JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 3 Feb 2005

Health Policy: Ministerial Presentation.

Chairman

I welcome the Tánaiste and Minister for Health and Children, Deputy Harney, and her officials. Members will have noted from the timetable and accompanying e-mail circulated that the Tánaiste intends to focus on the following issues: accident and emergency services; new hospital developments and beds; long-term care policy; recruiting consultants; disability services and cancer treatment services. Members should note that the allocated time slots will be strictly applied and we will not tolerate members speaking after their allocated time has ended. I am anxious to ensure we use the available time as efficiently and fairly as possible in order that our meeting will be productive. I ask the co-operation of all members in this regard. Is that agreed? Agreed.

The Tánaiste will make her opening statement in the next half hour, after which the four parliamentary party spokespersons will have five minutes each to ask questions. Members are reminded of the long-standing parliamentary practice that members should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.

Tánaiste and Minister for Health and Children (Deputy Harney)

I am pleased to come before the committee to discuss health policy and my priorities as Minister. I am accompanied by Mr. Paul Barron and Mr. Dermot Smyth, assistant secretaries in the Department of Health and Children, and Mr. Fergal Goodman, who is a principal officer in the Department.

I do not propose to speak for half an hour or to circulate a script. I do not have a prepared script but intend to speak for a few minutes and then engage with the committee, which might be more fruitful than giving a long speech. There are many debates in the House on health issues. Every couple of weeks there is a Private Members' debate on health and there are also debates on legislation and issues of concern to Members. It is more appropriate when one engages with a committee that has a particular interest in health matters to do so on policy priorities and ideas.

Everybody agrees, regardless of their political perspective, that the focus of the debate on health services must be on patients. Sometimes, in many of the debates that affect different people who work in the health services, one would be forgiven for thinking that we were talking about patients. Whether it is hospital services, services for people with disabilities, community services or health reform, we must focus on what is in the interest of patients and particularly what is in the interests of sick patients. I am impressed by the interest members of the public have in health reform. If we approach the issue of reform from a patient's perspective, particularly from the perspective of how we can deliver the world class health service I have spoken about on a number of occasions, and if we could agree on certain priorities, it would be a major advance not only for politics in this country but also for patients.

Sick patients cannot have services too quickly. Sick patients are more concerned about clinical outcomes than anything else. However, they are also concerned about care settings, facilities, resources and after care. When one talks about health services, therefore, one must have an all-inclusive approach. One cannot separate the different pieces.

There is much debate at present about accident and emergency services. These services are for accidents and emergencies but because of deficiencies in the health service, many people end up in accident and emergency departments who need not be there. That is the reason the approach this year to the issues surrounding accident and emergency services includes out of hours general practitioner services, providing more step down facilities for those who do not need to be in hospital beds and providing a more appropriate setting for those with high dependency requirements who do not need to be in the acute hospital service. In addition, we wish to provide acute medical assessment units in order that those who require to be treated in a facility such as that can have the resources available to them.

The speed of delivery of health reform will also be important. We have many strategies. We have generally been good across the political divide and across Departments at devising strategies. One can never have effective reform without having a strategy or road map indicating where one wants to go and how one wants to get there. The most effective strategy is the one that delivers improved services for those who require them.

When we discuss improved services there is much emphasis on bed capacity. This morning, I will also focus on bed usage. I was impressed recently by a number of comments from leading experts in health care. Conor Burke, one of our leading lung specialists, who is not just an Irish leader in that field but a global leader, conducted an analysis of 4,000 patients. He concluded that more appropriate and effective use of beds would have eliminated the pressure points that arise at accident and emergency departments. When we discuss more beds, we must also discuss the more effective use of the current stock of beds in the hospital system.

The issue of discharge policies, particularly daily discharge, must be on our agenda. Miriam Wiley of the ESRI has also spoken at length about some of these issues. When a doctor certifies that somebody is fit to leave the acute setting it is often many days later, sometimes many weeks later, before that person is moved to a more appropriate setting, whether that is their home or a different setting. The issue of bed capacity, therefore, is not entirely about new beds, and new beds are needed, but also about the effective use of existing beds.

In today's newspapers there are many references to the Hanly report and to letters I am supposed to be writing to Mr. Hanly. I do not know if somebody is being innovative and imaginative but I have no proposal to write to Mr. Hanly. I will meet him next Monday. I have met him on one occasion since my appointment as Minister for Health and Children. Health reform is not off the agenda. We should not personalise the issue of health reform either with regard to David Hanly who has done an outstanding job on health reform, or anybody else.

We must create regional self sufficiency in so far as we can. It is not good enough that patients from the west, south east or south west must come to the Dublin area for essential health care. Of course, in the complex tertiary area we might only be able to provide at one centre in the country or perhaps two centres in the capital certain services or facilities. However, the vast majority of people who require hospital admission and the services of the acute hospital system do not need to come to the capital. Those services can be provided in the regions, particularly if we increase the stock of hospital consultants. We have greatly increased the number of consultants in recent years. The current figure is approximately 1,940 but that number must be increased substantially to more than 3,600 in the coming years. In some regions we do not have a specialist in some areas and, in many other cases, we may have only one or two specialists. No matter how good they are, they certainly cannot provide the kind of service required in the region. The EU working time directive will be implemented. It is a priority for me and for the Government.

In regard to cancer care, only yesterday I had an opportunity to meet representatives of the Irish Cancer Society to discuss the society's priorities and hear its perspectives. Of course, when we talk about cancer care, we must talk about cancer prevention and, in particular, population screening programmes. BreastCheck has been really successful. We must roll it out to the two remaining regions which do not have it — Cork and Galway — and that is a priority for me. Likewise, cervical screening is important and it is still only in place in the mid-west. Yesterday, I had the opportunity to discuss with the Irish Cancer Society — I have discussed it with other experts in the area and with my officials — the most effective way to provide these screening programmes nationally. Whether it is cancer screening, cancer prevention or other areas, we must be prepared to look at the most innovative way to provide services to the population.

Earlier this week I had the opportunity to do some work on the extension of the medical card. When the Government decided to extend the medical card on a doctor only basis to 200,000 people, we felt we could do that under the existing 1970 Health Act by ministerial order. However, in the light of advice from the Attorney General and the more cautious approach we are taking subsequent to the issue of charges for long-term care, we need primary legislation and a minor amendment to the 1970 Act. I have cleared that Bill and hopefully it will go to Cabinet on Tuesday of the week after next. The intention is that those cards will be issued from April.

There has been some public debate on the issue of extending the medical card on a doctor-only basis. The Irish Medical Organisation has made comments but I am satisfied that the card, and the issuing thereof, is not in breach of any agreements we have with the organisation. In fact, it welcomed the extension of the card on that basis. I have had discussions with the president of the IMO and the current contract with the organisation facilitates up to 40% of the population having a medical card as far as the doctor is concerned. Even with the extension of this card, it will only bring us to 34% of the population. The IMO has always maintained that if the card is given on a means test basis only and not on a class basis, like the over 70s, it is not an issue for it. An issue arises in regard to the form on which the prescription will be written. Clearly, since the card only covers the doctor, the prescription will be written on a private prescription basis rather than on the traditional medical card basis. Other than that, I am not aware of any other issue and nobody has brought any other issue to my attention.

Like other reform, we must focus on the patients and what they want. Certainly, the people are anxious to have this card. The reason we have extended the card on that basis is that it allows us to give cover to a greater number of people so they may at least have the advice of their doctor. The idea was first brought to my attention by members of the IMO and by Deputies, namely, that we should consider extending the medical card on that basis.

On health care generally, I said on many occasions since the end of September that we want to provide a world-class health service. When we talk about world class, we must talk in terms of how we manage and deliver health services and standards of safety and excellence. Above all else in the health reform debate, we must focus on safety. That must be the priority for all of us. Sometimes in this debate, safety is left aside. No chief executive officer of an airline would ignore the advice of the safety experts on how to operate an airline. No serious Minister for Health and Children should ignore safety advice when it comes to where, how and the basis on which services are provided. Therefore, experts in this area must be listened to. Experts sometimes differ but we know that in certain key areas, volume is important. If it is not safe to carry out only 20 particular surgical procedures at a particular facility and 100 are required, that must be the guiding principle in relation to health reform and we must have the courage to see that through. That does not mean closing facilities. What it means is that every facility should be used for its most appropriate purpose, whatever that might be.

As I said, I am a strong fan of regional autonomy in every respect, particularly in health care. I do not want to see people having to travel unnecessary distances and being away from home when they could be closer to home when they have serious illnesses. Having said that, we must be guided, above all else, by what safety dictates in this particular area.

The private, independent sector, has played an important role in Irish health care delivery for many years. We have a mixed system where approximately 50% of our population have private health insurance as opposed to 11% in the United Kingdom. I want to exploit how the independent sector can provide more services for patients in Ireland. Again, if services are to be provided privately and if private investment is to supply health care, then at national level, the Health Service Executive, the new Health Information Equality Authority or the Department of Health and Children and the Minister should decide the basis on which those services are provided. Services must be made available to everybody regardless of whether they have insurance. If services are available in a region, the State must be capable of buying those services if they are provided to high standards.

There is great interest among the private sector in the provision of health care facilities. We must move forward on a coherent and sensible basis. Recently, I asked Prospectus, following a tender process before Christmas, to work with me and my officials on drawing up a framework on how we can involve the private sector in the provision of health care facilities on hospital sites. I am very anxious to ensure that any new bed capacity and any new services are provided in conjunction with the existing hospital infrastructure. There is a host of reasons for that. The synergy and efficiencies which come from that are obvious. Also, we want to keep the medical expertise on site and ensure that the public hospital system gets the benefits of any investment that can be made in this area. Prospectus has been asked to come forward by the end of this month with some parameters on how we can have a framework in this area. After that, we hope to be able to move very quickly to support initiatives for health care development from the private sector.

Three new public hospitals are being built in Portugal by private sector investment and they will be run and operated by the private sector. The same has happened in Sweden. When we look at many other countries, we see how innovative they have been in bringing forward increased bed capacity and new services. Unfortunately, we have been too traditional. We have always felt that unless the Government does it, it cannot happen. We do not live in that model anymore and it is certainly not the model being followed in many other countries. The role of Government is obviously to provide services but, in particular, to ensure that the services provided are provided to the highest possible standards. The Government's role is to ensure the standards and the services are appropriate. It should not matter thereafter whether they are provided by the taxpayers directly or by other operators provided they are supplied to the highest possible standard.

I will conclude my opening remarks or else I will fall foul of what I said at the outset which was that I did not want to take a half an hour because there can be more engagement if we have a question and answer session. My Department supplied a long brief to members of the committee on the various issues of concern. I said during the debate on the HSE that I intend to supply members with the heads of Bills before they are finalised because we can have better debates and more effective legislation if we do that. Clearly when it comes to some emergency issues, that might not always be possible. There is a huge amount of legislation on the way from the Department of Health and Children, including the Medical Practitioners Bill, the Nurses Bill and the pharmaceutical Bill. As regards the latter, somebody recently commented that it is old legislation because we have been discussing it for over 12 years. Those Bills will come forward this year. The priority for me is the health, information and quality authority Bill. As stated earlier, standards and information are very important, particularly in the context of reform. We must be guided by what is in the best interests of patients, from a standards perspective, and the HIQA Bill is a priority for the earlier part of this year.

I look forward to engagement with all of the members of the committee because I know that everyone here is genuinely interested in health care. It is not about party politics; it is about patients. This, however, is notwithstanding the fact that people have different ideas about and perspectives on health reform and on how we can supply and provide services for the population. I confirm what I said privately to the Chairman, namely, that it would be my intention, if members so wish, to come before the committee during each Dáil session to discuss issues of priority outside the normal legislative framework. This would be beneficial for the committee and for me.

Chairman

I thank the Tánaiste for outlining her strategy and for her commitment to come before the committee during each Dáil term. I will now ask the various spokespersons for the various parties to make their contributions. We will begin with Deputy Devins.

Deputy Devins

I thank the Chairman.

Deputy McManus

The Opposition normally speaks directly after the Minister. We have been listening to the Tánaiste for 30 minutes.

Chairman

We are not going to argue over points like that. If Deputy Devins has no difficulty with it, the Opposition spokespersons will make their contributions now.

Deputy Twomey

What the Tánaiste says is fine, but there is a great deal of genuine anger among Opposition Members regarding the way the health service has been run in the past seven years. What is happening in Wexford General Hospital is a good example in this regard. A number of recommendations were drawn up in respect of the hospital approximately four years ago. One of these involved the provision of 19 additional beds. There has been an attempt to focus on those 19 beds as if this were the only issue affecting the hospital and that if they are delivered, the people of Wexford should be grateful. The accident and emergency crisis has been approached in the same manner. This crisis is merely part of the problem in terms of what has gone wrong with the health service. There has tended to be an attempt to consider it as the only difficulty affecting the health service and that if it is solved, everything will be fine.

The president of the Irish Association of Emergency Medicine stated that the crisis in accident and emergency is due to a progressive and sustained system-wide collapse of other parts of the health service. This indicates that the accident and emergency crisis is only part of a major problem. The Tánaiste stated that the Government will be judged on the success of the ten-point plan. The people do not want to judge the Government on solving what is merely part of an overall crisis in the health service. We should be seeking more from the Government.

I am angry about this matter, particularly in the light of the fact that Fine Gael submitted ten questions to the Tánaiste in respect of her ten-point plan and sought from her concise answers. The reply the party received is worth considering because there has not been any further clarification of the plan from the Tánaiste this morning. The reply states that the areas referred to are part of a ten-point action plan in respect of accident and emergency services which were announced in the Estimates for 2005, that a sum of €70 million will be available to the Health Service Executive this year for these initiatives, that the Tánaiste had met the senior management of the executive and that her Department is working closely with the executive to ensure early implementation of the measures. There are no targets, outcomes or anything else provided to show that there is a strategic plan to underpin all of this. We have been fed perception rather than reality. The Tánaiste should have provided clear answers in order that we would know exactly what is happening.

The health strategy was exalted as being something extraordinary before the 2002 general election. Now, however, it is being air-brushed out of history faster than Ray Burke. The primary care strategy was another major Government initiative prior to the 2002 general election. We have entered the fourth year and only one out of 600 primary care centres has been delivered on. The Tánaiste failed earlier to remark on the importance of primary care. She should clarify the position.

The Tánaiste commented on breast and cervical screening and on the fact that they are not available nationwide. Both these services have been available to the population of Northern Ireland for at least a decade. I do not understand why patients in the Republic do not have access to such services on a nationwide basis. The least the Tánaiste could do would be to allow women who possess medical cards to obtain cervical screenings on STC forms. This would allow us to make some progress in respect of resolving the difficulties in the health service.

There has been far too much generalisation in the debate. We need to discuss specifics and the sooner we do so, the better. Our hospitals, particularly those in Dublin, have been used as the most expensive nursing homes in the country for the past decade. The Tánaiste's advisers have spoken to her about this matter. At present, there are anything between 500 and 600 patients who have been inappropriately placed in our acute hospitals. The total cost to the Exchequer in respect of these people in approximately €100 million. If they were appropriately placed in even the most expensive nursing homes in Dublin, the cost would only be approximately €20 million per year. This would pay for the Tánaiste's accident and emergency plan. Why is this crisis, which has been in existence since I was a medical student, only being dealt with now, a year and a half to two years before the next general election, particularly as all the resources of the State could have been brought to bear on it during the past seven years? I am angered that people are being sold a perception that this crisis is something new. It is not; it has been around for a long period. I have not heard any genuine remarks about it as yet.

My final comment relates to radiotherapy services in the south east. Will the Tánaiste give a commitment in this regard and outline her plans? What are the two centres for Dublin? A radiotherapy report and an expert report have been in circulation since last September but no decision has been made in respect of the two centres.

Deputy McManus

It is frustrating that we have been given only five minutes in which to make our contributions.

Chairman

Agreement was reached on the arrangements long before this meeting.

Deputy McManus

I am aware of that. I do not agree that the committee should be placed in a situation where it is obliged to make such decisions. I am merely making the point that it is extremely frustrating.

Chairman

The committee agreed on the arrangements.

Deputy McManus

I am not arguing with the Chairman. I am trying to make the point that the Tánaiste has a reputation for getting things done. The reality is, however, that the hallmark of her short time in the Department of Health and Children is that we now have more aspirations and less accountability. That is why we have been stuck with five minutes each in which to try to deal with serious matters.

My first question relates to the Hanly report. Is the report dead, what is the Tánaiste's view on it and, if it is dead, what is her outlook on future changes in the hospital service?

Deputy Harney

I apologise for interrupting the Deputy but I stated earlier that the report is not dead.

Deputy McManus

If it is not dead, what are we going to do in respect of its recommendations? Is it fully alive and will accident and emergency departments be downgraded to nursing stations in future?

My second question relates to the Health Service Executive. Is the Tánaiste in a position to outline one improvement that has taken place since the HSE was established? Has she succeeded in finding some unfortunate victim to take over the job of chief executive officer of a body where the new structure overlays the old and where everybody remains in place? Is it correct to state that the next 20 senior posts must be filled by people who are in the service at present in the health board structure?

In terms of inequality, when the Tánaiste assumed her new position she clearly stated that people would be treated on the basis of need rather than income. That was her aspiration. When is she doing to deal with the gross inequality in our system where private patients are given preferential treatment over their public counterparts who are often more ill? Is she of the opinion that, when she speaks about Prospectus considering the private sector, yet another report from the Department of Health and Children is what we want? Will Prospectus consider the track record in terms of projects such as the car park at Beaumont Hospital? Will it consider the additional costs involved in over-reliance on the private sector?

When will the 3,000 additional acute beds and the 850 nursing units that were promised be delivered? I hope someone is taking note of everything I am saying.

Deputy Harney

I believe the Deputy is being recorded.

Deputy McManus

I appreciate that but I hope to get questions.

Deputy Harney

I presume the Deputy means answers.

Deputy McManus

I have only five minutes. Would the Minister mind not interrupting?

Deputy Harney

The Deputy will get answers.

Deputy McManus

These are important questions and this is the only opportunity I will have to put them to the Minister at the committee.

With regard to existing developments, the Minister must have had a weird Monty Python experience when she visited Mullingar Hospital to open a ward but, as soon as she left, it was closed because there was no staff. What is happening regarding wards which are available to be opened? The James Connolly Memorial Hospital in Blanchardstown is in a similar position.

How is the Minister dealing with the indemnity cover crisis facing hospital consultants, who are meeting next Sunday? How can the Minister justify her comment that there is no issue about medical cards given that the head of the IMO stated in today's newspapers that there is a scarcity of general practitioners in the disadvantaged areas in which these cards will be most plentiful? How will the Minister deal with the shortage of general practitioners?

She needs to address the serious problem in our medical schools. We are not producing enough doctors. There is an over reliance on foreign students to pay the bills of colleges. That is the most important issue facing the Minister because it will take ten years to produce consultants or general practitioners. That needs to be done because it is not being done.

Is the Minister aware there is a high number of vacancies in front line services at community care level? All the administrative posts have been filled at health board level but 50 community care posts in the mid-western health executive area are vacant. These posts are for physiotherapists, speech therapists, social workers, psychologists and others who work on the ground to keep people out of hospital and to protect their health. These vacancies are rampant.

I refer to cancer care. How can the Minister justify a delay in the roll-out of BreastCheck? Women are dying because they cannot avail of screening for breast cancer and promises have been made many times. The same promise was made by her predecessor, yet the director of BreastCheck in Cork recently expressed extreme frustration because yet another year will be added to the 2007 deadline. How can a Minister justify that?

Deputy Cowley

I met the Minister a few days ago together with representatives of Cancer Care Alliance and she made a positive commitment to provide a radiotherapy service in the south east. However, the people of the north west and the mid-west also need such a service. The Minister continually refers to private medicine but, as long as the service is available to patients at a reasonable price, nobody will have a major hang-up about it. It is ridiculous that patients should be deprived of a service that is economically sound given that what is proposed is economically unsound. The cost is ridiculous and the proposal is bankrupt from a humanitarian point of view.

Accident and emergency services highlight a total lack of planning. Mayo General Hospital had a system of reporting on X-rays whereas nowadays patients must wait for days to be discharged because of a lack of a report. This is pure and utter bureaucracy and this service could be easily sorted. Tenders were sought by the hospital but that was abandoned. I call on the Minister to address the posting of consultants on the front line. Decisions are made because consultants are not available. Surgeons, physicians and the casualty consultant should be available in accident and emergency departments.

There is a lack of planning and capacity. A total of 3,000 beds have been taken out of service while 38 beds were promised for Mayo General Hospital. Accident and emergency departments are overloaded. A total of 1,000 patients are on waiting lists. Mayo General Hospital does not have a neurologist or a rheumatologist and people must wait five years for appointments. They therefore present as emergency cases because they are ill. The lack of an ambulance base in west Mayo is another issue. If a general practitioner calls for an ambulance on Achill Island, it takes two hours to travel the 50 miles to and from the hospital. Since the patient is sick, it may become an emergency because of the travel time involved. This is again the result of poor planning.

A new 33 bed orthopaedic unit has been provided in the hospital but 20 beds are lying idle because the elective unit has been closed down due to the need to look after trauma cases. An excellent elective service has been provided in the hospital since last September with the waiting list reducing from 1,700 to 300 and the waiting period from five years to 11 months. That theatre is lying idle and it does not make sense.

Deputy Gormley

I thank the Minister for appearing before the committee. However, while she is good at identifying problems, she is powerless to do anything about them. When will the world class health service she promised be provided? What is the benchmark of her success? What does she hope to achieve before the next general election? She stated the problems do not relate only to bed capacity and she was asked when the 3,000 beds will be replaced. When will the 300 beds promised in the ten-point plan be provided, given that the Health Service Executive has been vague about this matter?

I refer to discharge policy. I was contacted by a man recently whose parents were in hospital. A number of weeks ago, a consultant said they were fit to leave and they could be looked after at home but the equipment they need is not there. They have spent six weeks in hospital, even though they should not be there. This is par for the course and it is unacceptable. What will the Minister do about discharge policy?

Does she agree the primary care policy is in tatters but it ought to be the cornerstone of a world class health system? However, she has stated more than 90% of illness could be addressed in her health strategy, the implementation of which is non-existent. When will a proper primary care strategy be put in place? Does she agree the basis of good health is good food, exercise and water?

The Minister stated in the past that the Progressive Democrats' philosophy is liberal and it is about the individual.

Deputy Harney

I never mentioned that.

Deputy Gormley

The Minister has stated this previously, not today. She referred to the importance of the individual and the need for less government, which she did mention earlier. How does that square with the idiotic policy of putting fluoride in our water? Should it be up to the individual to decide whether to take fluoride?

Deputy Harney

We may have done a lot of bad things but we did not put fluoride in the water.

Deputy Gormley

This does not square with the Progressive Democrats' philosophy. Each individual should decide whether he or she wishes to consume fluoride. Where this practice has been discontinued, there has not been an increase in dental cavities. The Food Safety Authority of Ireland has confirmed Dr. Hardy Limeback's statement to the committee that fluoridated water should not be used to bottle feed babies but the fluoride forum overturned that decision. How can the FSAI and the fluoride forum reach contradictory decisions?

Chairman

I ask the Deputy to conclude as he has gone over the time allowed.

Deputy Gormley

Will the Tánaiste take a fresh look at water fluoridation and will she, please, listen to me rather than speak to her colleague?

Deputy Harney

I was trying to get information for the Deputy, that is all.

Deputy Gormley

I appreciate that. I thank the Tánaiste.

Deputy Devins

I will share my time with Deputy O'Connor. I welcome the Tánaiste to this meeting. She has completed her first 100 days in office as Minister for Health and Children and from the evidence so far, we can look forward to an exciting time in the health area. I welcome the fact that she has stated publicly that patients are the most important people in the health service. As we frequently forget this in the various debates, I welcome her views.

We could discuss many issues but I will confine myself to two or three. First is the accident and emergency service. There has been an interminable crisis in the accident and emergency area in recent years. For that reason, I welcome the Tánaiste's ten-point plan published recently. In my local hospital in Sligo, in the past couple of weeks, patients had to wait on trolleys. This does not happen often in Sligo, but it happened this year. As a result, there has been no elective surgery, particularly in orthopaedics, for the past month. That is a situation we cannot allow to continue. Will the Tánaiste tell us where we stand with regard to the plans for the setting up of an acute medical unit in the various hospitals?

A term I do not particularly like, "step-down beds", is used to describe beds for people who do not require the level of care supplied by a general or regional hospital. Where do we stand with regard to the provision of those beds?

In the United Kingdom, usually starting in October, the NHS runs an intensive publicity campaign advising patients that they do not need to attend the accident and emergency unit for many ailments. As has been stated, accident and emergency units are for accidents and emergencies and not for many other problems that could be dealt with better and more promptly by the general practitioner. Are there plans for a publicity campaign on that line?

I welcome the fact that the Tánaiste has stated that the Hanly report is not dead. I do not really care what name is put on reform of the health service. However, I care that the reform should continue and am delighted it will. Reform will, obviously, mean a significant change in the way our hospital services are delivered and will require the addition of another 1,000 to 1,500 consultants. There may be problems in that regard unless we change the limit on numbers for entry to medical school. In particular, we must increase the number of Irish national doctors we produce. There is a problem in that regard in that many of our graduates are non-Irish or non-European Union and return to their country of origin as soon as they qualify. If we spend money on educating doctors, they should have some commitment to our health service at the end of their training.

I am delighted that the extra 200,000 medical cards, the doctor-only cards, will be provided by April. I am a member of the IMO and strongly welcome the provision of those cards. We are all aware from those we meet in our constituency clinics that many people find it difficult to access primary care level facilities because of their lack of means. The extra cards will be a significant help and the sooner we have them the better.

Deputy O’Connor

I wish to be associated with the welcome extended to the Tánaiste. The attendance here indicates how important an occasion this is and I congratulate her on the progress she has made in the 127 days she has been in the Department. Despite the scepticism, it is an important milestone that she is prepared to engage with this committee.

I was worried this morning about how I was going to squeeze Tallaght into my short contribution. However, as there has been much mention of Mayo, Sligo, Wexford and elsewhere, I will be forgiven for mentioning it. I am aware that, because she represented my constituency, the Tánaiste knows all about Tallaght Hospital. It has had a particularly challenging and demanding week because of the vomiting bug. I appreciate the effort her Department is making to control the situation and to support the hospital.

I share the call made by everybody else for people to go to Tallaght Hospital, and other hospitals, only when there is a real emergency. I hope I have the Tánaiste's support on that issue. With regard to the debate on accident and emergency units, we have been making a strong case for a 38-bed acute medical assessment unit at Tallaght. It is important that is provided. The Tánaiste is examining the challenging oncology report relating to the Dublin services and will not mind me suggesting Tallaght in that regard.

I wish the Tánaiste well and offer my support. To calm Deputy Twomey down, it is at least 800 days to the next general election. These debates are not about that election, but about ongoing services and plans and ongoing reactions to problems. We should all be calm about the work we are trying to achieve.

Deputy Harney

I thank members for their contributions. However, I am a bit worried by the number of Deputies, including Government Deputies, counting the days since I entered the Department of Health and Children and the days until the next election.

I will begin with the vomiting bug mentioned by Deputy O'Connor. As he said, Tallaght Hospital has had a particularly difficult week with over 180 beds quarantined, but it is not alone. St. Vincent's Hospital has seven beds closed and so too does Naas Hospital. The Mater has 12 beds closed. We know, having spoken to the authorities in Tallaght Hospital, that it was a visitor who brought the bug into the hospital, obviously unintentionally. However, this emphasises how important are the management of hospitals and the issues of visitors, cleanliness and hygiene.

I have discussed this issue in recent weeks and have asked the new head of the hospitals office to put a new regime in place for our hospitals in so far as hygiene and cleanliness are concerned. He has appointed an individual to oversee a hygiene programme in all our hospitals because the issue has been raised by a number of Deputies and others in recent times. Whatever about the strains, difficulties and pressures of the health service, there is no excuse for hospitals not to operate to the highest possible hygiene standards. When nuns ran our hospitals, people used comment on how they were constantly polishing and cleaning. Many hospitals now outsource their cleaning work and pay full commercial rates for the service. We must ensure they get what they pay for because the implications for health care and patients are serious if a hospital is not run to the highest possible hygiene standards.

With regard to the comments of Deputy Twomey and others, I agree that primary care is the centre of health reform. It has the capacity to take enormous pressure away from the acute hospital system. The current deficiencies in primary care are part of the reason 1.2 million people per year are using accident and emergency services. In other words, 3,300 people every day use accident and emergency services. It is hard to believe there are so many in that category. They are there because of the deficiencies in our health care system, particularly but not exclusively at the primary care level. These numbers are on top of the further 1 million people who receive inpatient treatment in our hospitals either on a day or overnight basis. In total 2.2 million people a year, out of a population of approximately 4 million, are availing of services at our hospitals.

Primary care and the way we encourage investment in it is important. The tax incentives that have been given for hospital and nursing home developments have brought on stream much development and investment. We need to examine a similar initiative for primary care. The Irish Medical Organisation has advanced proposals in this area and I am certainly open to looking at them. I am conscious that Mulhuddart, for example, which has a population of 10,000 has no primary care or pharmacy facility. That is incredible, although I am aware of proposals to provide such a facility there. I am very supportive of efforts to provide such facilities which are absent in large parts of the city.

On the provision of beds in Wexford or anywhere else, the capital programme for this year will be announced shortly. We are working with the Health Service Executive on the issue. In the past there was a separation of the capital provision from the revenue implications. In many cases the necessary buildings and beds have been available but not the staff because the two have not been linked but this is changing. When deciding on capital developments, provision must be made for the revenue implications because nothing annoys people more than to see a new, modern state-of-the-art facility not in operation. While they can understand when a state-of-the-art facility is not available due to reasons of resources, they do not understand the reason it cannot be commissioned once built. We must try to be better at marrying the revenue implications with capital requirements. If we use initiatives from the independent sector, it may allow us to be more radical and act more quickly than has been the case up to now.

In reply to Deputy Twomey on the ten-point plan, the required beds have been tendered for and some 100 of the 300 beds have been commissioned since the start of the year. The step-down beds have been tendered for; in this context, the Department is required to tender through the EU Journal. The high dependency beds will be tendered for next week.

I do not wish to go into detail on all ten points. I have appointed a person to oversee the project. When one is spending on healthcare a large sum of money, over €11 billion, almost one quarter of total Government expenditure, unless the initiatives are project-managed, the results will not be up to required standard. This system was not followed in the past. Whether it is the issue of hospital cleanliness or the accident and emergency initiative, individuals will be made responsible for their delivery. In my experience, this is the most effective way of achieving results. The worst way is to put a committee in charge because then nobody will have responsibility and nobody will be accountable.

Angela Fitzgerald is working with Pat McLaughlin at the hospitals' office and overseeing the project. She has significant experience and knowledge in the area and is hugely committed. I am very confident she will have the accident and emergency programme implemented on time, that is, this year. The test will come in the winter of this year.

In answer to Deputy Gormley's statement about accident and emergency departments being the test of success, no matter what is done at tertiary level, with the acute hospital system or in cancer care, radiotherapy or rheumatology services, if patients have to wait on trolleys overnight before being admitted to a hospital bed, we will not be successful. I do not regard this as total reform; it is simply a question of acknowledging that if €11 billion is being spent and 14 or 20 patients have to spend the night on trolleys — last night I believe nationally the total was 180 — we are not being successful. There is no excuse when so much money is being spent.

The most effective method of changing the position is to put right all the causes. There must be development of out-of-hours GP services, more acute medical assessment units, greater usage of beds and a more rapid turnaround. I acknowledge Deputy Gormley's point which was also made by others that there are patients in the acute hospital system, at a cost of over €5,000 per week, who need not be there. We want to find a more appropriate setting for them.

That brings me to the issue of long-term care. As the committee will be aware, there have been proposals that 850 beds be provided by the State. We are examining different ways of providing them. I hope to be in a position to make an announcement on the matter shortly.

In answer to Deputy McManus's question about nurses, the number working in the health service increased by 25% in the past five years.

Deputy McManus

I am sorry but I did not ask about nurses.

Deputy Harney

The Deputy asked a question about front-line workers.

Deputy McManus

I was not talking about that. On a point of clarification, I am talking about persons employed by health boards in the community such as psychologists and social workers. It is showing up in my figures that there are many vacant posts in front-line services. It is true to say a few of them are nursing posts but there is a range of community services. Primary care and community care are talked about frequently but the reality is very different. Primary care services are being starved and seem to be characterised by a lot of vacant posts. Meanwhile, the number of administrators seems to be swelling.

Deputy Harney

The Deputy makes a valid point in respect of front-line staff, whether they be nurses or therapists, and those involved in administration and management. If we have been good at anything, not just in health care and other areas, we have always been good at developing administration and bureaucracy. While there is a need for competent administration and management, what is needed is fewer people involved in that area and more management. This year the Government has sanctioned the recruitment of an additional 1,000 staff to deliver the disability package, for example. Many of them will be therapists such as speech therapists and physiotherapists. However, I acknowledge there are shortages and it will be difficult to recruit staff. For example, there are huge shortages in occupational therapy services. We have doubled the numbers in training in some of these specialist areas in recent years. We have also doubled the numbers being recruited but there is a very long way to go.

I acknowledge what has been said about medical education. Foreign students are paying the commercial value of their education. As a result, to a large extent, our medical schools are very dependent on them. With the feminisation of medicine and all the changes taking place, real issues are emerging. At a recent meeting with me the INO brought forward ideas on this issue which clearly has implications for the Department of Education and Science which funds the education of doctors. The Department of Health and Children funds the education of nurses. The country has 13 nursing schools but there are eight times more students applying than there are nursing places. The number of places has been increased by 70%. This year there are 1,640 nurses in training. The nursing schools received a total of over 8,000 applications while the Government has invested €240 million in capital funding in the development of nursing education. However, much more is needed because it does not make sense for us not to be able to supply enough doctors from the indigenous population, whether at primary care or specialist level. It is accepted that people must travel overseas to acquire the necessary specialist expertise and experience but we want them to return. Many are interested in so doing.

Deputy McManus

Will the Minister specify what she intends to do about the matter?

Deputy Harney

It is an education issue. It would be very easy for me to say we should double the number of doctors and increase capitation funding but the person who would have to carry the costs would be the Minister for Education and Science. We have been talking about the matter on which I agree with the Deputy.

On the matter of radiotherapy services, I received a report from the expert group last Monday on which I hope to make a decision within a fortnight. While it is important to make decisions as quickly as possible, everybody will at least acknowledge that I should consider the report and talk to my officials and medical advisers in the Department before I make any decisions. In cancer care, radiotherapy and other specialist services, we need to talk more about developing networks around those with the required knowledge. The expertise is to be found in individual radiologists and oncologists as well as the large multi-disciplinary teams which are important in cancer care services. There are eight radiologists in cancer care services. We need all of these experts to work together for the benefit of the population at large. I recently visited Memorial Sloan-Kettering Cancer Center, one of the leading cancer treatment hospitals in the world. I was struck by its outreach programmes from its centre of excellence to particular regions in the United States. We need to consider clinical networks with outreach programmes rather than simply facilities.

I am not in a position to outline what will happen in the south east. In a previous job I stated that I am personally committed to ensuring that fewer people need to travel long distances for radiotherapy. The trauma of cancer is bad enough without unnecessarily adding that extra burden. Even in recent months when the radiotherapy facilities opened at the private Galway Clinic, we were instrumental in ensuring that many of the public patients could use them. It was ludicrous to have such a facility being used by private patients and have public patients driving past it to come to Dublin unnecessarily. Where there is a spirit of goodwill, such initiatives can be used to greater effect.

As I said in my opening remarks if private investment introduces facilities and if the State is satisfied that they operate to high standards, the State needs to be imaginative and innovative in ensuring they are used by people who might be excluded by not having insurance.

Deputy Cowley

The same could also apply to BreastCheck. The Galway Clinic offered to provide BreastCheck facilities, but the offer was turned down.

Deputy Harney

I was not aware of that. The capital programme will be announced in coming weeks and rolling out BreastCheck is a priority. With early detection, treatment of breast cancer is hugely successful. Only yesterday I discussed this matter with the Irish Cancer Society.

Deputy Devins asked me about the acute medical assessment units.

Deputy McManus

I would like to ask two other questions if the Tánaiste would not mind. I am interested in the HSE, as I do not get the impression it is working very well. How successful has the Tánaiste been in getting somebody to fill the hot seat?

Deputy Harney

The recruitment of the CEO is a matter for the Health Service Executive which will make the appointment totally independently of me. I spoke to the chairman of the HSE two nights ago and he told me a large number of applications have been received either directly or through headhunters being successful. The group appointed by the HSE to oversee the selection process is to meet today to review these applications. I hope interviews leading to a recommendation can take place very soon. Clearly any new organisation will have transitional difficulties. These can be greatly exaggerated by not having a permanent chief executive officer. While I am very grateful to Kevin Kelly, he is only acting in this role and giving of his best. While it might not be visible publicly, from my point of view it is considerably easier to deal with one organisation than to have to deal with a whole plethora of organisations when trying to make things happen. As far as the accident and emergency package is concerned, instead of having to approach each health board and determine what it is doing in its own areas, all of that can be managed and operated from the centre, which is more effective for a population as small as ours.

On the fluoride in the water, I plead "not guilty". As Deputy Gormley knows, we have had this debate in the House and at Government level. The experts differ in this area. The Green movement and much of the medical expertise take differing views of the implications for dental care. Mrs. Ryan, a friend of mine whom I know well, took the case in the 1960s. I know how passionate she is about the issue even to this day. For that reason I have had an interest in this matter for many years. I have read extensively about it and the jury is out. I would not be as definitive as the Deputy.

Deputy Gormley

Will the Tánaiste take a fresh look at it?

Deputy Harney

I do not want to see the headline tomorrow: "Harney to stop the fluoridation of water". My talking about a "fresh look" could lead my friends in the media to assume that this is all about to change. The Government is always open to considering evidence. Health care should be about evidence-based medicine.

Deputy Gormley

The Tánaiste should not be a hostage to her officials and should take an independent look at the matter. I am not casting aspersions on anyone.

Deputy Harney

I am a great fan of ordinary water. Many people feel they need to buy bottled water. Tap water is as good as any other.

Deputy McManus

It is obviously not good enough for Deputy Gormley.

Deputy Harney

I accept that.

Deputy Gormley

Mrs. Ryan appeared before this committee and was welcomed by the then Chairman, Deputy Batt O'Keeffe.

Deputy Harney

She is a mighty woman. I know her well.

Deputy Gormley

They may even vote for the Progressive Democrats on occasion.

Deputy Harney

As she lives in Drumcondra, I suspect not. I have never discussed how she votes.

Deputy Gormley

Most of her relatives live in Dublin South-East, which explains how I know.

Deputy Harney

The Deputy is well informed; I am impressed by his knowledge of his constituency.

Deputy Cowley

The computer system in Mayo General Hospital, which might not be available elsewhere, allows anybody in the hospital with authorisation to see X-ray reports. Some people need to wait for a week or two for results of a test that has already been carried out.

Chairman

I want to move on to those members who have not yet had the opportunity to ask questions. Deputy Cowley will have a chance again at the end.

Deputy Harney

A number of the acute medical units will be introduced this year. I do not believe there is a plan to have one in Sligo. If there is such a plan, I have not seen it or been made aware of it. Clearly we need to roll out acute medical assessment units in as many of our major public hospitals as possible, which can greatly alleviate pressures on accident and emergency departments and deal with patients more promptly and appropriately.

Chairman

I will allow the remaining members who have not already contributed to ask questions now. We will return to other members. I will allow the ladies first.

Senator Feeney

That is very fair.

Chairman

I do not even need to be sexist; it is the safest option I can find at this point. I call Senator Feeney.

Senator Feeney

The Chairman is even allowing a Senator to speak first. I thank the Tánaiste for agreeing to appear before this committee during each Dáil term, which is greatly appreciated. I was delighted the Tánaiste does not like people having to travel long distances, particularly for radiotherapy. Does she have any plans for a radiotherapy unit, perhaps located in Sligo, to cover what was the North Western Health Board area, which is a very spread-out area covering very difficult geographical terrain? What are the plans for paediatric-adolescent psychiatric beds for seriously ill young patients who are not catered for in our psychiatric hospitals?

Deputy Cooper-Flynn

As the Tánaiste knows, we have a nationwide accident and emergency problem. Part of the solution lies with earlier discharge of patients to a step-down facility. Currently, in the west while many people are on waiting lists for State facilities, many empty beds are available in private nursing homes. I draw the Tánaiste's attention to the level of subvention paid in the western part of the country vis-à-vis what is paid in the east. A patient can get €220 and, if a hardship case can be established, an additional €80 in the west. However, in the east a patient will get €220 plus up to an extra €300 per week for a bed in a nursing home. If a bed is contracted out in the southern region €650 per week will be paid. If a bed is contracted out in the northern or western region only €430 per week will be paid. What is the reason for this discrimination? Using private nursing homes represents a solution to the accident and emergency problem in our part of the country and could be implemented overnight. The Tánaiste mentioned that the Department of Health and Children had tendered for beds. In what areas has it done so?

In the Tánaiste's comprehensive reply about the national rollout of BreastCheck, she said the design, construction and commissioning of the units would take approximately two and a half years. In 2003 members of the Western Health Board were told it would be rolled out in 18 months. Given that the Tánaiste has now established it as a priority, can the two and half years be reduced and, if so, by how much?

Deputy F. O’Malley

I welcome the Tánaiste, whose reputation has heaped expectation upon her. As she has said on many occasions, she is not in a position to deliver the reform on her own. She spoke of the speed of the reform, which is vital, as the Government will be measured by what has been delivered. What does she see as the biggest obstacle to the speedy delivery of services she mentioned?

The Tánaiste also spoke about the independent sector. How quickly does she envisage that independent services will come on stream?

At the risk of incurring the wrath of Deputy Gormley, can I ask the Tánaiste whether she has considered adding folic acid to this country's flour? The benefits that would accrue from such a supplement are well established.

Senator Henry

I welcome the Minister. I wish her good luck in her new portfolio, naturally. I have examined her legislative proposals. As I have said previously to departmental officials and at meetings of this committee, we have had dreadful trouble with blood safety. An EU directive which aims to prevent the transmission of diseases to donors and recipients should come into force on 8 February next. It is astonishing, however, that the heads of a Bill to enact the directive have not yet been brought before the Government. Officials in the Department have told me they are waiting for reports, but there must be plenty of reports for them to read because I have seen thousands of them.

I have no problems with the Tánaiste's intention to rely heavily on private facilities. Will more legislation be needed in that regard to ensure that standards are maintained? There was a serious incident earlier this year involving a genetic laboratory, which looked as if it was attached to NUI Galway but was not. Some people were given inaccurate test results because the standards at the laboratory were not high enough.

I agree with the Tánaiste that people should not have to travel for treatment, if possible. I ask her again to maintain standards, which is terribly important. I sometimes hear people saying they would prefer to receive treatment near their homes, even if the outcome of such treatment was not better than that received at a bigger centre. We have to be firm about such matters and ensure that we maintain standards.

Tomorrow will be too late to discuss the appalling state of medical education with the Minister for Education and Science. Some €8,000 is provided each year for the education of a medical student, compared to €27,000 for the education of a veterinary student. Surely the training of those who will treat people is worth more than a third of the training of those who will treat animals.

There are serious problems with the recruitment of consultants. There were no EU applicants when an orthopaedic surgeon post was advertised recently. Similar problems are found in all sectors. Can the Department of Health and Children which is still in charge of policy try to recruit consultants in sectors to which the health boards did not pay much attention? I refer to sectors such as neurology, rheumatology, rehabilitation medicine, respiratory medicine and psychiatry. The more high profile consultancies are sometimes put forward by the Department of Health and Children. The areas I have mentioned could be up and running quite quickly because they are among the less expensive sectors.

I applaud the Tánaiste for opening the Ballymun health centre. I wrote to her personally about the matter.

Senator O’Meara

I thank the Chairman for the opportunity to ask about the Hanly report. While Mr. Hanly might be leaving, it seems the Hanly reforms are here to stay. What does the implementation of the Hanly reforms mean now? Can the Minister clarify the matter? I understand that under the Hanly reforms, 26 general hospitals will lose their acute medical units and accident and emergency departments. A nurse-led or doctor-led trauma room does not equate to an accident and emergency unit. We have seen in the Monaghan area the consequences of a policy that involves people having to travel long distances for emergency care. I am not the only person who claims it is not working — GPs are saying it is putting lives at risk. Does the Minister intend to implement that aspect of the Hanly report? Will it be implemented by the Health Service Executive?

I totally agree with the Minister about regional self-sufficiency. It is not good enough that there are 1.2 cardiologists in the former Mid-Western Health Board area. Why does regional self-sufficiency have to involve the sacrifice of accident and emergency units? Why does it mean that a small but efficient hospital like Nenagh General Hospital which is giving value for money for every bed used has to be sacrificed at the altar of the Hanly report, to use the phrase used by my constituency colleague?

Deputy Neville

I welcome the Tánaiste. I would like to raise two issues. This committee has had tense and difficult meetings about orthodontic services. The Minister's predecessor was invited 11 months ago to discuss the matter with the committee, but he did not do so. Has the Minister examined orthodontics issues? I refer, for example, to the difficulties we face in training orthodontists. Consultants have proposed a reversion to the earlier approach to training. I am interested in the changes that would mean for the delivery of services. Some categories of people are being excluded from orthodontic treatment in certain areas. I do not have time to discuss the matter further. I would like the Minister to deal with it.

The Minister did not refer in her presentation to the delivery of mental health services such as psychiatric services. Some €90 million has been spent in this area since the Government took office in 1997. By contrast, over €50 million was spent on electronic voting in a single year. I could give other examples of such wasteful expenditure to put the Government's spending on mental health services in context. I have been informed that €15 million will be spent on the delivery of such services in 2005, which is less than the expenditure on the Punchestown project last year. That €15 million will be swallowed up by the need for extensive funding for the construction of the new Central Mental Hospital.

Substantial investment is needed to remedy the problems caused by the neglect of mental health services over many decades. The need to invest heavily in improvements in psychiatric services should be accepted. Does the Minister plan to deal with such problems? Must we continue to read the criticisms contained in the reports of the inspector of mental hospitals, which are becoming repetitive because nothing is being done? One can anticipate the contents of each year's report because one is familiar with the difficulties being experienced.

The Irish College of Psychiatry told this committee last year about the absence of certain professionals, such as psychoanalysts. Does the Minister have any plans to deal with that problem?

Senator Glynn

I welcome the Tánaiste. The issue of inappropriate bed occupancy is not pertinent to the acute hospitals sector. It is pertinent to psychiatric services, however. Hospitals are being used as hostels, which is a gross misuse of acute services. I can provide details of that at a later stage.

Many people who are boozed up to the gills take up important time when they arrive at accident and emergency units. What are the Minister's plans to hit such people hard in the pocket? Members are familiar with the phrase "elective procedures" — those to whom I refer elect to cause themselves to need accident and emergency services. Not only do they take up the time of accident and emergency workers, but they also create great disruption. Such people should be hit hard in the pocket. I would like to hear the Minister's proposals in that regard.

Child and adolescent psychiatry and psychiatry of later life are important. Psychiatry of later life is especially important when one considers that people are living longer. That specialty should be fast-tracked in regions where it does not exist.

What are the Minister's proposals for fast-tracking capital projects? I refer to phase 2B of the Mullingar project, for example. The Minister was made welcome on her recent visit to the area. If the rainbow coalition Government had provided the money to commission phase 2A of the project, much more progress would have been made.

Deputy McManus

Pull the other one.

Senator Glynn

It was lying idle for seven years.

Deputy McManus

The Senator is a trier.

Senator Glynn

Not only that but the Minister responsible had the brass neck to bring in a bed when he could not provide €2.2 million. We had to get the minister, Deputy Cowen to do it when he took over. Deputy McManus does not like the truth.

The fast-tracking of capital projects is very important. The original estimate for phase B was €30,000 but now stands at €115,000, or almost four times as much. Given the importance of the projects, what plans does the Tánaiste have to fast-track them?

Great strides have been made in the provision of good, well trained nurses and the numbers applying for places are welcome. Will the Tánaiste especially consider nurses with an interest in mental handicap and sensory disability services?

Deputy T. Dempsey

I congratulate the Tánaiste on the initiatives she has taken to change a history of failure in the health service in the ten-point accident and emergency plan and the expediting of extra medical cards and for her instinct to reform. I am here to appeal to her as there does not seem to be any parallel timing between pay and capital budgets in the health service. In Wexford we were told in March 2004, before the Tánaiste's appointment, that finance had been cleared for 19 beds. The expectation was a builder would be appointed within five to six weeks. Since then, two of the most eminent doctors in the south east have resigned from management structures. While Deputy Twomey was correct to say it was not simply a matter of 19 beds, my appearance here today is because of them. People do not believe us anymore. It would be better for me as a Government Deputy if the announcement had not been made. The expectation was given that we would provide 19 beds but nothing has happened. While I accept the announcement was made before her appointment, I appeal to the Tánaiste to appoint a builder. Protest marches have been arranged and frustration is being exhibited. I differ with my colleague, Deputy Twomey, in that I consider the provision of the 19 beds in question would constitute a signal that we were telling the truth when we announced them.

Senator Browne

I receive many representations on the National Rehabilitation Centre in Dún Laoghaire where the number of beds is completely inadequate. Unfortunately, the people who attend the clinic are there because of car crashes or sudden strokes and it is unacceptable to tell them they must wait three to six months. I understand the centre is not under pressure for space to expand as there is plenty of land available. Its plan to expand should be given priority in the capital works programme.

I am not sure if medical insurance is the responsibility of the Department of Health and Children or the Tánaiste' previous Department of Enterprise, Trade and Employment. Is the Department of Health and Children pushing the idea that medical insurance should also cover dental work now that there are three medical insurers in the market? The Department should have a view on the matter and put pressure on insurance companies to provide cover.

I am delighted to hear the Tánaiste has appointed someone to deal with cleanliness in hospitals which I understand is a major problem. Will she take matters a step further by establishing an awards scheme? Centra, for example, has such a scheme in place and a team visits its stores every few months and publishes a list of the cleanest shops in the country. The Department of Health and Children should adapt the idea to the health service. I hear from patients and specialists in hospitals that there is a major problem in this area. A specialist told a relation of mine who was receiving medical treatment that there was not one clean hospital in Dublin which I thought was a terrible statement to make. The Tánaiste must take on this issue and go a step further.

The Tánaiste has indicated she received the radiotherapy services report on Monday. Will it be made public and, if so, when?

Deputy Twomey

I agree with colleagues that meetings of the committee are too short. The Tánaiste said earlier the Health Service Executive had worked very well from her perspective by providing her with more information. I have heard the opposite from someone at senior level in the health boards who said that whereas one used to have to talk to two people to get in touch with the Department of Health and Children, one must now go through five. In some respects, the Tánaiste is increasing bureaucracy in the service.

As we are the only ones who can evaluate the Government's actions on the health service, committee members require far more information on current and future plans. The Tánaiste spoke extensively about investment in private hospitals and is in significant discussions behind the scenes on private investment in primary health care. She is also discussing out-of-hours private general practitioner cover. These policies will have significant implications for primary care and the acute hospitals sector in the next five to ten years. The short-term benefits will be felt in the next two years.

Chairman

The Deputy has only a one minute slot.

Deputy Twomey

I want more information for the committee on what is happening to ensure we do not make mistakes in future which will require correction.

Chairman

I remind members that they have one minute to wind up.

Deputy McManus

I agree with Deputy Twomey. I ask that the committee agree to require the Tánaiste to send us a full response to all the issues we have raised. Clearly, we are not receiving full answers. It is not possible to get them. We need a full response on all the issues raised to evaluate progress in terms of the Tánaiste's response.

Public health nurses have written to me in their hundreds to raise concerns about changes in qualifications and registration. Can the Tánaiste respond?

While the GMS report has been leaked, we have not seen it and I have asked that the committee be provided with a copy. Can it, please, be provided?

I raised the issue of equality with the Tánaiste in the context of access not just to hospital procedures, but also to specialists. How will the Tánaiste deal with grave inequality in that context? While I do not expect an answer now, I would like a written response.

Deputy Gormley

The Tánaiste said this morning that if the accident and emergency crisis was not resolved, it would be a mark of failure. The question is about the timescale involved in resolving the problem. The other question is when will we have sorted out our primary care strategy as a solution looks to be a long way off. I would like the Tánaiste to provide the committee with a timescale in which she expects to resolve these matters. Are we talking about a decade or the unlikely deadline of the next election?

I take comfort from the Tánaiste's comment that the jury is still out on the issue of fluoride but that was not the view of others. If the jury is out, it is up to us to convince it. I hope we can do so.

Deputy Cowley

I do not expect answers now to the questions I asked but would appreciate if I could receive a response at some stage. I asked about the screening system at Mayo General Hospital which was put out to tender and lost. It is a very useful system which could ensure the early discharge of patients.

I also asked about the value of consultants in the front line. My experience tells me having a consulting surgeon as well as a consulting casualty officer in place would make a major difference. The Tánaiste should consider this very seriously. As surgeons do not have time to come downstairs to give opinions, the elective system is delayed.

BreastCheck must be fast-tracked as 2008 is a long way off. In the meantime, will the Tánaiste see what she can do about allowing people in the west to access BreastCheck at the Galway Clinic?

I asked the Tánaiste about circumstances in which there was no urology waiting list or consultant at Mayo General Hospital. Approximately 1,000 people are waiting, some of them suffering from cancer. This is not acceptable. They are holding up the system by presenting as emergencies. If someone is left on a list for five years, he or she will present as an emergency at some point with acute retention or a cancer which has spread by the time he or she is diagnosed.

What progress has been made in providing an emergency helicopter service?

Deputy Devins

I thank the Tánaiste for attending. I welcome her indication that she will attend the committee once a term to have a similar session with members. The importance of the committee has increased enormously since the changeover from the old health board system to the HSE. I will refer briefly to the Tánaiste's interesting comment that she is considering the possibility of using private facilities in public hospitals. Perhaps she will develop this approach in primary care, which is probably the only area in which patients do not appear to have problems with the delivery of the service. I am aware, however, that problems occur within the totality of primary care. The mixture of public and private appears to work well and I ask the Tánaiste to develop it.

Deputy Harney

As regards the final issue raised by Deputy Devins, the idea I have is that private investment should be married with public hospitals. Incentives should be available for public hospitals to explore investment opportunities from the private sector to deliver additional services and have more consultants on site, rather than having separate facilities and people working on two different sites.

I have not commissioned a new report from Prospectus but sought its assistance in drawing up a framework. Mr. Vincent Barton of Prospectus, who has considerable expertise in health care, is working on this project and I understand we will hear from him by the end of February.

Three different groups are interested in building a private hospital in Waterford where we do not need three private hospitals. As I do not know how anyone could choose between the three applications, it is necessary to have a framework and policy for this process. One of the advantages of the tax incentives for private hospitals is that they encourage investment in this area. One of their downsides is that this investment is not focused around current hospital facilities.

I strongly believe in marrying private investment initiatives with the public hospital system as this creates winners in both systems. The public system can purchase services if such services are provided for patients at the appropriate standard, as is the case in many instances. The national treatment purchase fund, for example, purchases private services all the time. It is a universal insurer which acts as insurer of last resort. I have asked the NTPF, whose budget we have increased by 50% this year, to examine some of the long outpatient waiting lists. I am conscious of the comments of Deputy Cowley and others regarding certain specialties in which there are major shortages in many parts of the country. The NTPF can play a part in that regard and I look forward to hearing from it on this matter.

We need more technology in health care. The modern hospital of the future will be almost paper-free. The consultant at the patient's bedside will be able to order laboratory tests or X-rays and the results will be automatically provided by the laboratory for the consultant and the general practitioner on a palmtop or other device. Everything will be linked. That is the way of the future. While few hospitals operate in this way, there are examples in Madrid and Palma. This is the direction in which the world is moving. The Midland Health Board has made a case for making the new hospital in Tullamore such a facility and the proposal is being examined by the Health Service Executive.

The HSE has appointed a director of IT for the health services generally because information and communications technology has a major role to play in improving, in the first instance, the flow of information between general practitioners and those who do diagnostic work and in ensuring that access to the relevant information is much more rapid with a view to improving patient care.

With regard to dental care, in conjunction with VHI and the Delta health care company, I launched a new dental policy in my previous position. VHI is promoting and distributing the product on behalf of Delta, an American company headed by an Irishman from County Mayo — I believe that Deputy Cowley knows the man in question. His company has made major investments here, particularly in regional locations such as County Mayo. It recently launched a product on the market with VHI. Dental care is expensive and different policies are available. Those who want to have expensive orthodontic work done will pay much more than those seeking basic dental care.

With regard to Deputy Neville's question, I have not examined in detail the issue of orthodontics, although I have had a number of preliminary discussions on the issue. It is an area on which we need to do some serious thinking. We have a shortage of expertise and many different schemes, including the social welfare, PRSI and medical card schemes. We will need to do a great deal of work in this area in terms of remuneration for specialists and the way in which we work with children at an early age. I have seen many examples in my political career of children whose orthodontic problems were not identified early enough, with the result that they were forced to have treatments in their 20s and 30s which they should have had in their teenage years.

With regard to mental health, only yesterday I met the chairman and the chief executive officer of the Mental Health Commission. As members will be aware, the commission will establish panels to examine the issue of involuntary admissions to mental hospitals. Unfortunately, psychiatrists have refused to participate on the panels because of the dispute with the Irish Hospital Consultants Association. Approximately 50 psychiatrists are required to participate in the panels but only 27 have expressed an interest. As a result, we have not been able to get the panels up and running, which is a great pity. Perhaps the most vulnerable people in the country are those with mental illness. I appeal to psychiatrists to participate to allow the tribunals to be established in order that they can examine the 600 cases required in the first instance.

The current direction in mental health is to move into community based services. Last year we provided more than €600 million for mental health services. While I have not yet received the service plan for the HSE which we will get later this month, last year's figure will be substantially increased. It is intended to provide more than 100 new community places per annum from next year until 2009-10, as we move people out of the traditional institutional setting into a more appropriate community based system.

Senator Feeney asked about children and adolescents. This year we are providing €15 million for new facilities for children and adolescents in this area.

Senator Henry asked about blood safety and so forth. We will transpose a European directive on this issue under the European Communities Act rather than by way of dedicated legislation. Quality assurance is important, particularly in the area of blood. We know the consequences of what happened here in recent years. Besides the trauma and the dreadful thing we did to so many people through faulty blood products, we are also paying a heavy price financially. If my Department and other Departments did not have to carry the cost of the outcome of past mistakes, we would have much more money — approximately €600 million — to invest in facilities.

This brings me to another issue. The Dr. Neary case and others have generated considerable discussion in the media and the Houses. People ask how this case could have occurred and why it went on for so long. Why do we not empower medical boards? The medical board of a hospital effectively has no power. The chairs of boards act on a voluntary basis and are not given time off in lieu of doing the work required. Best practice internationally suggests that the position of chair of a medical board in a hospital should be at least a half-time position, should be given resources and must be empowered to intervene. There is no point expecting people to act if they are not given powers. This is one of the lessons we need to learn from some of the mistakes made in the past. If nobody has the power to intervene, we cannot expect intervention. With the prospect of litigation and reputations at stake, we cannot expect miracles of people unless we give them the resources and powers to intervene.

Deputy McManus

Is that matter being addressed?

Deputy Harney

It needs to be examined, and I have studied the approach taken in some other countries. The debate is raging and I need to read the international medical press. There is no point expecting the chairman of a medical board to intervene in the case of a doctor who is doing something he should not be doing if the chairman has not been given the power to intervene. We need to make such provision in legislation. We will need to examine this issue in the context of reviewing the common contract. I am a strong fan of medical research. We are lucky that some of the world's leading consultants work in our health system. Many of them want to be engaged in more serious research, a fact not sufficiently acknowledged in their contracts. We need greater flexibility in contracts.

This brings me to the issue of the Medical Defence Union which Deputy McManus raised. The MDU has behaved disgracefully and betrayed Irish doctors and patients. I will not allow it to walk off the pitch. I will not betray taxpayers. Equally I will not leave any doctor without cover or any patient without compensation. I made that clear at the annual meeting of the Irish Hospital Consultants Association at the end of September. I confirmed that in writing on 14 October and that remains the position. However, we have to move forward in a way that does not jeopardise any legal proceedings we might take. Yesterday when I met hospital consultants for the third time since becoming Minister for Health and Children, in addition to attending their annual conference, I made it clear that that remains the position. The doctors and the Government should be together on this issue. We should be, and I hope we can be. We each have to understand the other's position.

Deputy Twomey

Is it correct that the HSE is suing a consultant?

Deputy Harney

That is in regard to the issue in the north east. I am aware of the case to which the Deputy refers, in which a settlement was made with the plaintiff.

Deputy Twomey

A settlement was made but that contradicts what the Minister said, that she will not leave patients or doctors out on a limb.

Deputy Harney

I do not wish to discuss this matter in a public or semi-public forum. I am looking at the particular issues around that matter.

Senator Henry

I accept the MDU situation is very difficult but the Minister's predecessor made an awful mistake in concluding a secret deal with the Medical Protection Society. However, that is not the Minister, Deputy Harney's problem.

Deputy Harney

As I do not know what that means, I will not go into it. We must ensure doctors and patients are protected, and they will be. If that must be done as a last resort by the Government and taxpayers, that will happen. The Government is now covering the medical profession by way of enterprise liability but the issue arises in regard to past liabilities, particularly to cases that are not yet known about. Given that the premiums were accepted by the MDU, which on occasion reduced its premiums to get more business even though its costs were going the other way, which is extraordinary, there are serious issues around that. We are engaging with the MDU. An expert will meet the MDU on behalf of the Department on 11 February with a view to establishing whether we will be able to carry out a due diligence review to establish what is the situation.

Deputy McManus

The commitments the Minister has given are very clear but the difficulty as I understand it is that the MDU has some legal strengths. Nobody disagrees with the Minister but as I understand it the Department was asked by the MDU to start dealing with this issue years ago and it did not do so. The Minister has made commitments in public but they are not sufficiently legally grounded to have any meaning for hospital consultants. If this matter is not resolved we are heading for a collision course.

Deputy Harney

Whatever agreement we entered into, we have to be sure we do not jeopardise our legal position. I have a duty to the Government, taxpayers and patients to ensure that does not happen. Apart from the duty I have as a member of the Government to ensure that does not happen, we have responsibilities to the Committee of Public Accounts and the Comptroller and Auditor General that we do not sign off on committing taxpayers' money in an irresponsible way without exhausting all the avenues. That is really the issue. We have not yet exhausted all the avenues.

The Department of Health and Children behaved impeccably in terms of the way it handled this issue. It is a very tricky and difficult issue on which different interests have different perspectives. It has sought all along not just to protect taxpayers from over-exposure but to look after the needs of doctors, patients and so on. That is the responsible way to proceed.

We need a body in this area equivalent to the Personal Injuries Assessment Board so as to minimise the number of cases that go through the adversarial court system. We also need to have a different forum for resolving issues around malpractice or medical mistakes in order that those who are genuine victims of medical mistakes do not have to go through the adversarial court system to be compensated. That is something which I look forward to discussing when we get around to discussing issues of concern in health reform with the Irish Hospital Consultants Association.

I have a great deal of notes with me. I know all committee members want answers and I hope somebody is genuinely recording all this.

Deputy Gormley

People are doing a great job.

Deputy Harney

I know that is the case with Deputy Gormley. He is probably recording it all in his head.

Deputy Gormley

There are people sitting behind us who are doing a great job.

Deputy Harney

I thank them. In regard to phase 2B in Mullingar, when the new facilities were built in Mullingar a shell was built on top of it because it was felt that extra beds would be required in future. It was considered that the most effective way of coping with that need was to put a shell in at that stage rather than having to close down the ground floor at a later stage to provide new beds. It would not make sense to commission those new beds without new theatres being in place. We could finish the shell and put new beds in place but we will not have patients for the beds unless the theatres are there to ensure increased activity. That is really the issue.

In the context of capital programmes and so on, as I said, we have to marry the capital provision with the revenue implications, otherwise we will end up with facilities, beds with mattresses and curtains around them, but no patients and no staff, as I have seen in some places. That does not make sense. Sometimes even when one gets patients the beds are out of date and that does not make sense either.

I think I have dealt with most matters. I wish to repeat the point I made regarding safety. Senator O'Meara asked me about the Hanly report. I want to ensure regional autonomy and to have that we need more consultants. We also need more consultants to comply with the working time directive. For example, there is no plastic surgeon in the mid-west region. One cannot have regional autonomy if there is not even one specialist. We need to build up medical teams in the regions. We also need to ensure that procedures take place only where it is safe for that to happen. If the president of the Royal College of Surgeons, who is recognised not just as an expert in Ireland but throughout the world, says that certain procedures should not take place here or there because it would not be safe for patients and that they are being put at risk——

Deputy Cowley

That has to do with absolute volume.

Deputy Harney

No, that is not the case, but volume is a factor. We cannot have a hospital or a world class service in every town but we have to make appropriate use of every hospital because if a seriously ill patient goes to the wrong place — the doctors on the committee will be aware of this — and ends up spending unnecessary time there before he or she gets to the right place, the chances of recovery are greatly reduced. We know that the chances of survival are often reduced.

Senator O’Meara

Travelling long distances in ambulances to accident and emergency units also impacts on patients. Acute medical units are the issue.

Chairman

I am sorry, but we are not going back to that matter.

Deputy Harney

It is not a question of all or nothing.

Deputy McManus

We need to know if the Minister agrees with the Hanly solution. The Hanly report is clearcut; either one is for the proposal on accident and emergency units or one is not. The Minister should tell us.

Deputy Harney

We should not personalise the Hanly solution as there was a group of experts involved with different perspectives. Senator Feeney was a member of the group and I understand the group was unanimous in its recommendations.

I agree we need hospital reform, regional autonomy, more consultant-led services and that hospitals be appropriately used. I will not say what should happen in one hospital or another as I am not an expert.

Chairman

If I allow one committee member to speak, I will have to allow everybody to speak and I will not do that. I thank the Tánaiste.

Deputy F. O’Malley

The Tánaiste has not replied to me.

Deputy Harney

This issue was raised with me only last week or the previous week. We need some expertise on this matter and we intend putting together a small group of people to advise on it. That will have implications, but if one thing must be done in the interest of safety, that is what we should do. Patient safety will determine policy.

Deputy Cowley

What good is safety if a person cannot get to hospital? It is also about geography.

Chairman

Deputy Cowley should allow the Tánaiste to speak without interruption.

Deputy Harney

Of course it is. I agree with Deputy Cowley.

Chairman

We will concentrate on members whose questions have not yet been answered.

Deputy Cooper-Flynn

I asked some questions about discrimination in the level of payments for subvention and contract beds. Will the Tánaiste outline examples of where there has been tendering for beds? Will BreastCheck be fast-tracked in a shorter period than the two and a half years that was outlined in the Tánaiste's briefing note?

Deputy Harney

We are looking at whether it can be extended at a faster rate. One of the advantages of having the new unified system for the provision of capital facilities is that I hope we will be able to reduce the number of teams involved. At present there is a hospital team, a health board team and a departmental team of designers, architects and so on. I hope that if we can reduce the number of teams, we can speed up the development of some of these facilities.

The unified system will achieve unity in terms of supports. The Deputy mentioned the north west. I have seen cases closer to the Dublin area in which one side of the road was in one health board area and receiving a certain level of subvention while the other side of the road was in a different health board area and receiving a different level of subvention. People get very angry about that, particularly those who are receiving lower subventions. We will have uniformity but we must gear the level of support according to market rates. Property is more expensive in certain areas than in others and, therefore, we want in so far as possible to gear the supports according to the cost of the provision of services.

There are many reports on long-term care. We know that the number of over-65s will double over the coming 15 years. Significant issues need to be addressed in terms of how we provide long-term care and where we provide it. I am strongly in favour of giving more supports to people for family and community-based care. We need to take this seriously. Among the initiatives that feature this year is the home-care package, which will be very much customised around the needs of people. The idea is that if a patient whose doctor is ready to discharge him or her is not in a position to return home because of the absence of certain supports, we will discuss with that patient the level of support he or she requires and, within reason, help him or her to move home.

Deputy Cooper-Flynn

Are the tenders spread countrywide?

Deputy Harney

The tender is general and the price is neutral. We want to get the best value.

Deputy McManus

Does it require legislation?

Senator Glynn

I made a point on inappropriate bed occupancy. What does the Minister propose to do with those who abuse the accident and emergency service? What is her position on the fast-tracking of capital projects, on bringing forward the consultative forum which will correct the democratic imbalance and on the training of nurses interested in caring for those with a sensory disability?

Deputy Harney

Deputy Tony Dempsey mentioned Wexford General Hospital, regarding which I am very optimistic that the programme introduced by the HSE will include the resources for the 19 beds. The Deputy spoke to me on this subject on a number of occasions.

On Deputy Cooper-Flynn's point, there are people in the acute system who do not need to be there, but there are not enough alternatives. That is why we are considering alternatives such as step-down nursing home facilities and high-dependency beds.

A Deputy mentioned the central rehabilitation centre. I know from my last job that an agreement has been made to build a new hospital. An issue arose concerning Pfizer making an investment in Dún Laoghaire and requiring land. At the time, a decision was made that a new hospital with additional capacity would be provided. When we are building a new public hospital, we need to provide additional bed capacity. This is the case in respect of the Mater Hospital. In addition to having a more state-of-the art facility, we also need greater capacity. We must provide for the latter as we go forward.

I do not have an answer to Senator Glynn's question on the training of nurses interested in caring for those with a sensory disability. However, the disability package for this year includes provision for the employment of 1,000 more personnel in the disability sector.

Senator Glynn

What is the position on the consultative forum for local representatives from county and borough councils?

Deputy Harney

I hope to get that up and running as quickly as possible. I have had discussions with the HSE on its resources for dealing with public representatives, particularly Members of the Oireachtas. It told me it will be a priority——

Senator Glynn

I am sorry for interjecting. The Minister should not forget the locally elected members. They comprise a very important conduit through which complaints by patients can be relayed to the appropriate authorities.

Deputy Harney

It is to deal with public representatives. The members of this committee raised the matter with me during the legislative process.

Deputy O’Connor

On the Minister's last point, given the abolition of the health boards, clarification is required regarding public representatives on various hospital boards, including that in Tallaght. I am not pressing the Minister on this issue but just drawing attention to it.

Deputy Harney

On the issue of public representatives on hospital boards, let us put the best people on those boards, regardless of whether they are public representatives.

Senator Henry

I encourage the Minister to get together with the Minister for Education and Science as soon as possible because the situation is dire. The number of points required to get into medicine is not the problem, the problem is the number of places available.

Deputy Harney

I accept that. We expect the Fottrell report. Maybe it has been submitted but, if not, its submission is imminent. Among the issues being considered by its authors is graduate entry to medical school, which is common in many countries. I understand that those concerned are to be positive about an element of graduate entry, but not graduate entry exclusively. We need to consider these issues. There are considerable resource implications for the Department of Education and Science, as the members know, but we cannot avoid the matter. We have taken many initiatives in nursing and it would be ironic if we produced world-class nurses through our university system and failed to produce doctors.

Deputy Gormley

What is the state of preparedness regarding the possible flu pandemic? It seems that we do not have enough anti-viral drugs. Is the Minister working assiduously to deal with that problem?

Deputy Harney

Yes. As the Deputy knows, we are not a producer of vaccines and, therefore, we are very vulnerable. I believe we have not had a flu pandemic since the 1960s but all global experts concur that we will have another, although we do not know when. I am awaiting a report on this matter by the advisory group headed by Professor Hall. Some €9 million has been allocated towards purchasing the drugs.

Deputy Gormley

When will we have them?

Deputy Harney

I cannot give the Deputy a specific date.

Deputy Cowley

The Minister made a point about bed blockers, which term is unfortunate, but the fact remains that there is no acute elderly care facility in south Mayo. That has been the case since 1971, from which year people have been campaigning for such a facility. The problem is leading to congestion in the accident and emergency departments. The Minister should consider this in respect of the capital programme.

Deputy Cooper-Flynn

The Deputy announced on radio that it was not going ahead, although the Minister replied to the contrary.

Deputy Cowley

Deputy Cooper-Flynn did nothing and should stop this critical nonsense.

Deputy Cooper-Flynn

The Deputy did absolutely nothing about it and went on radio to say that the Tánaiste was not going ahead with it.

Chairman

We cannot discuss that issue.

Deputy Cowley

I have the floor.

Deputy Cooper-Flynn

The Deputy misled the people——

Deputy Cowley

The Deputy was the chairman of the Western Health Board.

Deputy Cooper-Flynn

——and misrepresented the reply he got from the Tánaiste.

Deputy Cowley

How about the helicopter emergency service?

Chairman

Deputy Cowley.

Deputy Cooper-Flynn

He misrepresented the reply.

Deputy Cowley

How about all those matters?

Deputy Cooper-Flynn

He should not come in here now and——

Chairman

Deputy Cowley, we are not here to discuss the issue of Mayo.

Deputy Cooper-Flynn

He misrepresented the Tánaiste.

Deputy Cowley

Geography is critical.

Chairman

I am trying to be as fair as possible.

Deputy Cowley

That is fair enough. Geography is critical and the Tánaiste is correct that safety is a very important factor. However, if one cannot get to the facility, what good is safety to one? One has to be able to get to the facility within a certain period. We do not have an ambulance base in west Mayo, for example.

Chairman

There are to be no speeches on that point. We are not going down that road.

Deputy Cowley

That is the position.

Chairman

I ask Deputy Cowley to listen to the Chair for one second.

Deputy Cooper-Flynn

It is also important not to mislead people or misquote the Tánaiste.

Chairman

We have had two hours——

Deputy Cowley

It is Deputy Cooper-Flynn who is lecturing.

Chairman

Deputy McManus, the final word.

Deputy Cowley

She had her opportunity.

Deputy McManus

On the point raised by Deputy Twomey and me, may we have a full response to our queries in writing? Many issues have been covered and time is very limited. On the next occasion that the Tánaiste, or Kevin Kelly, is due to meet the committee, will sufficient time be allowed for the meeting? Everybody is rushed and that makes matters difficult and frustrating.

Chairman

I thank the Tánaiste for attending.

Deputy Harney

I am not rushed. I pencilled out the whole morning for this meeting but I did not decide on the time slot.

Chairman

I am sorry about that, but our understanding was that the meeting would last until 11.30 a.m. We will avail of the full morning on the next occasion. I recognise that members want much more time. To clarify, we will receive a written response to all the issues raised. A written response was circulated to members yesterday.

Deputy McManus

I know that. It was very helpful and that is why I want a follow-up.

Chairman

I understand that point. I thank the Tánaiste and her officials for attending and I look forward to the next session.

The joint committee went into private session at 11.40 a.m. and adjourned at 11.55 a.m. sine die.