Health (Miscellaneous Provisions) Bill 2014: Second Stage (Resumed)

Question again proposed: "That the Bill be now read a Second Time."

Deputy Michael Healy-Rae

I thank the Technical Group again for giving me some of its speaking time. General practitioners from around the country, who have provided an excellent service to their patients over the years, are coming to Dublin this morning for a protest. It is unprecedented, in my memory, for hard-working GPs to take time out of their busy schedules to engage in such a strong and genuine protest about the detrimental effects of Government policies on their practices. Every politician who is elected to this House knows and appreciates the value of local GPs. Unfortunately, these doctors have had to endure a 40% reduction in funding for patient services over recent years. Many things that have happened are making the operation of GP services very difficult. Distance codes for call-outs have been abolished. This is affecting GPs in rural areas. The people of Feakle have been trying to get a GP to come to the area. Any GP should be able to make a living by operating out of such a location. Unfortunately, it has not been possible to get a doctor to go into the area. It is a fright to think that the difficulties being faced by GPs are making it hard for them to survive financially. The rural allowance, which used to be available to a GP who had a certain number of patients within a three-mile radius, has been abolished.

I wish to refer to the unworkable contract that doctors are being asked to sign up to. Perhaps I should say they are being coerced or forced into doing so. Along with some of my colleagues, I have met large groups of GPs from County Kerry who have explained to us in great detail that certain elements of the document are impractical. The doctors will not sign up to the proposal that is before them. Having read and studied the document, I have seen the gagging clause that will prevent GPs from advocating for the rights of their patients. One of the small and simple things included in the document is the imposition of certain conditions on doctors' surgeries. The walls and floor coverings, etc., will need to be of a certain type. If this approach is taken to its logical conclusion, it is clear that if one tells a doctor he or she cannot treat a patient in a room that is not of a certain standard, one will do away with the home visit. When a doctor goes to a person's home, it is unlikely to meet the standards that the doctor's surgery will have to meet under this proposal.

The waiting lists for home visits will be very long in the future because of the lack of GPs. We do not have enough doctors in this country. The Minister of State, Deputy Kathleen Lynch, will be aware that a person who wants to see his or her GP today will be able to do so. That has always been the case. If this unworkable document is implemented, I fear that future patients who want to see a doctor today will not be in a position to do so. That was never the case before now. If a person in any part of Ireland wanted to see a doctor on any given day, he or she would get to see one. This great service was provided out of hours. Doctors called to people's homes. Very bad weather conditions in the winter months did not stop them from calling to see their patients.

I appreciate the opportunity to speak on this matter on the morning that GPs are taking the unprecedented step of coming to the Dáil to let the Government and the people of Ireland know that they are upset. People always had the idea, found in the expression that "the doctor is well off, he is doing fine, there is no problem with him". I know GPs who are struggling with financial difficulties because it is so hard for them to run their practices. Irish GPs have 24 million contacts with their patients each year. One million of these contacts take place out of hours. The out-of-hours service provided by GPs has always been excellent. Approximately 95% of problems are sorted out by GPs without further referral. It is great that a person with a medical difficulty can go to his or her GP and get sorted on the day without having to be referred anywhere else.

Just 2.3% of the total health budget is spent on GP care. This compares with an equivalent figure of 9% in the UK. As I have said, funding for patient services has been cut by 40% over the past five years. GP costs have not remained unchanged. They have increased dramatically, as the Minister of State knows. In light of the additional cost burdens faced by GPs as they try to run their practices, it is disgraceful that the remuneration paid to them is now at the same level as it was in 2002. I am concentrating on the situation of GPs because it is vitally important. It is hard to believe GPs are struggling through such tough times at present but that is the case. I know other politicians will have had similar experiences in their constituencies. Every Deputy knows the local doctors. I am sure they will say the same thing. I am highlighting this in the House this morning because something needs to be done about it.

When I asked the GPs to make suggestions about amendments to the document they are being asked to sign up to, I was told in no uncertain terms that it is unworkable. It is not feasible to implement it. I was told it needs to be torn up. We should start again. I ask the Minister of State, Deputy Kathleen Lynch, and her senior colleague, the Minister for Health, to examine the GP contract with a view to amending it. They need to work with the GPs and their association to agree a workable document that will encourage young newly qualified doctors to stay in this country. It is a shame to think that after we have educated our young doctors, the only realistic option open to these young men and women is to go away and practice in some other part of the world, rather than staying in Ireland. This will lead to some very bad situations. I know doctors who should not have retired, but who did so at an early stage because they think the current position is unsustainable. They decided to get out while they could. Older doctors are pulling out early and younger doctors do not want to go into the profession in Ireland because they do not think they can make a living. That will be detrimental to patient care. We will pay a very high price for this in the future, particularly because we have an aging population. Older people who try to live at home have always relied on the good services of GPs. They will no longer be able to avail of those services on a daily basis as they might wish. That will surely be a detrimental situation.

I ask the Minister of State to use her common sense and her knowledge of the situation on the ground. She knows as well as I do that her local general hospital - Cork University Hospital, which provides a great service - is under immense pressure. I will give an example of what is happening in Kerry General Hospital at the moment. In recent months, the blood laboratory at the hospital has been experiencing trouble in processing blood tests. This has led to delays in patients finding out about the results of their samples. These things should not be happening in a modern health service. I hate to be critical of anything - I would prefer to be positive when I stand up here - but I have to criticise situations that are wrong.

I have had nurses pleading with me to stand up in the Dáil and fight for them and their patients, about whom they are extremely worried. Nurses are under the most unbelievable pressure on the wards, trying to take care of patients. All they are interested in, at the end of the day, is taking care of their patients. That is what is in their blood, if not their DNA. They are finding it genuinely difficult to do so, however, because of cuts. Why are we continuing to spend so much money on agency nurses instead of hiring full-time nurses? If one does the sums it is surely obvious that it costs more to pay agency nurses than to employ young people on a full-time basis. We must increase the numbers working in our hospitals.

On a positive note, some of the services in our hospitals have improved enormously in recent years. People who would have died in the past due to certain conditions now have a better chance of surviving. However, what is missing from the system is the person working in our hospitals as a nurse or doctor. The Minister of State knows that. I know she would not try to cover up for the Government on this issue and would tell the truth in this regard. She has personal experience of this and has seen it herself. As the Minister of State knows, cuts are also having a detrimental effect on our psychiatric services. I ask that the Minister of State takes on board the points I have made and fights with the people on that side of the House to ensure better services are provided to patients who are of paramount importance.

Deputy Liam Twomey

I welcome the Minister of State to the House. I also welcome this very important legislation which concerns the regulation and registration of all health care professionals. We are not just talking about doctors and nurses but also opticians, optometrists, radiologists, radiographers and all of those working in the health care sector. Such people must be registered properly and engage in continuing education. This will give comfort to patients and reassure them that they are being looked after in the most professional manner possible.

Some of the remarks made by Deputy Healy-Rae regarding GPs require a response. While I do not want to down play the seriousness of the concerns raised by GPs, it must be said that being a GP is a great privilege. It is a privilege to be able to work with patients and to have their trust. It is an extremely rewarding job. That said, GPs do have genuine concerns. Their job is not getting any easier but that has a lot to do with the fact that peoples' expectations have changed. The Minister of State has a full grasp of the issues, as does the Minister for Health, Deputy Varadkar.

Deputy Healy-Rae referred to the fact that there must be certain minimum standards in general practice. It is ridiculous of the Deputy to suggest that patients in the 21st century should be seen in general practice surgeries that do not meet minimum standards. Those who take pride in their work would like to think they are working in premises which are fit for purpose and meet minimum standards. Years ago when I was a locum I worked in GP surgeries which did not have hot water or functioning toilets and which had consulting rooms which were totally unsuited to seeing sick patients. In recent decades, that situation has changed quite dramatically and the quality of GP premises is generally up to standard now. There is no need to worry about the setting of minimum standards. It must be possible to clean a GP surgery properly. Allowances must be made for the possibility of spilling blood or other potentially dangerous substances. All surgeries should have autoclaves for sterilising equipment. It might sound ridiculous to say this, but all surgeries should have running hot water. It is essential that we would aim to achieve such basic standards.

The draft GP contract that was presented earlier this year is not the contract that will be offered to GPs at the end of the day and it is important to put that on record. There is no gagging clause for GPs. An estimated 350 GPs are expected to voice their concerns outside the Dáil today, which indicates that there is no question of them being gagged. There are general practice forums on the Internet. There are health forums where politicians express the concerns of general practitioners. That is the way it has always been and it will remain so. There is no such thing as a gagging clause on anyone who is practising medicine in this country. That notion needs to be put to rest and that nonsensical talk must stop.

It is important to ensure that we have enough GPs in the country and that we have a contract that is fit for the 21st century. The contract that GPs are currently working under dates from the 1970s. It is an acute illness contract and will not work for the future because the future of general practice, sadly, is about developing chronic illness care and management programmes for patients. We have had an explosion of health issues like diabetes, hypertension, obesity, high cholesterol and so forth. These are all chronic illnesses that must be managed. GPs who were practising in the 1970s when the current contract was introduced can tell stories of patients presenting to them with end-stage cancers - fungating masses of breast cancer or bowel cancer that had gone way beyond any chance of effective treatment. Those days are gone because we screen for so many illnesses now. We have very effective screening programmes for breast, bowel and other cancers as well as much more effective treatments for same. The medicine that was practised 40 years ago is not the medicine of today. I qualified 20 years ago and some of the treatments that were lauded at that time would be laughed at now. General practice has changed dramatically in recent decades.

The biggest investment needed in general practice is in ICT. Technology has changed dramatically in the past 15 years. When I started in general practice, many GP practices had no secretaries or practice nurses and no IT infrastructure whatsoever. Nowadays, all patients notes are on computer and all blood test and X-ray results are transmitted via broadband. GPs are not yet able to refer patients to hospital via computer because the hospitals have not developed their IT structures to allow doctors to refer by e-mail, but such developments will come about. I have not vaccinated a child in three years because my practice nurse does all of the childhood vaccinations, as well as the influenza vaccinations for my elderly and chronically ill patients. In contrast, 15 years ago there were very few practice nurses in general practice here. General practice is evolving at a tremendous rate and we must have a contract that reflects that reality. Change always frightens people and I have no doubt that the draft contract upset many people. Some of the issues raised in the contract were controversial but much of what is in the draft must be included in any new contract. We must have chronic illness care programmes in place. Structures must be put in place to allow us to deal with chronic illnesses for the next 20 to 30 years and the new GP contract must reflect that.

The increase in obesity levels here is shocking. A doctor examining children 20 years ago would have been able to see their ribs but that is not the case today. Obesity is reaching epidemic proportions.

I am in favour of what Dr. O'Shea, the endocrinologist who specialises in obesity problems in this city, is saying, that we should ban soft drinks from secondary schools. Soft drinks are a curse on this nation. We should get it across to the public that one should not have soft drinks in the fridge at home and one should not have easy access to them. Soft drinks are a significant part of the problem of childhood obesity. It is amazing the sugar load across a number of products that children and teenagers include in their diet on a daily basis and it has contributed to a significant obesity issue. For many of these children, this leads to issues around their self-image and self-esteem and that then reduces their participation in sports activities which only compounds the problem. When we used to diagnose patients with non-insulin dependent diabetes, we would hardly ever check anybody under the age of 60 to see if they might be diabetic. Now I am diagnosing patients in their 40s and it is becoming quite common to diagnose those in their 50s with non-insulin dependent diabetes. That quite significant change has occurred over a generation and it is one that will get worse unless we take this issue seriously and do something about it. That is built around the issues of preventative health measures and health promotion. These messages do not seem to be getting through to the general public and it is a serious issue. We need to be a little more proactive and we should reconsider the issue of not having soft drinks available. In regard to the health of the nation, soft drinks are more of a threat to this country and others, such as America, than al-Qaeda could ever be. There is a need for us to do something about it fairly urgently.

Deputy Healy-Rae raised the issue of agency staff and retaining doctors. We are in an incredible position in this country where we train 600 doctors a year in six or seven medical schools, if we include the postgraduate schools, over half of whom we export in three years. There must be an issue here. Those graduates are going, for instance, to the HSE, to take up senior positions and consultancy jobs. There must be more of an issue than merely what Government can do in this regard. There is a serious issue around the postgraduate training in this country and that is something that the postgraduate colleges must face up to and do something about. We might as well close two or three medical schools and invest the €20 million or €30 million we would save as a result in postgraduate training or at least in making these positions more attractive for our own graduates to stay in this country. Many of the graduates who leave to go to the United Kingdom enter full training graduate schemes where they start as senior house officers, go right through all of the ranks of medicine and qualify as consultants. We need to put that sort of system in place in this country, where one will finish an internship here, start as an SHO, and go through SHO, registrar, senior registrar and specialist registrar and qualify as a consultant, and that one will know exactly where one will work and for how long in this health care system. Such a scheme does not exist at present and that is why other countries which have better postgraduate training schemes in operation, such as the United Kingdom, Australia and America, are attracting the best and brightest of our graduates. Unfortunately, when someone goes to work in another health care system for more than four or five years, he or she finds it difficult to come back. I have seen that with some of my classmates over the years where they have come back to consultancy posts in this country, stayed for between six or 18 months, and then gone back to the system that they are used to and comfortable with. We are then left behaving like a parasite towards Third World countries in looking for their best and brightest. It is an unsustainable way of operating the health care system. It is not only the Government that is responsible. There have been many reports, dating back to the Fottrell report in 2006, on this. There were reports on both undergraduate and postgraduate training for medicine. The issue here is that the postgraduate training schools must face up to their responsibilities too. The hospitals and universities are closely linked and they need to put together schemes to train our own graduates and keep them interested in working in this country.

The issue of agency staff also relates to training. I hope that there will be less reliance on agency consultants. The agency consultants issue has nothing to do with the moratorium. The moratorium on employing nurses definitely is having an impact on the hospitals and that needs to be looked at by the Ministers, Deputies Howlin and Varadkar. In many cases, when it comes to hospital consultants it is merely that the hospitals are not attractive for young doctors to work in. Doctors who trained in large hospital training centres where they experience much peer review and many colleagues with whom they can liaise, are not interested in going to work in small departments in medium-sized hospitals where they feel isolated and left to their own devices. The new hospital groups the Government is establishing will improve graduate perception of these consultancy jobs, and we need to speed up the groups' establishment. If such doctors are involved in such groups, if they work with other doctors and if they are able to do specialist operations in the bigger hospitals and then do the more minor procedures in the medium-sized hospitals, that will make a significant impact in hospital medicine in the future.

I welcome the Bill. It is important that every person working in health is registered and regulated and every person who has a role to play in patient management participates in continuous medical education of his or her profession. It sounds astounding but if one qualified prior to 2006, for instance if one qualified as a GP in 1966, one would not have to show any competence that one had kept one's medical education up to date in such a case from 1966 to 2006. That has now changed. We must participate in continuous medical education and that is the right way forward because, as I stated, the treatment options that we would have been using when I qualified in 1993 would be to some degree out of date now. It is important that we keep up to date in what we are doing.

Deputy John Halligan

The Bill, essentially, applies to the professions of optometrist and radiographer.

I take this opportunity to raise an issue which is critically worrying in University Hospital Waterford. The former Minister for Health, Deputy Reilly, to great fanfare early in the year, officially visited the hospital to launch the €1.75 million new CT scanner and now the scanner, which patient groups state is critical to stroke victims not only in Waterford but in the south-east region, is still lying idle because there are not enough trained radiographers to operate it. It is outrageous.

This scanner was not a significant cost to the Department because it was funded last year through a donation from the Waterford City and County Infirmary Trust. It is state of the art. It is located in the new unit adjacent to the hospital's accident and emergency department, which was the requirement of the radiographers in the hospital at the time. It caters for a population, as I stated, not only for Waterford but for the entire south-east region.

There have been constant delays in getting this machine operational, first, because there was not sufficient support staff and, then, because of a failure of the HSE to train diagnostic staff.

One would not hear of any other European health service not being able to train diagnostic staff to operate such a critical scanner, one which is of paramount importance to thousands of stroke victims across the south east. On several occasions, I have been told by hospital staff that diagnostic training sessions were cancelled because of understaffing at the hospital. Radiographers could not be released for the training sessions because, as I was informed earlier in a telephone conversation with consultants, it would have created a crisis.

It was anticipated that the development of this second CT unit would provide improved overall access for CT diagnostic services. Its location adjacent to the new accident and emergency department at the hospital would have provided more immediate and safer access for critically ill patients, as well as supporting the implementation of stroke protocols for patients presenting every day to the emergency department at the hospital. Patients requiring CT scans are still being brought to the older machine, however, which is completely unacceptable, as has been pointed out by consultants at the hospital. The machine is located two floors away from the accident and emergency department in the basement of the hospital. Extra staff are required to bring patients to the basement in case there are any emergencies or accidents on the way. Last year, a total of 7,014 CT scans were completed at the hospital, meaning a large volume of patient traffic goes through the basement. The former Minister, Deputy James Reilly, saw the location of the older machine in the basement. It would be interesting to hear an explanation from the present Minister as to why there have been so many delays in the provision of the new scanner. Are there clinical issues?

Radiographers at Waterford Regional Hospital have long warned that they cannot work safely with their current staffing numbers. Patients are undergoing urgent MRI scans at private hospitals following referral from the South Tipperary General Hospital due to insufficient capacity at Waterford Regional Hospital. The weekly slot for MRI access for south Tipperary hospital patients was restricted to two sessions a week earlier this year because of the high volume of patients at the emergency department in Waterford Regional Hospital. I know what I am speaking about as my father recently had a stroke and is critically ill. If the Minister speaks to the specialists at Waterford Regional Hospital, they will all say that immediate and quick access to every piece of medical equipment such as a CT scanner is of paramount importance in dealing with stroke victims. Up to 7,000 stroke patients at Waterford Regional Hospital, however, are shuffled down into a basement or to other hospitals. I cannot believe what I heard from the professionals in the hospital yesterday and today about this facility. Government Deputies have gone to great lengths to give assurances to people in the south east, particularly people in Waterford, that there would be no downgrading of services when the hospital was grouped with Cork University Hospital. This is not the case, however. I appeal to the Minister on behalf of stroke victims in the south east to get the Department responsible to get its act together in ensuring this scanner is operating instead of stroke patients having to go down to a basement to an old CT scanner or be transferred to another hospital. It is appalling and unacceptable.

If I had to do so, I would have no problem in criticising the management of the hospital in this Chamber, on local media or to their faces. In fact, they know I am raising this matter in the Dáil this morning. Hundreds of people have a stroke every day. It is important a stroke victim gets access to vital medical care very early on, but this is not happening. I do not understand how expensive equipment could be left idle in a hospital for months on end when we cannot provide diagnostic training to the radiographers to use this scanner. When will this scanner be up and running? This morning I was informed by a consultant at the hospital in a telephone conversation that it may be November but that I should ask the Department of Health for more staff to work the scanner. It is unacceptable that stroke victims from the south east - in Gorey, Tipperary and Wexford, constituencies that I do not represent - will be shuffled in, if possible, for a CT scan in the basement of Waterford Regional Hospital.

Deputy Bernard J. Durkan

I must declare a family interest in so far as opticians are covered in this legislation.

The Bill’s purpose is to subsume the Opticians Board into the Health and Social Care Professionals Council which has caused some concern among opticians in general. From my point of view as a public representative, I do not have a problem with this move as long as the quality, standards and degree of services available to the public are maintained while nothing militates against the provision of a steady stream of professionals to provide these services, a problem that has occurred in other areas. However, as has happened in other health areas, because of the competing demands within a professional council, there might be a diminution of interest or emphasis on supervision, encouragement or representation of individual professional areas.

In recent years, the view has emerged that by putting several agencies together, one gets efficiencies. This is not necessarily the case. One may get financial efficiencies with a reduction in overall costs but one may not get an improvement in the provision of services by professional bodies. For example, the idea of administering the medical card system from a single centre did not work simply because the sheer volume of queries to that single centre was impossible to be dealt with unless massive numbers of staff were recruited. The economies achievable in such circumstances are debatable at the best of times.

If it has worked well, then let it continue, but if it is not working well and it needs review and revision then by all means let us deal with it. That is the purpose of Bill in general.

We must remember one point in the context of the delivery of health services that has been referred to by a number of speakers. I was concerned to hear GPs are protesting outside the House. That is a serious issue for a number of reasons. The issues involved include lack of resources and a lack of investment in the provision of the services they require. Changes continue to take place in the way the health service is being delivered throughout the country; some for the better. Other changes are still in the test phase. We must be mindful that health services in general are demand driven. It is not something for which one can necessarily plan ahead in general because one cannot anticipate various illnesses or epidemics that might occur. We must examine the extent to which the professionals in the field are happy in their work. If people are content in their workplace and have job satisfaction, they will deliver a better quality and standard of service and in general the community at large is the better for that. I hope in the course of the discussions now taking place both in the context of the Bill and in the general area of the delivery of health services that sufficient dialogue can be entered into with the professionals to try to ensure the issues on which they have expressed concern are addressed.

Deputy Twomey referred to the training of junior hospital doctors and the fact that so many qualified professionals and postgraduates go abroad. There are various reasons for that – sometimes conflicting ones. For the past 15 years I have made the point that it should be a priority to encourage, or at least give the opportunity to professionals to provide a service in this country in the first instance, having trained them to a high standard. The lure of other parts may be great. Sometimes, far away hills are greener than they look. It would be hugely detrimental to the delivery of health services if it were to transpire that our professionals go abroad on graduation. I was given various reasons for that when I raised the issue previously. They range from a lack of job satisfaction, lack of fulfilment and doubt about a reasonable career. They are all issues that must be addressed. That said, we must also try to encourage graduates to have a greater regard for the needs of the population in this country, which is growing. It is almost twice what it was in the mid-1950s. In the next 20 years we can expect the population to grow further. We must plan ahead for the provision of the full range of disciplines that are required in the health service in the future.

There are plenty of examples from which we can choose. We heard in recent years about the French system, the Dutch system, the Canadian system, the Cuban system and other perfect systems. In Cuba, the professionals might not be at the top of the salary scale. The fact remains that health is a serious issue that concerns every single person in the country; the young, the old and middle aged, without exception. At some time in our lives every person in this House will have to have recourse to medical aid in one form or another.

It is obvious there are serious deficiencies in the health service at present. They are not new as they have existed for some time. I was strongly opposed to the dissolution of the health boards and the creation of a single system of administration for the entire country. It did not work. It is as simple as that. Every time the current system comes under pressure we hear the same story and the same issues arise again and again. One of the reasons given for the dissolution of the health boards is that different criteria were applied in respect of qualification for medical cards in different areas. The simple response to that is to ask why that was the case when the same legislation applied across the country without exception. If some people took the law into their own hands and decided to set their own standards, there were ways and means of dealing with them and the issue should have been addressed. Having served for a long time on a health board, it was clear to me that the quality and service was much more personal, available and accountable than is the case currently. The key word was "accountability". All of the responsible professions came before a board on which they themselves were represented and they had to answer questions in a meaningful way that were raised by public representatives and their own members. Matters had to be addressed at an early stage.

I have listened with a certain amount of inward mirth to the calls from some Members on the other side of the House. I remember being in this House when the system was breaking down simply because the plan was not right. Once the system broke down and the focus was taken away from the management and delivery of services to the public, and people began to defend their own turf, then the health boards became weak and unaccountable. People went through the form and did not engage to the same extent. The sad part about it was that as a result the then Government decided to increase the number of health boards to 11 or 14, which was another foolish mistake. It was a case of going in the wrong direction. The proper structure to deliver the health services in a country of this size is approximately four regional structures, all of which are governed by the same rules and laws where the health Act applies, not one which we had until recently – we are gradually moving away from it – whereby a single health board administers the entire country. There was a time when you and I, a Leas-Cheann Comhairle, could table a question and have an instant answer but that is no longer the case and has not been for a long time. I compliment this Administration not for political reasons, but due to the major improvement in the response we can get to some of the questions we raise. We at least get a reply which says the matter has been referred to the HSE and it will correspond with the Deputy in due course. It does not always happen in the way intended but there is a considerable improvement between what happens now and the situation that prevailed during the previous seven or eight years.

In the context of the various reformations of the health service, we must upgrade our services and provide a higher quality and standard of service. We must also provide state-of-the-art services that are accessible in all regions of the country without exception. It should not have to follow that somebody in one part of the country has better access to health services because of their geographic location. It is as simple as that. Many consultants’ reports have been produced on the management and delivery of services in this country and elsewhere. It seems to be difficult to achieve what is required, and from time to time there are changes in how best to deliver. Delivery is the important part. If we lose contact with the need to deliver a service quickly then we have lost the battle in terms of the provision of health services. There is no good in people on the opposite side of the House saying that did not happen in their time. I am sorry; it did but it was a lot worse.

There is no doubt about that and such improvements continue to be made. I hope this remains the case but we must recognise that we cannot relax on this issue because it changes from year to year and sometimes from month to month. Demands change all the time and if we do not make provisions, we will not be able to provide the service the public deserves.

In the 1980s there were five or six health boards in the country and administration was duplicated. Comparisons were made between Ireland and the Greater Manchester, Calderdale, area, which had a similar population, and it was suggested our health system should be similar to the one in Manchester. That was wrong as the situations were like chalk and cheese. One place was a concentrated area of population that one could walk across in a couple of hours while the other was a country a couple of hundred miles in breadth. The comparison was nonsense and this has been proven over the years.

The Irish health service is in a state of evolution and we must take account of how to deliver an efficient service quickly and evenly throughout the country. This does not mean we should cut back on what is required to deliver the management of the service but that we should plan for the future. We should plan in terms of the number of consultants and radiographers required and continue such plans across the board. It is no good starting to plan when deficiencies become obvious as it is necessary to lay the groundwork well in advance.

I welcome recent indications relating to the national children's hospital as the matter should have been dealt with years ago and I am glad it is coming to fruition. There are competing suggestions as to where the hospital should be located but I hope this issue has been resolved. Some of these competing suggestions only served to delay the provision of the service and we cannot afford this.

The public, rightly, has higher expectations now than in the past as standards have risen in every profession across the board, with the possible exception of the likes of the construction sector. The public expects improved service delivery. I was amazed in previous debates on the location of the children's hospital that proximity to public transport was deemed to be an important factor. However, when the mother of a sick child learns that child needs urgent treatment, she will not take the bus, train or Luas to the hospital, rather she will take the fastest mode of transport available to take the child to emergency treatment in the shortest possible time. This is of great importance when it comes to some illnesses, such as meningitis. I could never understand why bus access was deemed a reason to promote the previously suggested location because that is not how it works. At last, this part of the problem has been resolved. It is a question of providing maximum quality of service in a place that is accessible at all times, regardless of time of day, traffic and so on.

This legislation is, essentially, regulatory and I hope my optician friends will be satisfied with the final draft, after amendments. I hope the other professionals affected by the legislation will find that it does not impede their enthusiasm for providing health services to the public through the public health sector. I could go on about the differences between the public and private sectors, including costs, but I will not. Instead I compliment the Minister of State on her work and dedication and her knowledge of the health service in general.

Debate adjourned.

Dáil Éireann debate - Wednesday, 24 Sep 2014