minister.

The mismanagement of our health service must stop. We can no longer engage in quenching fires on every street corner and in every county. That must stop. The people want a Minister — they have one now — who will be responsible, accountable and with whom the buck will stop. People no longer have confidence in the Health Service Executive. That confidence has been shattered. We need a new regime and joined up thinking which will ensure delivery of service. The Minister and new board must work in tandem. I call on the Minister not alone to get rid of the board of the HSE but to dismantle the HSE. The Minister should go back to the drawing board and start again. What happened is wrong.

Deputy Durkan is correct that there is no accountability in the HSE. The bureaucratic system that has unfolded as a consequence of the creation of the HSE has not worked. It has failed. The Department of Health has acquiesced by passing the buck between A and B, taking no responsibility and leaving no one in charge. It is time this changed. I say that knowing that many of the staff who work in the HSE are good public servants who do great work. However, there is no leadership or joined up thinking in this area. In my humble opinion, we should get rid of the HSE and start again. I praise the Minister for bringing a resolution to this issue.

Deputy Mitchell O'Connor asked a good question and I ask the same question. Why do so many of our young junior doctors emigrate? Career advancement must be made available to our young qualified doctors.

I very much welcome section 8 of the Bill. I am pleased that there will be no issue of quality or dilution of service and that there will be a rethinking of how we treat our non-consultant hospital doctors many of whom have been unfairly treated regarding their recognition. There is a strong case to be made for career advancement and not just to have them used as stopgap measures in the delivery of a health service. Without these doctors there would be no health service and we would not have a service of the highest quality being delivered. It is important that training for junior doctors and professional development are included as part of their career advancement. Many doctors in our hospitals speak of how they have been treated as we heard on "Morning Ireland" and other radio programmes.

We need a new vision, approach and dynamic in the health service. We must never allow vested interests to monopolise and dominate. We must never allow the chosen few to become the loudest voice. It is important to get what is best for the people, in this case patients. The patient must be at the centre of a health policy. Having listened to Deputy Cowen and other Members speak, we need a debate on the centralisation of services, which in some cases is not the right approach. We need a fundamental plan that is joined-up, real, practical and implementable. While I understand we live in different economic times from when we started on the journey of reform of the health service, we still spend billions of taxpayers' money every year, some of which is wasted.

While I may be in a minority in this belief, with political representation on the old health boards there was accountability and answers were being given because people had to report. Deputy Cowen spoke about the Dublin mid-Leinster regional health forum. The creation of health fora was the greatest ever cosmetic exercise in appeasement by a Government to its backbenchers and local authority members. Its reports are not worth the paper on which they are written. No official attending a regional health forum is worried or concerned about what might happen because nothing happens and it is just a forum. We need to go back to reality and there must be delivery of service with accountability and real responsibility given. The Minister is absolutely correct in insisting on not providing more funds to a hospital that has overspent. If Deputy Kelleher overspent at home, his wife would come and ask where the money had gone. If I overspent my bank manager would be on the phone asking where it had gone. We need to be real and the Minister is being proactive.

I am glad we have cross-party support on this measure, which is about the patient, delivery of service and ensuring what we do is right. However, we need to go back to the drawing board regarding the vehicle to deliver the health service the country requires.

I would not claim to know much about medicine or how the health system works, but I am very interested in it. Given that I have so much to learn about it, I would have liked to have got the Bill earlier than yesterday. The HSE seems to be a monster that is out of control, much like the NRA in the transport area. Too much decision making has left this Parliament and gone into the hands of civil servants who could be good, mediocre or disappointing. These are people who cost a considerable amount of money. In the long term we should not relinquish so much power to bodies such as the HSE, the NRA and many other quangos which have more power then they are entitled to.

It is very disappointing that we are educating Irish students who are not here to fill the vacant posts. Deputy Clare Daly stated we should consider making it a precondition that there be some payback from those students and that they be required to serve here for a period of time before disappearing to greener grass. I do not blame anybody for wanting to travel, which is good, but if the taxpayer goes to such expense to train these people it is a pity if the State does not get anything in return.

I do not agree with Deputy Ó Cuív who said we were robbing the Third World by bringing in Indian and Pakistani doctors. In the construction sector I had approximately 80 people from eastern Europe working with me at one stage. If I did not have them we would not have got the work done at all. They were very good workers who were honest in their approach. We paid them the same wages that we paid Irish people and it was good for both sides. I do not see a problem with employing people from other states; we need to be more open than that. We must remember that the Irish doctors who are not filling these posts are going abroad and being accommodated and welcomed in other countries. What is sauce for the goose is sauce for the gander. I have found all Pakistani and Indian doctors I have met in my life exceptionally good. An Indian doctor has been working without pay for the past five years for Wexford Youths. He is an absolute gentleman and brilliant at his job.

Deputy Twomey made some good points — he knows more about the set up than I do. He mentioned the problem of the number of faceless bureaucrats in the HSE which needs to be addressed. He also said that accountability and transparency are lacking. This is not particular to the health service and goes through many aspects of Irish life. We just do not do accountability and transparency very well. It would be wonderful if we changed our approach. The lack of accountability and transparency is soul destroying for people observing what is going on all the time.

I will not waffle on about a topic about which I do not know much. During this week's debate on the Private Members' motion, Deputy Ó Caoláin said:

It has been known and widely recognised for years that the hospital system is totally over-reliant on junior doctors. Successive Governments have failed to address [this] and now it is looming again, worse than ever. Recruiting sufficient additional junior doctors will be required in the short term, but this is not enough. Nurses [need to] be freed up to fulfil more responsibilities in [our hospital A&E] departments as they are qualified and willing to do this work. Hospital consultants [must] be required to fulfil their contracts to serve the public hospital system, contracts which [are being] widely breached. More consultants are required in [our] public hospital system [and] the current excessive remuneration for consultants [needs to] be reduced to facilitate the employment of more consultants.

The House does not need to hear from me that consultants in most areas of governance in this country are madly overpaid. I have heard they do not totally fulfil their obligations to do work on the public side because they are too busy making a fortune on the private side. This must be addressed because it is a serious abuse of the people.

The Minister has my utmost sympathy in dealing with the HSE. I wish to bring a case to his attention which refers to University Hospital Galway, UHG, which is a centre of excellence for cancer care for the people of County Mayo. I regret to tell the Minister that a woman cancer patient has been waiting since the beginning of February for surgery. I am told her GP has been in contact with the hospital and her family is waiting by the telephone but she has not been given a date yet. She would be operated on by a consultant urologist in UHG but the theatre for this surgery has been closed down, and when the consultant returns next week, no staff will be available to support him in theatre. Notwithstanding a substantial waiting list, this woman still does not have a date for surgery. I have contacted the hospital but I can get no clear answers. The consultant is very frustrated.

This is no service. Are there service level agreements in place? What impression does this give and what distress must this put upon the woman and her family, as well as all the other patients who are waiting but do not have a date? I cannot understand how a cancer patient can be left in this situation or how I can get no answers to my inquiries from the HSE. I take it from those who carry out the work at the hospital that the theatre is closed and, even when the surgeon returns next week, the theatre will remain closed until the end of the month. I will pass on the woman's details to the Minister. I would like this matter addressed. This is no service for people when they need it most.

I welcome the opportunity to speak to the Bill. It is excellent that we are in such broad agreement on this essential emergency legislation, which everyone of sound mind should support. Obviously, there will be a few who may find some reason it should not be supported, but the people will see their objections for what they are.

I wish to highlight certain observations from this side of the House. The Medical Practitioners Act 2007 allows for four divisions, namely, the general division, the trainee specialist division, the specialist division and the visiting EEA practitioners division. The Bill provides for the establishment of a new fifth division to allow for the difficulties we are having in obtaining non-consultant hospital doctors in sufficient time for them to be processed, pass the relevant tests and be approved by the Medical Council. This new supervised division will allow the council to assess applicants under a range of headings and link doctors' registration with an identifiable supervised post in a specific speciality for a contract period which will be less than two years.

The HSE has been very busy recently in the filling of these points. I am informed that as of three days ago, 4 July, data collected from individual HSE hospitals indicate approximately 172 posts were still vacant. Up to then, there were 4,660 non-consultant hospital doctors in the country, with a vacancy level of some 5%. In filling these posts, much activity has been undertaken by the HSE. Some 208 appointments were made following round one, 294 additional applications were made in round two and there were 229 additional applications in round three. Round four closed on Wednesday, 22 June, with 101 applications received, and round five opened on 23 June and closed on 30 June, with 215 applications received. It is anticipated that the number of appointments from these rounds will be low but will further reduce the existing vacancy levels.

Interviews were held in regard to Indian and Pakistani doctors between 2 and 14 May. Some 34 consultants and six HSE staff participated in the process. In Pakistan, 314 candidates were interviewed and 276 individual follow-up meetings were held. In India, 233 candidates were interviewed and 179 follow-up meetings were held, followed by meetings entailing detailed assessment, confirmation of relevant documentation and preliminary offer of employment. During the recruitment process candidates were informed they would be offered a post and that the HSE would provide the following: an allowance of €700 towards the cost of the flight to Ireland to take up the contract of employment with the HSE; an allowance of €100 per week towards the cost of accommodation for the first eight weeks of the contract of employment with the HSE; refund of the Irish Medical Council registration costs; and refund of their Irish visa costs, all of which is welcome.

I acknowledge that the issue of proficiency in the English language is very important. The HSE informs us that the interviews were conducted through English, using the standard approach, and that the applicants were assessed on this issue.

An issue that arises regularly for Deputies in our daily lives is that of Garda vetting, although I raise it simply in the form of a request for information. Are doctors exempt from Garda vetting? If a person is on a FÁS scheme delivering meals on wheels to elderly people, he or she cannot do it without being vetted by the Garda. This can take up to six months to complete and we all know of people who have been unable to take up posts working with vulnerable cases, including elderly people and children. It goes without saying that anyone who attends an accident and emergency unit, by definition, is in a vulnerable position, and they deal with doctors in sensitive situations. While I am not suggesting there is a scintilla of an issue in this regard, I would like by way of information to know are doctors required to be vetted by the Garda or are they exempt from the general legislation. If it is required, will this be built into the process?

Many issues have come to light and HIQA has prepared reports identifying a number of significant issues relating to hospitals with a similar skills profile to Ennis hospital. Some have referred to the "HIQA ten", which are the hospitals it lists as a particular risk and where issues are being addressed. The hospitals include Our Lady's Hospital, Navan; the midland regional hospital group, including Midland Regional Hospital, Portlaoise; St. Columcille's Hospital, Loughlinstown; Mallow General Hospital; Bantry General Hospital; the Mid Western Regional Hospital, Ennis; Nenagh hospital; St. John's Hospital; and Roscommon County Hospital, which, as we all know, has been in the news.

A high level status report detailing the progress on each of these hospitals has been prepared by the HSE and was presented to HSE management. I have just come from a meeting of the Committee of Public Accounts. The chief executive of the HSE, Mr. Magee, was present to answer detailed questions about accident and emergency services which, although not specifically related to this week's events, arose from a report produced on the subject. Among the information he presented to the committee was an internal report on the ten hospitals mentioned. In respect of Portlaoise hospital, it states the volume and complexity of surgical cases are under review with the clinical leads and that risk is otherwise being managed in accordance with HIQA requirements. I am happy to hear that the accident and emergency, pediatrics, obstetrics and psychiatric departments at Portlaoise hospital are being managed in line with HIQA requirements.

The approach adopted by the Department of Health is to designate hospitals as models 4, 3 and 2. It appears Portlaoise hospital will be designated as model 2, which means it will carry out more day cases and fewer overnight or complicated procedures such as heart stents. As I am not a medical professional, as will be obvious to the Minister, I will not speak further on that subject. We all understand as lay people that complicated surgery needs to be carried out in hospitals which offer a range of services.

It is important that senior medics and management in hospitals such as Portlaoise be proactive, rather than refusing to let anything go, with the result that they will be left swinging in the wind when it is all over. Portlaoise hospital is in a unique position. I am speaking for the benefit of the people of County Laois, rather making a criticism. Historically, the hospital was tied with Tullamore and Mullingar hospitals, although it no longer has a relationship with Mullingar hospital. I see our natural hinterland as including Naas, Tallaght, the Coombe and St. James's hospitals. From Portlaoise it is a 30 to 40 minute drive to the southside of Dublin city. I advise the senior medics and administrators in Portlaoise hospital to get on their bicycles and start negotiating with the hospitals mentioned because we do not want to lose out in terms of the direction of the Tullamore-Mullingar axis. There are clear opportunities for development provided the initiative is taken locally.

Everything is contingent on having a good ambulance service. It would be remiss of me to say the ambulance service in County Laois is adequate. There are regularly two ambulances in the county, but sometimes there is only one which may be used to transfer patients to Tullamore. It is often the case that an ambulance has to be despatched from the far side of counties Offaly and Kildare. The ambulance service in the county is not sufficient, but centralisation will only work if an adequate service is guaranteed.

Overall, I support this excellent Bill. The changes it introduces are necessary and, while it will not solve all of our problems, it will allow an appropriate arrangement to be put in place from next week.

I welcome the opportunity to speak to this Bill and commend the Minister for introducing it. It deals with an important issue which has been a feature of medical staffing for several years. The crisis with which it deals recurs twice a year and needs to be resolved. While the legislation is a stop-gap measure to deal with the immediate problems presented, we need to take a radically different approach to hospital staffing. I look forward to hearing the Minister's proposals for the putting in place of a comprehensive strategy to address the issue. It is not acceptable that the problem recurs on such a regular basis and it throws the management of hospitals into confusion. We regularly criticise the management structures of the HSE and the management initiatives taken by hospitals, but dealing with this issue puts extraordinary pressure on hospital management.

I ask for the Minister's assurance that what will happen on 11 July will not impact on the mid-west region. He will be aware that it was one of the first regions in the country to embrace the process of reconfiguration. From the point of view of hospital management, staff and patients, great leadership was shown in this regard. A previous Minister provided an assurance that the appropriate level of staffing and investment would be provided to ensure the success of the reconfiguration process. It would be a retrograde step, therefore, if those who jumped on the bandwagon of reconfiguration were told service provision would have to change once more because it was not possible to employ the necessary staff. I urge the Minister to use his good offices in order that the people concerned will not be penalised for having agreed to difficult decisions.

Reconfiguration in the mid-west region was vigorously opposed by both Fine Gael and the Labour Party every step of the way. They were scaremongering in regard to the number of people who would be negatively affected. I have always believed reconfiguration is the appropriate solution from the perspective of patient safety and care. Although it was a difficult concept to sell to the public, it was in the best interests of patients in the long-term. For some reason, the Government backbenchers who made inflammatory statements on the potential numbers of deaths that could ensue are the same people who last night trooped through the lobby to inflict the same level of service on the people of County Roscommon. Either the Minister has succeeded in educating them on the benefits of reconfiguration or their statements were disingenuous.

The policy of reconfiguration is progressing in County Roscommon as it did in the mid-west. I supported the policy in the mid-west region and Ennis, in particular, while I was in government and continue to believe the Minister is correct to follow the approach adopted by the last Administration. However, he needs to provide for an appropriate level of resources if he is to assure people it is not solely intended as a cost saving measure. In addition to the potential cost benefits, patients will have better outcomes because they will be treated in the appropriate hospitals. Investment in the ambulance service will also be required if we are to ensure a positive outcome. In this regard, it is welcome that Dr. Cathal O'Donnell who, with Mr. Paul Burke and others in the mid-west region, was a champion of the reconfiguration process has been promoted to the position of clinical director of the ambulance service.

Having accepted reconfiguration in respect of acute surgery, we should not rush to judgment on the delivery of acute medicine. I recognise that certain aspects require centralisation but others should be provided in smaller hospitals to reduce pressure and demand on the system. I refer, in particular, to the cohort of older patients who suffer from pneumonia and other conditions. They have no business being in centralised hospitals because they can access an appropriate level of care in smaller units. There was an acknowledgment that certain services should be moved to smaller hospitals, but, sadly, this has not happened at the rate one might have expected. This can partially be explained by staffing and personnel issues, but the Minister needs to ensure services are delivered in the appropriate settings. That will mean decentralisation of certain services.

If the Minister is to be successful in what he is attempting to do in Roscommon and other hospitals, he must look at the pilot project that took place in the mid-west. He will be required to ensure the services which can be delivered in places such as Ennis and Nenagh are decentralised quickly in order that he will have a benchmark to be used in other areas. To that end, there is a necessity to ensure a coronary care unit, currently in place at both Nenagh and Ennis, will be retained. These services are a fundamental part of ensuring we can continue to deliver a safe medical service and not having a coronary care unit in these hospitals will impact on the capacity to deliver the medical services that can be delivered in smaller hospitals. I, therefore, urge the Minister to ensure some of the views maintained in the HSE will not be allowed to be realised. Everyone accepts acute surgery must be carried out in the appropriate hospital with 24-hour accident and emergency facilities. There was potential for people in smaller hospitals to have less than adequate outcomes based on the service delivered. However, from a medical perspective, there is a necessity to retain coronary care units in order that smaller hospitals will have the capacity to deliver those services which can be delivered.

In respect of the air ambulance service, the western seaboard of County Clare is a considerable distance from Limerick. There were discussions between the previous Ministers for Transport and Minister and a body of work has been done by Mr. Cathal O'Donnell and the Irish Coast Guard on the provision of a service. I know there is a difficulty with funding, but I call on the Minister to support the work done and ensure the project which was identified a long way back reaches fruition, as it is unusual to have an opportunity to provide for a greater level of service at no additional cost to the State. This would be of benefit to the Irish Coast Guard in maintaining the proficiency of EMTs and ensuring there was the required level of activity in order to maintain their professional standards while availing of the downtime in their schedules. If a service can be provided as part of a pilot project, there would be an opportunity to overlay it across the country using the Irish Coast Guard. There should not be an air ambulance service available to cover every event, only where it is a matter of life or death and there is an absolute necessity to get the patient to hospital on time. I would appreciate it if the Minister put some effort into dealing with this issue.

It will be very difficult to respond in five minutes to everything that has been said. I hope, therefore, that those Members whose comments I will not address will forgive me.

I thank everyone who took part in the debate and for its tone, which, in the main, was very constructive. I thank the colleges and the council for their co-operation. I also thank the HSE officials who put a great amount of work into this legislation, especially Mr. Seán McGrath, as well as my departmental officials for the work they have done.

I apologise for the late appearance of the Bill, but the reality is that the Office of the Attorney General has been very accommodating in achieving what we have achieved. I hope Members will take this on board.

Deputy Catherine Murphy referred to the need to assess fully the doctors involved, while several Members spoke about the future training requirements of doctors. We will put in place a forum with the various stakeholders involved which will report not later than the end of the autumn in order that we can provide for proper manpower planning.

Deputy Clare Daly was concerned about the specific nature of the Bill and asked why people would be tied to a particular job. The reason is they will be examined in their area of expertise beyond which we do not want them to wander into other areas in which they might not be as competent, in respect of which we will not examine them. The forum was also an issue for Deputy Calleary.

There is a need for a protocol on how people behave, senior colleagues deal with their peers, juniors and patients. The special delivery unit will introduce and implement such a protocol. There is a poisonous relationship in one hospital to which NCHDs just will not go. That is not good enough in 21st century Ireland.

Deputy Calleary also spoke about the level of complexity involved. We want to treat patients at the lowest level that is safe and in a timely and efficient manner as near to their home as possible. That is why smaller hospitals are so important to us and have a bright future. One can use the term "downgrading" in terms of making something safe, but I do not accept this. We should bring to smaller hospitals the patients they are capable of treating. I have listened intently to what Members have had to say and it is a problem that the so-called centres of excellence do not divest themselves of all the other non-specialist stuff, which is what they should be doing. I have already used the analogy of taking a ten year old Volkswagen car to the Ferrari testing centre. I am sure it would do a great job, but there is no need to bring such a car there. Why are patients with a hernia, varicose veins, or a gall bladder problem going to hospitals such as Beaumont Hospital, the Mater Hospital or University College Hospital, Galway instead of going to hospitals such as Roscommon County Hospital, Our Lady's Hospital, Navan or Mallow General Hospital in which they would be cared for every bit as good and in a far calmer and nicer surroundings?

Concern was expressed about the monitoring of private clinics by HIQA, which body will soon have the right to inspect these clinics and have licensing authority over them. I want to see the HIQA standard extended to primary care centres and GP surgeries. There ought to be a role for HIQA wherever health care is delivered in order to ensure standards are maintained.

Deputies Mitchell O'Connor and Wallace, among others, spoke about doctors undertaking a two year internship programme. We should examine this issue in the context of the forum. I am a great believer in using the carrot rather than the stick and would prefer to ask why they are leaving, rather than telling them they cannot leave. Let us get a fix on the reason they are leaving, which is the lack of career opportunities, a clear career pathway, proper training programmes in some instances and the fact that they are used as gofers. The economics in training someone at a cost of €150,000 and having him or her run around a hospital looking for X-rays and blood test results are just crazy. Deputy Healy also spoke about this issue. Registration for two years should mean we will not have to face this problem again. As I said, we will aggressively pursue the matter.

Deputy McHugh called for the redesignation of Letterkenny General Hospital. I am very familiar with this issue and I am going to address it because the hospital should be redesignated, as it is losing out on the fees that should be paid by insurers for treatments carried out on private patients.

Deputy Ó Cuív raised a number of points, in particular, what he sees as the hold of consultants of the system. We have had a few years of consultant bashing here, during which they were portrayed as the rogues in the system. It was stated we needed a new consultants contract and that once that bugbear was out of the way, all would be well in the health service. We have a new consultants contract, yet we know all is not well with the service. The bulk of consultants are hard-working, good and committed professionals. There are only a few rogues and I have undertaken publicly to follow and deal with them. They will be dealt with, but to tar all of them with the one brush is not fair. There is no doubt, however, that they work differently and as such, the need for a specialist grade must be examined closely.

That would significantly address the number of manpower issues we face.

I did not want this to get political but Deputy Ó Cuív decided to go there. I never made a promise which I knew was undeliverable. I made a promise in good faith. I was not aware of the HIQA Mallow report as it had not been published. I did not have access to all the information I have now as Minister for Health. The reason I alluded to the smaller rural hospitals as being likely to suffer as a result of an NCHD shortage was that one must prioritise the larger hospital because it looks after the larger population. It will be temporary.

I thank everyone who contributed and I will take on board everything said and examine many of the aspects. In regard to the mid west, had that teamwork report been followed properly, it would have been a great success but instead it stripped out what was in Nenagh and Ennis and did not put in what was supposed to go into Limerick in terms of extra consultants, a new accident and emergency department, a 40-bed high dependency unit and extra beds in the hospital.

Question put and agreed to.