JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 15 Feb 2007

Health Issues: Discussion with Minister for Health and Children and HSE.

Chairman

I welcome the Minister for Health and Children and her officials, and Professor Drumm, chief executive of the Health Service Executive, and his officials.

I will call on the Minister first to make her opening remarks, followed by Professor Drumm, after which I will ask members to put their questions. Members are reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I invite the Minister for Health and Children, Deputy Harney, to make her opening submission.

Minister for Health and Children (Deputy Harney)

I do not propose to read my submission because I have circulated it and everybody has had a chance to read it. I will make some brief comments and will then be happy to take questions on issues of interest to the members.

Ireland has moved from a position in 1997 where spending on health was 15% below the OECD average to 17% above the OECD average by 2003, notwithstanding that we have one of the youngest populations in the OECD. A total of 5% of our budget is spent on capital investment, placing Ireland at the top of the league with Norway. Taxpayers fund 80% of funding for health in Ireland which is far above the OECD average.

For 2007 current spending will be €14.9 billion, which is an increase of 11.21% above 2006 spending. Capital investment is €656.5 million between the Health Service Executive, HSE, the Department and the Office of the Minister for Children under the Minister of State with responsibility for children, Deputy Brian Lenihan.

This economy has been able to generate the resources for significant investment in health services in Ireland. The challenge for us as we invest more money in the service is to ensure that we achieve the best possible outcome and results for the investments made for patients and service users. For the past few years we have been involved in the painful process of changing the way we do our business, beginning with the establishment of the HSE and making it responsible for the delivery of services and accountable for the money the Oireachtas allocates to it. That was the appropriate route to take and I strongly believe the reform agenda is working.

Several operational issues will arise in members' questions. There has been serious concern about accident and emergency services in recent years. I am delighted to acknowledge the great improvements in those hospitals that have major problems with people waiting for long periods in accident and emergency departments for access to a hospital bed. We want to move from a position where we measure the time between the decision to admit and occupation of a bed, to one in which we measure it from arrival at an accident and emergency department to being attended, whether or not people need to be admitted. Most of those who come to an accident and emergency department are dealt with there and return home.

Several key policy issues have arisen since I last addressed the committee. We have published the new Medical Practitioners Bill, Second Stage of which will be taken in the Dáil at the end of next week. I look forward to coming to the select committee to discuss Committee Stage of that Bill. The intention is to enact the Bill as quickly as possible because it is important legislation. The regulatory environment governing medical practitioners is 30 years old and everybody agrees that it needs to be modernised. This entails, in particular, the introduction of what is broadly known as competence assurance.

Much of the change that occurred in the Medical Practitioners Bill was informed by the report of Judge Harding Clark. A majority of the council will comprise lay persons and the legislation specifies how they are to be appointed. There will be a majority of lay persons on the fitness to practise committee and it will be a matter for that committee to hold hearings in public, which should be the norm rather than the exception.

The HIQA legislation is before the House. It will have a significant impact because for the first time there will be a State body independent of the HSE examining the quality of the services it provides. One key function of the HIQA will be as a social services inspectorate. It will inspect on a national basis residential places for children, older people and persons suffering from disabilities. We are devising a new national standard of assessment for persons with disabilities which will come into effect on 1 June 2007 for all children under the age of 5 years. They will be entitled to an assessment of needs and to have a service plan provided for them. Last week a two-day conference was held with service providers and users. The draft standard will be issued shortly and it will be confirmed by the HIQA. Recently, standards for nursing home care were published. We want to see consistency and uniformity in nursing home care standards in both the public and private sectors. That is why it is necessary to have a national standard against which inspections will take place.

The Government has endorsed the decision of the HSE board to have a single tertiary children's hospital co-located with the Mater Hospital in Dublin. That hospital will also provide secondary care for the Dublin area. We are all familiar with the McKinsey process and the task force report on the matter. Recently, RKW was appointed as the consultant to the project and it is working on the specifications of the hospital. For many years, tertiary paediatric facilities have been spread across several sites. From international best practice we all know that with a small population like ours that is not in the best interest of children. In recent years, haematology services were centralised at Crumlin Hospital, even though the service can be delivered in about 16 places around the country. We have gone to the top of the EU league in children's cancer care because of the manner in which we provide that service. All the evidence suggests that the manner in which we are proceeding is the appropriate way to proceed and there will be no change from the Government's perspective on that issue.

Several members have raised the issue of violence against women and the provision of sexual assault treatment units. Substantial additional resources have been provided in the 2007 Estimates. A forensic training programme for nurses who will work in these centres will be introduced. There will be new centres in the midlands, Galway city and Letterkenny. While there have been some staffing issues, we have a centre in Dublin. The HSE is proceeding rapidly to ensure all these centres are operational as quickly as possible and that they have the appropriate staff.

Professor Brendan Drumm

I am joined by my colleagues Mr. John O'Brien, director of the National Hospitals Office and Mr. Pat Healy from the primary continuing and community care directorate.

Last year was my first full year as chief executive officer of the HSE. We have laid some important foundations upon which to build a world class health service. To build a sustainable health and social care service in quality and cost, we must stop thinking that acute hospitals are the only places capable of providing quality care. We must move from a position where they remain the primary focus of our health care system. It must be recognised that the majority of care can and should be provided in local communities. Advances in medicine in the past 30 years have made this possible and we must seize the opportunity rather than cling to the past. No member would have believed we would aim to see 90% of patients treated as day care surgical patients 20 years ago. By concentrating on building up our primary and community services we will be able to provide more appropriate and convenient care closer to people's homes while freeing up our hospitals to focus on delivering world class acute and specialist care.

The difficulties that have faced some of our accident and emergency departments have been tackled in an integrated approach. In a nationally co-ordinated effort, under the umbrella of the winter initiative, we have significantly reduced the average length of time people who need hospital admission have to wait in accident and emergency departments. The initiative is an approach similar to that adopted in other health systems internationally and involves primary care, population health, hospitals and communications in a co-ordinated and sustained project at national and local levels.

Our concentration has been on putting in place facilities to keep people out of hospital, improving management process in hospitals and community services and increasing capacity by making available more appropriate beds, namely, long-stay beds. In 2006 an extra 1,050 long-stay care beds were contracted with a further 800 planned for 2007. The impact of these initiatives has been a significant reduction in waiting times and numbers waiting, with reductions of up to 50% in January. I accept we are still experiencing difficulties in four hospitals, each of which has different difficulties. The National Hospitals Office and the primary care directorate are actively working closely together to address the underlying issues in these hospitals. Contrary to the views expressed by some, these improvements have not come at the expense of patients who require elective procedures.

The year-on-year figures up to December 2006 show that overall elective rates have increased. The exception is four hospitals, the Mercy Hospital, Cork, University College Hospital Galway, Mullingar and Tullamore hospitals. The rates in these hospitals have come down to rates more in line with the national trend which, for elective admissions, are in the order of 22% to 26% of a hospital's overall admissions. This is against a backdrop where the number of people presenting to accident and emergency departments has increased by 4%. The progress made under the winter initiative highlights the commitment and dedication of our staff both in hospitals and in community facilities. It also highlights the potential of the HSE when operating as a single integrated system.

The HSE is now in a better position to be able to compare the performance and output of hospitals and local health offices regarding the funding they receive. High-performing services can now be rewarded. It marks a move away from the present funding based around organisations to a person-centred approach, with funding directed to the entire care continuum rather than either hospital care or community-based care. That approach supports the integration of services to enable patients and clients easily to access all the services they need. It is now easier to apply learning accumulated in one part of the country to the development of services in another. Examples include the roll-out of primary care teams which are fundamental to the development of such services and the development of the out-of-hours GP service in north Dublin in the form of D-Doc. Some 90% of the population now have an out-of-hours GP service available locally.

We can keep rigorous control of our finances and in the past two years have met our budget. With the implementation of our human resources business solutions programme, we will be able to apply greater transparency and accountability to the largest single area of expenditure — payroll costs.

As a single unit, we are in a stronger position to secure savings on our purchases. Last year we agreed a deal with the Irish Pharmaceutical Healthcare Association, representing drug manufacturers, with the potential to yield huge savings in coming years. Last autumn we also agreed a deal with the Association of Pharmaceutical Manufacturers in Ireland, representing generic manufacturers, which could save a further €20 million in the next four years.

We now have one person responsible for managing our full property portfolio and can for the first time bring a national perspective to maximising the value gained from that important asset. For those who use our services, we now have a national consumer service programme. This means it will be easier for anyone to make a comment or complain about any aspect of the service which is supported by legislation and an accountability process.

As a single national organisation, we are better placed to seek the views of the public. Last year we commissioned a study among people who had attended emergency departments during 2006. The results make for encouraging reading. Carried out by the independent organisation, the Irish Society for Quality and Safety in Healthcare, in partnership with the Royal College of Surgeons in Ireland, the survey found that 93% of patients felt that they had been treated with dignity and respect during their visit. Three in every four patients, or 76%, were satisfied with their experience, while the majority of patients, or 86%, who had a choice said they would go back to the same emergency department. Coupling these data with the results of research carried out by the Irish Society for Quality and Safety in Healthcare in 2004 which showed that 93% of inpatients were satisfied with the care they had received, it is clear that the health care system provides a level of care with which people are relatively satisfied. The challenge for our organisation is to make it easier to access that care.

The issue of the consultants' contract is currently topical. The new consultants' contract on which we are about to start negotiating with consultant representative bodies during the coming weeks will go a long way to addressing the access issue; it is imperative that it do so. Our primary objective for the new contract is to enable all patients equitable access to consultant-provided services when they need them. I am hopeful that we will be able to agree quickly on a new contract that will enable us to appoint in the region of 1,500 additional consultants as quickly as we can train them in the coming years and decrease proportionately the number of non-consultant hospital doctors. I would like to comment on the suggestion that the impact of employing 1,500 more consultants would be minimal, unless we added substantial numbers of acute beds. That suggestion is based on a model of health care that we must leave behind. If we have more consultants, patients will be seen by senior clinical decision-makers and diagnosed more quickly. The need for patients to be admitted will be reduced, while our admission rates should be more in line with international trends. Research carried out last year in the north-east region, for example, showed that the number of patients admitted to hospitals was as high as 5.9 per 1,000, more than three times the admission rate in parts of the United Kingdom, which stands at 1.7 per 1,000. That discrepancy is even more stark when one considers that the United Kingdom has a much older population and should, therefore, have a much higher admission rate.

With more public consultants, patients admitted will be seen by senior clinical decision-makers more regularly, at least once each day, enjoy more rapid access to diagnostic services and, as a result, spend less time in hospital. It is worth highlighting that, in general, patients spend significantly longer time in hospital in Ireland with the same condition than in countries such as Australia. Health care is changing rapidly. Many procedures that in the past would have required hospital admission are now carried out as day cases. For example, last year the number of patients treated in Ireland on a day-case basis increased by almost 9%, compared with 2005, to more than 550,000. I stress this figure, since the number of patients who had their elective surgery cancelled must be considered in that light. It is a trend that we have seen since the 1990s, creating a better experience for patients and better value for the health service. Linking the number of consultants to the number of acute beds takes little account of the changing face of health care and is, as I said, an approach from which we must move away if we are to create a consistently high quality health service that is sustainable with an aging population and that our children will be able to support.

I would like to cover one or two other areas of interest to members. Two human resource issues were raised within the last week and will be discussed today in the context of potential disputes. I do not propose to comment on any of the specific matters raised, but it is important that those who work in the health service realise that we all share a responsibility to transform it into one where everyone will enjoy easy access to care, a service in which people will have confidence and that staff will be proud to provide. People must move on from thinking that it is helpful to criticise the services for which they work, be they consultants, managers or team leaders. I have always said we wish to engage in constructive dialogue and take on board constructive criticism, but it must operate at that level. We must make significant strides in the way that we work if we are to deliver our four-year transformation programme. While I am fully committed to developing the public health care system, we should recognise that, as public servants, our monopoly in providing public health care services is not guaranteed.

I will refer to the HSE's engagement with Members of the Oireachtas. During 2006 we focused a great deal of attention on our performance in dealing with information requests from them. When the new Dáil term commenced in 2007, we had answered almost 96% of the 3,500 questions referred to us. Although we are making progress, we recognise that we have much more work to do. Each month at our management team meetings I raise the issue of our performance in responding to parliamentary questions and representations with my national directors and I expect to see further improvements in the speed of our replies. We are also examining ways to monitor and improve the quality of replies, a significant issue that we must address. In addition, we are opening up other lines of communications for Members of the Oireachtas. I invited Members to a meeting in the Davenport Hotel last June, from which we commenced bi-monthly briefing sessions for Members structured around the HSE's four administrative areas. These briefings provide an opportunity to present information to Members on key initiatives and developments, as well as affording them an opportunity to ask operational questions of senior managers. We have also commenced local briefings at county level. To date, it has been mainly a case of local health managers meeting Members in their area, but we hope to expand this further this year.

That concludes my opening statement. I thank members for their attention.

Chairman

We are half an hour into the meeting. Before starting the question and answer session, I remind members that some 34 issues in total have been submitted for the Minister and Professor Drumm outside the presentations they have made. On top of this, 11 members are present, each of whom has expressed a desire to speak. I will try to get through it as best I can. Nodding or frowning at the Chairman will not move matters on. Therefore, let us get down to business.

Deputy McManus

I thank the Minister for Health and Children, Deputy Harney, and Professor Drumm for their attendance. Does the Minister agree with her party leader, the Tánaiste and Minister for Justice, Equality and Law Reform, Deputy McDowell, that the health service's problems are essentially crises manufactured by men in white coats for their own interests? Perhaps Professor Drumm might also comment on this, since he finds criticism of the health service so unhelpful.

There has not yet been a change of heart regarding the HSE's position on beds. Neither Professor Drumm nor the Minister recognises that there is still a capacity problem, which cannot be disregarded. Is either aware, for example, that in St. James's Hospital procedures and operations for heart patients were cancelled yet again because of the lack of intensive care beds? I do not know whether Professor Drumm is aware that his figures appear to be incorrect. According to the Intensive Care Society of Ireland, the ratio of ICU to acute beds is 1.6%, one of the lowest in the OECD. Professor Drumm's figure is 2.2%. Is he aware that his figures are also inaccurate when it comes to nursing home beds? Documentation which has been produced states there are 12,000. Apparently, there are 17,000, but not on the north side of Dublin. Is he aware that, again because of a lack of beds at community level, more than 100 beds at Beaumont Hospital are blocked by patients who should not be there? Does he not accept that, essentially, the HSE is putting its head in the sand if it does not deal with the issue of limited bed capacity?

To cite a particular example which I experienced and found very distressing, a patient who needed open heart surgery had to wait six months to have the operation carried out in St. James's Hospital because an intensive care bed was not available. He had to avail of the National Treatment Purchase Fund scheme and the same consultant operated on him in the Blackrock Clinic. This means the same consultant was literally paid twice — by salary, while he was twiddling his thumbs at St. James's Hospital since he could not access an ICU bed, and under the National Treatment Purchase Fund. Does either the Minister or Professor Drumm seriously believe this is a cost effective way to run the health service?

Will the Minister now accept that she misled the House when she said emergency patients in public hospitals would never be able to access private beds? In a recently published annual report Beaumont Hospital pointed out that 40% of private bed capacity was being used by public patients, either as emergency cases or when isolation was required. Perhaps the Minister might set the record straight because she is misleading the House in saying no public patient accesses a private bed in a public hospital.

As regards the consultants' contract, why has the Minister changed her line? She said she was going to have public only contracts. Now she is saying there will be private and public contracts for consultants. Did she do this under pressure from private interests which are attempting to build private hospitals on public lands? Have they pressurised her into changing her view to ensure they will be able to employ doctors and piggy-back and feed off the public hospitals with which they will be co-located, if she gets away with this? There has been a severe shift in policy and it is important for the public to know why.

How will the Minister deal with the nurses' dispute? Nobody relishes the idea of nurses walking off wards. How exactly will the dispute be dealt with to ensure we will not see the health service being affected in this manner? As regards nurses, is she aware that changes are proposed to the green card system for workers coming from non-EU countries? This is likely to have a major impact on nurses and care assistants, particularly those working in private nursing homes. If such a person is not employed in a Dublin teaching hospital or a major general hospital, he or she will face problems as regards the new green card system. Perhaps the Minister will respond.

I will make one last point, namely, that the Minister might reconsider that she is rushing through the Medical Practitioners Bill and, as I understand it, guillotining the debate in a way that does not provide for good law, particularly in such a crucial area.

Chairman

I thank Deputy McManus. For the record, all her questions were posed within a timeframe of six minutes. We shall endeavour to replicate this during the rest of the meeting. We shall take questions individually, rather than banking them. I invite the Minister to respond.

Deputy Harney

Some of the questions refer to operational issues which the HSE, perhaps, might like to deal with.

Deputy McManus has asked whether I agreed with some of the comments made about manufactured crises. There is an extensive debate among consultants about advocacy on behalf of patients, an issue on which I have commented before. We want to see advocacy on behalf of patients. Unfortunately, when it came to Dr. Neary's patients, I did not see many advocates for some 25 years, which was a great pity. I shall shortly be bringing a redress scheme to the Cabinet to compensate the unfortunate women concerned because their records were destroyed and they have no means of vindicating their rights through the courts. I certainly hope we can bring an end to that era. The issue has very much informed the Medical Practitioners Bill and it is important that we enact it. I published the heads of the Bill, with minimal change, for consultation. We received an enormous number of submissions and the Bill finally produced was very much in line with the proposed legislation published for consultation. There were just two or three minor changes. I hope we can have a debate and committee time assigned in order that the legislation can be quickly enacted. It is important to introduce competence assurance, in particular, in order that the Medical Council will be able to certify that every doctor on the register is competent to do the job required. That is in keeping with what happens in the best health care systems in the world.

I cannot tell the committee how many beds are needed. A review is under way, but regardless of how many beds there are, it is imperative we use the existing stock effectively. I regularly meet various specialist groups. I told one group recently that if I was to add up the numbers of beds needed, we would need double the number available. Everybody tells me how few beds are available in his or her particular specialty. Professor Drumm has noted in his comments that for some 20 of the most common procedures patients spend 50% more time in hospital in Ireland than in Australia. Even for something as simple as an appendectomy, in Ireland a patient could spend 3.5 days in one hospital or 5.5 in another. For a hip replacement, a patient could spend 12 days in one or seven in another. There is no consistency. Clearly, we must have the required capacity. The number of day patients now accounts for more than 50% of all hospital cases. The figure has increased by 9% on that for last year. Of the 1 million patients registered in the public hospital system in the past year, some 550,000 were dealt with on a day case basis, an increasing percentage in line with trends in health care systems all over the world. Capacity has to reflect this trend.

As regards nursing home beds, we had a public nursing home system, with private arrangements. If someone was being cared for in a public nursing home, he or she contributed no more than 80% of his or her non-contributory old age pension. If somebody was being cared for in a private nursing home and the bed was not contracted by the health authorities, the family concerned paid a substantial amount, perhaps 80% of the cost of care. Clearly, that was unfair——

Deputy McManus

I did not ask for any of this. It is not relevant.

Deputy Harney

I just want to tell the Deputy——

Deputy McManus

Will the Minister please answer my questions?

Deputy Harney

It is very relevant. If a person takes one route and effectively has a free bed, but then opts for another route whereby the family may have to sell the home or remortgage——-

Deputy McManus

This has nothing to do with the questions I asked.

Deputy Harney

Yes, it has.

(Interruptions).

Deputy Twomey

The Minister guillotined the debate on the legislation dealing with this issue yesterday.

Chairman

We are losing time.

Deputy Connolly

We are five minutes into the answer.

Deputy Harney

I have answered all the questions, as I am entitled to. The new policy initiative will dramatically alter the capacity of people to afford appropriate nursing home care for their loved ones, regardless of whether it is in the public or private system. There will no longer be an unfair system in the private sector. Only last week I met a woman in my clinic who was paying €4,000 per week in nursing home fees for her mother. She took her out of a Dublin hospital and left a bed available for someone else. That will have a major impact on care of the elderly.

Deputy McManus

Why are beds in Beaumont Hospital blocked?

Deputy Harney

We are acquiring more than 800 community beds this year, the majority of them in the public system. Last year we contracted 1,050 beds in the private nursing home sector and hope to contract a further 350 this year. We are expanding public capacity by 446 this year and 414 in 2008.

I met representatives of the Intensive Care Society of Ireland on three occasions, but the HSE might like to deal with the issue of ICU beds. However, I drew their attention to the fact that their figures did not cover any of the ICU beds in the private system. They acknowledged this. Some of the doctors told me that they worked in private hospitals with ICU beds. There are 60 to 70 such beds which must be factored in if we are to compare one country with another.

There has been no change in policy on the consultants' contract. We want a public hospital contract. We do not want a situation where our key doctors are working in two, three or four hospitals. Nobody can organise health services on that basis. The contract introduced in 1979 is not in place anywhere else in the world. It does not serve the needs of the public health care system.

I have had no discussions with private operators about doctors and how hospitals are to be staffed. It is a matter for those who make investments to employ their staff. It is not a matter for me or the public health care system to be concerned with that issue. We want to see doctors operating in public hospitals. Sime 20% of our beds are private and the hospital is paid for them by the insurers. The doctors, with the exception of consultants in accident and emergency medicine, are paid for every private patient, regardless of the bed the patient has taken. If the patient has private health insurance, the doctors are paid.

A number of Deputies — admittedly not from the Labour Party — have approached me regarding the new maternity hospital in Cork to make the case that we have not designated enough private beds in a hospital which has been 100% funded by the public system. They want additional private beds in that hospital, but that is not acceptable. We must acknowledge that there is an enormous amount of private activity in our public hospitals. Anyone who does not acknowledge this fact is not living in the real world. The reality is that patients with private health insurance receive preferential treatment when it comes to access to hospital beds funded by the taxpayer. That is not fair and why equality of access must be fundamental to the resources provided by the public health care system for the new consultants' contract.

I will be disappointed if the nursing dispute proceeds. I hope it will not happen. I floated the idea that we needed to change dramatically the way we worked in the health care system. We need people working longer hours, not as individuals but as teams covering patients' requirements. It is frustrating when diagnostic equipment invested in by the taxpayer in public hospitals cannot be used for longer periods because of work practices. Therefore, we need much change. The Labour Court has considered the eight issues over which the nurses are in dispute. It recommended that two of them be considered further. One concerns the mental health area, where porter nurses might receive €3,000 more per annum. About 1,000 nurses were affected by this. I have conceded that we would like to see it dealt with in the benchmarking process. The nurses are also looking for a Dublin weighting allowance. If such an allowance applied to nurses, it would equally have to apply to other public servants, including gardaí, teachers and so on.

These are not simple issues. There is also the question of the 35-hour week which nurses currently work. In the United Kingdom their counterparts work 37 hours a week. These issues should be discussed in the fora in place for such discussion. Some nurses are members of SIPTU and have voted for the new national agreement which will give nurses and others a 10% pay increase in the next 27 months. Other nurses have not yet voted on the national pay agreement. I encourage their representatives to enter the benchmarking process and the other processes in place for determining issues of public pay, work practices and so on. I am in favour of a forum within the health system in which all players could come to the table, similar to the arrangement devised during the national economic crisis in the mid-1980s which allowed the various parties to find innovative ways of working together to resolve the issues involved. Such a spirit would deliver major benefits for the health care system.

I am not certain what Deputy McManus's concern is in regard to green cards. The Government has decided that labour immigration will henceforth be based on skills requirements. A person from outside the European Union who wishes to work here will require a card that will cost €1,000 for two years. Under the old work permit systems, the cost was €500 per year. I do not know whether the Deputy is raising the issue of the cost or expressing concern that green cards will not be granted.

Deputy McManus

I seek clarification on who will be responsible for employing the person concerned. I will talk to the Minister about this later because it is a complex issue.

Deputy Harney

I have dealt with all the issues raised.

Deputy McManus

I understood Professor Drumm wished to comment.

Professor Drumm

Deputy McManus spoke about capacity issues in the system. I hope I have been clear at all stages that I am absolutely convinced that we need more long-stay facilities. I have never said otherwise. However, I have questioned the notion of creating more acute capacity to deal with the problem in isolation. The figures are startling. The numbers of patients admitted are totally out of line with international practice, as are the statistics for length of hospital stay. We must focus on these issues. Irish people do not deserve such treatment; it is a patient's right only to be admitted to hospital when necessary. Patients have a right to move through the system and get out as quickly as possible. If we could bring the figures for average length of stay into line with those in Australia, for example, there would be a more than adequate supply of acute beds.

I have said all along that the solutions include reducing waiting times for diagnostic services, ensuring patients do not have to wait around for an ultrasound or CAT scan because services are only available between 9 a.m. and 5 p.m. and rectifying the situation where patients must be admitted to an outpatients clinic because the only prospect of attaining a CAT scan appointment in a timely fashion is by securing a bed. These issues must be dealt with before adding additional capacity.

I accept responsibility for the fact that the system is not dealing efficiently with patients. It is unfair to them if efficiency is not ensured. That is my focus. If we are successful in this regard, the beds issue will be resolved. There is absolutely no doubt that part of the solution, as Deputy McManus observed, is making sure patients who should be in long-stay care facilities do not take up beds. The Deputy would accept, however, that there should also be increasing focus on home care packages to allow some of the patients concerned stay out of long-stay care facilities. The results of a dependency review we have just completed show that in some hospitals up to 50% of patients on a given day should not be there. We must deal with issues such as this in terms of the processes in place.

I agree that we must have clarity on the numbers of intensive care unit beds required. As we focus on keeping people at home and only having those in hospital who need to be there, there is no doubt our need for high dependency and intensive care support beds will increase as a proportion of total beds because those in hospital will be sicker. This is happening as part of the bed review. I would not, however, compare Ireland to other countries with regard to the number of beds available. As with other measures, we should have significantly fewer ICU beds than in other countries. Some 10% of the population in Ireland is aged over 65 years, whereas the figure is 25% to 27% in Germany. It is not correct, therefore, to compare the two. The requirement for ICU neets in Germany or the United Kingdom will be well beyond that here.

Deputy McManus

The ICU beds available in St. James's Hospital are not even being used.

Professor Drumm

Mr. O'Brien will deal with that issue.

Mr. John O’Brien

With regard to the specific issue raised by the Deputy, I am not in any way questioning what she said about the heart surgery issue but I know St. James's Hospital well. The cardiac surgery ICU beds are independent of other ICU beds in the hospital where this has never been an issue. I am not suggesting——

Deputy McManus

Perhaps they need Mr. O'Brien back.

Mr. O’Brien

Cardiac surgery ICU beds are independent of other ICU beds in the hospital.

Deputy McManus

Mr. O'Brien should believe me.

Mr. O’Brien

I am not questioning what the Deputy said. However, I find it astonishing that this would have been given as the reason for a procedure not going ahead. The cardiac unit at St. James's Hospital has been one of the biggest successes in the country. It managed to reduce the cardiac surgery waiting list in many cases from well over one year or two years to approximately four months. The independence of the ICU unit was at the root of that change.

Deputy McManus

Mr. O'Brien should have a look at it.

Mr. O’Brien

I will certainly have look at it and come back to the Deputy directly. If she gives me the name of the patient, I will check it for her. I find it astonishing that this would happen. It is not an issue that would arise at the hospital because it is not one——

Deputy McManus

Operations were cancelled yesterday.

Mr. O’Brien

That is different. The hospital is experiencing a surge, of that there is no question. We met hospital representatives yesterday and are examining mechanisms to deal with the issue. There is a bed that can be opened and there is no reason it should not be at this stage. The hospital will do this. We are also considering converting some of the general beds in the hospital to high dependency unit beds. It is not ICU but high dependency unit beds which are needed for the cancelled operations to proceed.

As the Minister stated, neither the HSE nor the hospital has sufficiently explored the issue of capacity to accommodate many long-term ICU patients in the private sector. The Beacon Hospital and the Hermitage Clinic are the two hospitals which could potentially offer something in this regard.

Deputy McManus

I thank Mr. O'Brien.

Deputy Devins

I welcome the Minister and Professor Drumm. Certain issues have emerged in the discussions that have been ongoing between the HSE and the IPU, particularly with regard to individual contracts and how they must be discussed. This might have implications for other professions in coming to discussions also. Will the Minister and Professor Drumm explain this issue?

Will the Minister update us on the roll-out of the BreastCheck programme, an issue in the south but particularly in the west? We have been assured it is on target for the middle of this year but I would like the Minister to confirm this.

The third issue concerns Sligo General Hospital, in which I have a particular interest. For over 20 years the hospital has sought a new paediatric unit. There is a feeling among staff who work there that they are now considered part of a Cinderella specialty. We would like to see progress on this issue.

The Sligo area has one excellent community paediatrician who shares half her time with the hospital. Unfortunately, she is only able to cover south Sligo. An application has been made to the HSE for a fourth paediatrician who would cover north Sligo. Perhaps Professor Drumm could provide an update us on that issue.

The only rheumatological unit between Galway and the North is the excellent, well staffed and modern 30-bed unit at Manorhamilton hospital. However, the unit has apparently been closed at weekends for several weeks. There is a fear among the local community that moves may be afoot to either relocate the unit or downgrade it. I would like to have the matter clarified.

Deputy Harney

On the BreastCheck programme, the roll-out is on target. Screening will begin in the spring in the west and south. All the clinicians and other staff required are being recruited.

The position in Sligo is a matter for the HSE. With regard to the IPU, there are serious legal issues to do with the setting of fees and agreeing prices — perhaps Professor Drumm would like to deal with this — which have arisen in the context of the discussions between the HSE and wholesalers. Legal advice was submitted by pharmacy representatives. The HSE received its own legal advice. The Attorney General has also advised. There are issues around the capacity to agree fees or set prices. I agree it would have implications for other professional groups.

Professor Drumm

Historically, negotiations with the pharmaceutical industry go through three stages. First, there are negotiations with the manufacturers' group; second, negotiations with the wholesalers' and distributors' group and, third, negotiations with the retailers' group, representing pharmacists on the street. As I said in my opening statement, the negotiations with the manufacturers have been completed. From the HSE's perspective, we procured €2 billion in basic pharmaceuticals and devices that come through the industry, a massive amount. We saw this as an area in which we had to seek value for money.

Having gone through the negotiations with the manufacturers, we moved to dealing with the wholesalers. However, during these negotiations, we received a submission from the retailers' representatives, the IPU, stating they had an objection to us negotiating with the wholesalers, given their absence from the table. It seemed remarkable to us that we would have to deal with anybody but the group involved, namely, the wholesalers. The retailers had sought a legal opinion based on the fact that our negotiations with the wholesalers would have an ongoing effect on their income. The HSE then had to seek a legal opinion in response. The legal advice we received was unexpected in that it stated not only should we not be dealing with the IPU when dealing with the wholesalers, but that we should not, under competition law, be dealing with the wholesalers or any other group representing suppliers. The legal opinion was generated from a challenge from the pharmaceutical side. This was subsequently taken back to the Department and from there to the Attorney General who has issued a forthright view that the legal opinion is correct.

We are now dealing with the issue on the basis that, because there is a monopoly, it will be dealt with in accordance with the rules in operation across Europe. We will go through a public process of advertising for an input from everybody with an interest in how prices are set. The original one referred to the wholesale distribution cost. That process is under way and almost complete. It allows any member of the public to make a contribution. Economic analysts have also been brought in to examine what the costs involved in distribution would be and what payments apply in other European countries in order to bring fairness to the process. The process, as we have been advised by the Attorney General, will have to be brought to bear at the retail level in setting the prices to be paid and remuneration at that level.

Deputy Devins raised a question as to whether that has implications. It clearly does; not just in health, but in many other areas. I have received verbal representations on the issue from the dental association. I was asked if it affects negotiations on behalf of general practitioners. We have sought clarity from the Attorney General on whether the same advice would apply. I am not a lawyer. However, it does not look on paper as if that advice will be significantly different. We are still awaiting the advice.

I am very aware of the paediatric unit at Sligo General Hospital, but I would like to ask Mr. John O'Brien to comment on it.

Mr. O’Brien

The unit has received permission to revamp the paediatric facility in Sligo General Hospital. To that end, we have put forward a plan that will integrate outpatient, day case and inpatient facilities. This project has been put into the capital programme for 2007, at a cost of €10 million. However, it is at an early stage and it is expected that the planning will begin this year. While that comes to fruition, there is a need to do something with the existing ward. Upgrading will be affected in the existing area through the minor capital programme.

There are three paediatricians in the hospital, as the Deputy pointed out. We fully recognise that there is a need for a fourth and that he or she be a hospital community-based paediatrician. This has appeared on my desk and on the PCCC desk as a significant priority and we are looking between the two pillars to see if we can create the revenue base necessary to establish that post.

Professor Drumm

A temporary situation was put in place many years ago and everybody recognises that we must move on this as soon as possible. The commitment is there.

I am not in a position to answer the question on Manorhamilton Hospital, because I need to get the information. I am not aware of any plan to move rheumatology services out of Manorhamilton, which is certainly not on our agenda. We will have to find out why it might have been affected by closure.

Mr. O’Brien

We will check that for the Deputy.

Deputy Devins

Patients from south Donegal, Sligo, Leitrim and further afield are all catered for in Manorhamilton Hospital. Quite a few of them were quite upset that they were inpatients and that they had to go home for the weekend. As a result of that, this fear has built up.

Chairman

We will suspend for 20 minutes because a vote has been called in the Dáil.

Deputy Devins

I just want to welcome the fact that the paediatric unit has been allocated €10 million in Sligo. That is great news and I am delighted.

In regard to the IPU, if the legal advice as currently structured is correct, could we face a situation where every pharmacist would have to negotiate a contract with the HSE on an individual basis?

Professor Drumm

We do not know that, but we hope to set a reasonable and fair price and have it adjudicated by people independent of our system. We hope it will acceptable to the vast majority. It may arise for all pharmacy services that operate in isolation or those that may have to be funded at a different level. It may raise as many opportunities as threats. Some people provide services in certain areas that are more difficult than other areas. However, we do not want to reach a stage where we have to negotiate with each pharmacist. That would be an enormous challenge.

Sitting suspended at 10.45 a.m. and resumed at 11.10 a.m.

Deputy Twomey

This morning, I felt we were at an extended press conference for the Minister for Health and Children, her Department and the HSE. Everything positive was highlighted. It is good to see Government representatives in election mode and clarifying good things for their constituency. Unfortunately, it does not lead to much critical analysis of what is going in the health services. We are not really discussing the issues and being more critical, as we should be. What has gone on so far has involved backslapping.

There is a time limit in respect of questions. Unfortunately, I must focus on Professor Drumm because the Minister comes before me every day. She might try to guillotine the legislation she is discussing. The legislation on medical practitioners will be guillotined. The Minister spoke about the issue of nursing homes yet the legislation dealing with this was guillotined last night. The Minister has also put a guillotine on the legislation dealing with the Health Information and Quality Authority. There will not be the proper debate we need, but I sense the Government does not want a proper debate on HIQA and the Medical Practitioners Bill purely because of the impact it will have on patient care. Some of this legislation is significantly faulty, but I will get to this quickly if I can.

I received an answer from the Minister for Enterprise, Trade and Employment, Deputy Martin, to a parliamentary question on MRSA. He said that in 2006, the Health and Safety Authority carried out 148 inspections in the health care sector. As part of these inspections, 13 hospitals were targeted nationwide, focusing on the spread of MRSA. Enforcement action was taken in 12 incidents. Could Professor Drumm indicate what sort of problems the Health and Safety Authority had with regard to these 12 hospitals to lead to enforcement relating to the spread of MRSA within those hospitals, considering that we were supposed to have a hygiene audit and to be moving much further in inspecting these hospitals? As Professor Drumm knows, the Health and Safety Authority only deals with the threat to workers or where workers might be a threat to patient care. I would like Professor Drumm to answer this question because it is extremely important.

I also received a letter. This is becoming very important because we are all aware of the significant concerns about the lack of occupational therapists in primary care. Some patients cannot get improvements in disability grants because they cannot get a report from an occupational therapist so, in some respects, this report is almost a limiting factor in respect of what patients can get in the community. We are talking about taking care into the community, but it is not happening on the ground. There is a significant lack of community physiotherapists. Professor Drumm mentioned that 97 primary care teams were established and that another 107 teams are in development phase. With many of these primary care teams, the only development that has taken place is that the HSE has written to GPs inviting them to join these teams. In my constituency, where I would be more aware of such developments, I am not aware of any primary care teams being established under the HSE.

There is another concern with regard to private home care packages. We are all aware of Leas Cross, the total lack of supervision of nursing homes in recent years and all the concerns that were consistently raised, with Leas Cross being, more or less, the pinnacle.

The Minister and I received letters from an 82 year old lady concerning her 86 year old sister. As the former had her hip replaced and the latter was a stroke patient, it was suggested that they should get private home care. In her letter, she wrote that the care provided at great cost was inadequate, the agency did not know whether carers were trained, it had difficulty in providing care for the time suggested, time-keeping was unpredictable, bathing was unsatisfactory, cleaning was hit and miss, washing was unsatisfactory and there were a number of question marks over hygiene.

Are we moving the types of problem found at Leas Cross into the private sector? I do not know whether the HSE's mandate allows it to enforce its strict regulations on home help services, which comprise part of its brief. When we move patient care into the private sector, are we removing our responsibilities?

I know of a case of a gentleman in his 80s whose wife was sent home from hospital requiring per endoscopic gastronomy, or PEG, feeding. For those who do not know, this involves stroke patients who cannot feed themselves being fed via a tube into their stomachs. The man was told to get private nursing care and that it would be paid for by the home care package. A man in his 80s with a sick wife was expected to become an employer, advertise for a private nurse and run services for his wife. The package is not a success and is a despicable way to treat people. We must be more honest about what is happening in the community.

I was scathing of one of two recent reports dealing with a CAT scanner in Louth County Hospital and, crowning that, the DEXA scanner in Sligo General Hospital. The equipment has not been used for two years because the health service cannot determine who is supposed to use it.

Regarding the survey referred to, it is not satisfactory that 7% of people presenting at accident and emergency received treatment without care and dignity. We must not give ourselves or the Government credit by jumping on the back of the hard work done by doctors and nurses in hospitals and the community. The role of the Government and Professor Drumm is to identify and solve problems. The survey shows good results because hospital staff work flat-out, but when patients are lying on trolleys or waiting to be admitted or when there is a considerable number of delayed elective procedures, it is important to make those problems known.

Some of what was said was contradictory. For example, it was stated that there might not be a need for additional beds. I deal with Wexford General Hospital. Letterkenny General Hospital is at the other end of the country. While both have experienced significant difficulties in terms of trolleys in the past 12 months, they received additional funding from the HSE under the case mix programme, which showed that they were efficient in their elective work. I was a general practitioner in Wexford and I know that a considerable number of patients are having their procedures cancelled. In a 12-month period, a consultant at Wexford General Hospital cancelled all endoscopy procedures every second week, but the Minister is holding up the hospital as the gold standard for the health services. The real standard is St. Luke's Hospital in Kilkenny, which was penalised under this system.

The Minister pointed to a significant increase in the number of day cases in the system, which indicates it is working well, but in recent years inpatient and day case discharges have not increased dramatically. There is a range of contradictions. Does the figure on lengthy bed-stays in hospitals take into account the sizable number of patients who are better suited to accommodation in long-term care?

I jotted a few notes down regarding the Minister's comments, particularly in respect of the legislation. Second Stage of the Medical Practitioners Bill 2007 will be guillotined in a four and a half hour debate next Friday when no one else will be around. There will be no vote. We have waited 30 years for the legislation, but it will fly through Dáil Éireann on Second Stage and be guillotined in the select committee. Despite many discussions, no one has told me what competence assurance system the legislation will put in place. Whether there is a lay majority or professional majority is immaterial. This is a matter of protecting patients from a minority of poor doctors, not one of spin and telling the media what we are doing.

Regarding the HIQA, there is no whistleblower legislation. The Bill has the potential to gag doctors. The Minister stated that no doctor stepped forward to speak out about Dr. Neary. We know the treatment he received after he was exposed and the three consultants who bailed him out are a disgrace to the profession. They were sent to Louth by their representative body, not a statutory organisation like the Medical Council.

The Minister must be more honest with people. For example, Fine Gael and the Labour Party proposed a patient safety authority to protect patients while the Minister discussed setting up a commission. Why can she not go all the way and set up a patient safety authority? There is a bit of "Micheálitis" in establishing a commission, as the Minister for Enterprise, Trade and Employment, Deputy Martin, published reports when he could not make decisions.

Concerning last night's guillotined legislation, the issue of private nursing home packages was not debated on the floor of the House because the Minister hindered the discussion. A section addressed registering private nursing home operators, but we could not find out what the Government plans on doing to protect private patients. The private nursing home sector became so annoyed with the Government that it introduced its own standards, but those in the sector are being tarred with the same brush. Whenever a nursing home closes, there is a sense out there that every nursing home is the same. Ministers and, to some degree, Professor Drumm state that the Opposition is criticising doctors, nurses and allied health care professionals when we criticise the health services, but there is a perceived taint because the Government and the HSE have not done their jobs.

Will Professor Drumm cast his eye over another issue? If the HIQA was structured properly, would it not be more appropriate to separate the Social Services Inspectorate, which is concerned with protecting patients, from issues of whether patients should receive treatment or whether the HIQA should investigate information technology and combine it with the Mental Health Commission as a patient safety authority? I do not understand why the HIQA, which will operate like the National Institute of Clinical Excellence in the UK, will be able to deny patients treatment. The institute believes that certain patients should not receive a breast cancer treatment drug, but the Government is giving the same function to the HIQA, which is supposed to protect patients.

Before this meeting, I tabled a question on what will be done about MRSA in hospitals and asked for the guidelines to be given to me today. I was told the guidelines are still in draft form. I received a document a few weeks ago about a national influenza pandemic plan. We have three books on chickens and wild birds yet with regard to MRSA, which is a serious problem in our hospitals, we have a draft plan. That demonstrates the response to the media driven agenda as opposed to what is happening in our health services.

Deputy Harney

The plan to which the Deputy refers is not about birds, it is about the impact influenza would have on humans if it mutated.

Deputy Twomey

The Minister for Defence, Deputy O'Dea, is in charge if anything happens so I hope it does not get into this country.

Deputy Harney

I do not agree with including inspectorates of child protection, people in the disability sector and the nursing home sector under the Mental Health Commission. The Irish Social Services Inspectorate will be part of HIQA but the chief inspector will be independent with regard to inspection responsibilities. We could have created an independent agency called the social services inspectorate but we seek to combine rather than fragment efforts.

The role of HIQA is to ensure quality and standards in services provided by, or procured for, the HSE. This includes nursing home packages provided by private sector operators at home or services procured from private operators. Licensing or accreditation of health providers in the public and private sector is a separate task. We have no licensing regime in Ireland — anyone can build and open a hospital or provide other health care facilities. This is not appropriate or in the interests of patients care. For this reason we have formed a group to examine these matters. Deputy Twomey suggests simply setting up a body and calling it the patient safety body. Patient safety should be at the heart of everything we do, not a separate organisation. Every hospital must have patient safety at the heart of what it does.

Deputy Twomey

The Minister is missing the point. A patient safety authority would change the current ethos. It would influence the HSE, An Bord Altranais, the Medical Council and all parts of the health service. The Minister has admitted problems with patient safety across the health services, even in privatising home care packages, a matter dear to her heart.

The Minister lifted most of the proposals from the Fine Gael document but she should have read it closely. The point is to give legislative power to a patient safety authority that puts the patient at the centre of the process. Even the complaints process was only signed off before Christmas, two years after the HSE was set up. The patient safety authority suggested by Fine Gael and the Labour Party would change the current ethos.

Deputy Harney

As the Deputy is aware, in New Zealand, Canada, the United States and other European countries, some 10% of hospital experiences can be adverse. This may not be a fatality but adverse events happen. Under the new liability insurance system, all adverse incidents will be reported to the State Claims Agency. We must change the culture, move away from blame and encourage people to learn from mistakes. This did not happen in the past because of fear of litigation. Even that process is seen in a negative light in some quarters. According to Deputy Twomey, an organisation known as the patient safety authority should supersede the regulatory bodies. They are separate functions. The regulation of the professions must be a matter for regulatory bodies such as the Medical Council, An Bord Altranais or the Pharmaceutical Society of Ireland. One cannot separate regulation from patient safety.

Deputy Twomey asked about competence assurance. It is a voluntary scheme, a public confidence measure of peer review and assessment by patients involving 350 general practitioners. If one is on the register, one is competent to perform the job. It involves training and education in which the vast majority of doctors engage in any event. The scheme must be voluntary because the Medical Council has no power to run it otherwise. It will be very expensive for the Medical Council and the Government has given a commitment to assist funding of competence assurance. That is the least we can do if we wish the scheme to be established quickly.

Regarding the regulation of nursing homes, the inspectorate will apply to public and private nursing homes without exception. Of 27,791 residential beds, some 10,000 are public and 17,000 private. The vast majority of those in long-term care are cared for to a high standard. Families have confidence because the deficiencies, such as Leas Cross, are the exception. We must have a process of inspection that guarantees this. The new inspectorate will be resourced to carry out inspections throughout the whole system within months of its establishment. HIQA must decide standards of care of the inspections, which is more than a matter of kitchen, bathroom facilities and spaces between beds. The care the patient receives must also be considered.

I will table an amendment to the Health Bill to provide protection for those who draw attention to adverse events in the healthcare system. This will not represent a major change. The culture has changed. The three doctors who reviewed the Neary cases are three eminent clinicians at the top of their profession. The judge referred to collegiality and misplaced loyalty to a colleague. Everyone has learned from it. In a small country it is difficult to ask someone to review a colleague but it is necessary in the interests of patient safety.

Deputy Twomey

The idea of competence assurance is crucial. There is much bluff about it being doctor-led but this will make no difference unless competence assurance is working. If not, the doctors who need to be assessed will avoid it. At present it is voluntary and those who are good at their job, those who undergo continuing medical education and read medical journals, are most likely to volunteer. Those who represent a danger to patients are doing none of the above. How will the Minister root out those individuals? That is what the general public needs to know. At present the politicians have been given control. The new Medical Practitioners Bill gives the Minister for Health and Children significant powers. Patients are being asked to trust politicians more than doctors. The health service is already short of consultants and it is difficult to undertake competence assurance of them. How will it be done? These practical questions must be answered. It is not only about the Minister going on the six o'clock news to state she will protect patients and bring in a lay majority. This will not matter a damn if competence assurance is as ineffective as it is now. Only those who are good volunteer for competence assurance.

Deputy Harney

Deputy Twomey made a number of sweeping statements. For the reasons he outlined, competence assurance will be compulsory under the new legislation. One cannot have a voluntary competence assurance scheme. The vast majority who meet the standards will volunteer but others will not. I am not competent to decide whether someone is a competent respiratory physician, surgeon or general practitioner. It will be the function of the Medical Council which will use peer review and colleague and patient assessment. It is the type of process used in other countries and in the voluntary scheme.

Having a lay majority is about public confidence in regulation and not an end in itself. The Bar Council of Ireland went for a lay majority. In my previous job I was responsible for regulating the accounting profession. We put in place an oversight board with 60% lay membership. Most accountants I meet state it is fantastic. Competence assurance is by far the most important part of the legislation.

The power given to the Minister to make directions is similar to the powers given to the Minister for Finance regarding the Central Bank and those which Ministers have generally whereby a regulatory body must pursue Government policy. If medical education should take five, six or seven years the regulatory body cannot state it will take ten or four years. It will not and cannot be used for day-to-day or operational issues. The body will be responsible for regulating the profession within the context of overall policies pursued such as medical education.

Deputy Twomey

We can deal with the rest of it next week.

Deputy Harney

With regard to guillotining the legislation, we must get the Bill through the Oireachtas. We had widespread consultation and received many good submissions. The published Bill does not contain many great secrets. With goodwill we should get it through the Houses quickly and I hope that will be the case.

Deputy Twomey

The accountancy body referred to by the Minister was that on which I based the patient safety authority.

Deputy Harney

I am not a great fan of establishing bodies for the sake of it. It always sounds great.

Deputy Twomey

It is not about that.

Deputy Harney

Every time we have a problem people either call for legislation or an organisation. If we used the tools we have more effectively we could achieve the same result.

Deputy Twomey

It is about giving patients a real say.

Deputy Connolly

A number of the issues I wish to discuss were already raised, including cancer care and the nurses dispute. A major difficulty in nursing is that someone accepting a promotion loses money. It is one of the few professions in which this happens. The psychiatric service has a major issue with this. During a strike nurses provide cover and should be paid for that work.

I have a question on the document A Vision for Change on mental health policy and I will accept a written response from the Minister to save the committee's time. I am opposed to selling psychiatric lands. The HSE should hold on to any asset it has. We pay far too dearly to rent premises throughout the country with nothing to show for it. We must reconsider our policy of selling what we have. I wish to hear about the implementation of the suicide prevention programme on which I will also accept a written response. A number of pilot schemes are in operation on training people to recognise signs and symptoms. Will they be nationalised?

In a report in 2004, the HSE recognised the need for hearing screening for newborn children. Will the Minister and Professor Drumm comment on when universal newborn hearing screening will be implemented? Recently, I had representation from a parent of a two year old. The parent was told last September to seek an appointment four months later and see how long the waiting list was at that stage. This month, five months later, the parent was told to return in six months to see when an appointment can be made. People with hearing and speech difficulties encounter this issue on a daily basis. The Minister stated massive benefits were associated with such a programme. It is rather inexpensive and is a matter of putting it in place. It would represent excellent value for money and we deserve a response on this matter.

The last committee meeting attended by the Minister was long. I question the value of these meetings and whether the Minister takes what we discuss to her people at regional level. At that meeting both she and Professor Drumm made a commitment that no service would be removed from Monaghan General Hospital until a better and safer service was in place. At the same time as that meeting, the local general manager in charge of five hospitals put in train steps to remove the on-call cover at Monaghan General Hospital. He terminated a consultant's contract last Christmas. He was destabilising and preparing to remove the seven-day 24-hour service from Monaghan General Hospital. Since then, a locum has been put in place. The Minister sings from one hymn sheet here but different actions take place at ground level.

The Teamwork report on which much of this is based is laced with grades of staff which we do not have, such as advanced paramedics, advanced nurse practitioners and advanced accident and emergency nurse practitioners. We have one advanced nurse practitioner in Monaghan General Hospital. The Minister expects these grades to carry the Teamwork report which is a pilot project for the State. Before any change takes place the service should be up and running. I want to hear a commitment on this. It makes a mockery of democracy if we hear one thing here and the actions taken are different.

The Teamwork report does not fit the Border area and health services should be examined on an all-island basis. Approximately 1 million people live in the hinterland on both sides of the Border. Cavan and Monaghan have a long stretch of Border with Fermanagh, Tyrone and Armagh. We must consult with people on the other side of the Border. People who live near both sides of the Border are neglected. We hear about equity in the health service. However, people who live in Border communities do not have equity. Plans exist to remove the same level of access as exists in other hospitals. Border communities should be on the political agenda and this issue must be examined.

We must also examine the services delivered in regional centres of excellence, if such places exist. I will refer to them as regional hospitals because I doubt we can fairly refer to them as centres of excellence. During the past five years and possibly longer, Our Lady of Lourdes Hospital has been crisis-managed. This is not a reflection on the hospital staff. They can only do what they can. It is more a reflection on the system as issues are not addressed at a far more senior level.

People must deal with what they have but it reflects badly on the people who deliver care in overcrowded accident and emergency units or wards on which MRSA is prevalent. I ask that consideration be given to freeing beds in regional hospitals to allow them to concentrate on major work. Why should minor procedures or intermediate level surgery be conducted in regional hospitals rather than Monaghan General Hospital and other similar institutions? Such work would give smaller hospitals a viable future and would make better use of bed and theatre space. Monaghan General Hospital worked with Craigavon hospital to tender for work on inguinal hernias, and met its requirements exceptionally well in terms of clearing the waiting list. That type of work can give hospitals such as Monaghan a viable future.

An individual was interviewed on a recent edition of "The Late Late Show" about his experience of being employed as an outsider to investigate and address problems in the health services in England. When Henry Ford needed someone to run his organisation, he did not look for his best mechanic or paint sprayer. We must find people who have developed skills through making organisational decisions in the real world. Just because someone happens to be skilled in a particular area, that does not mean he or she can be put in charge of multimillion euro budget. I am aware my opinion may not be appreciated but that is how I feel.

The first reaction to outbreaks of MRSA in hospitals seems to be to keep quiet for as long as possible. I am aware of instances of nurses who have never received definitive answers to inquiries to other hospitals about MRSA infections in patients. Results of MRSA tests were not even recorded in the Mater Hospital, with the result that difficulties arose between the public and private hospitals. That is a classic example of the left hand not knowing what the right hand is doing. I understand that patients are swabbed for MRSA when being transfer between hospitals. I hope they are also tested for other infectious diseases. Has the HSE any plans to test all patients presenting to hospitals for MRSA? The disease is often brought into hospitals from the outside.

Every time we are given presentations on health, we hear about world-class services and best practices. I continue to be confused when I hear such claims because, despite knowing about the problems, we have gone no further in terms of addressing them.

Hospice care provides an excellent service to people who want to spend the end of their lives at home. I know of a large number of families who want to treat their parents in their homes. I recently met a family who described the care provided in Cavan and Monaghan general hospitals as nothing short of brilliant. However, they later brought their mother home and found that, while they had good hospice care support during the week, they were left stranded at weekends.

Deputy Cooper-Flynn

I was happy to hear the Minister refer to the nurses' pay claims in her introductory remarks. However, Professor Drumm did not make any mention of the issue, which surprised me, given that I presume he was informed of the motion in support of the nurses' pay claim passed unanimously by this committee two weeks ago. The motion stated that the committee believes the nurses hold substantial grievances, are prepared to engage in significant reforms to improve patient services and are seeking accommodations in line with those provided for other public servants. What will the Minister and Professor Drumm do to give expression to the committee's unanimous opinion?

Does the Minister acknowledge that public servants in the health service have been awarded pay claims outside the benchmarking process and is she prepared to make similar offers to nurses? Does she acknowledge that the nurses went to benchmarking one but their pay claim was ruled to lie outside the terms of reference? The 14 amendments they submitted for benchmarking two were rejected, which means their pay claims will not be heard under that process. In view of the motion passed by this committee, will the Minister engage with the nurses in order to resolve this issue and avoid a strike?

Deputy Connolly's claim that we have not made progress on any of the issues raised in this committee is not accurate in respect of one issue I raise regularly, namely, subvention. In the Minister's response to Deputy McManus, she addressed the issue of discrimination in subvention rates. The last time I attended this committee, the subvention rate was €190 in the west but €700 in the east. That has since improved and the rate is now €300, which is a step in the right direction. However, nursing homes in my area point out that advanced subvention is no longer being paid. I hope the rate increase is not merely a crumb thrown to us because a significant gap remains between the east and west. It does not matter to families with elderly relatives in nursing homes whether they are paid basic subventions or basic plus enhanced subventions because the money still has to be found. As far as the Minister is concerned, have we reached the end of the road in terms of equalisation across the country?

Professor Drumm visited my home county last week and we were delighted to welcome him to our local hospital where he saw first-hand the problems we are experiencing in accident and emergency services. He has previously stated that Mayo General Hospital faces particular problems in that regard. What will be done in terms of contract beds? It remains the case that beds in the hospital are not being contracted out. However, I understand from the hospital manager, who does a very good job, that a number of measures will be introduced to specifically address that issue. Professor Drumm also acknowledged the need for additional long-stay facilities.

Ballinrobe in County Mayo has waited 25 years for a public nursing home, which is exactly in line with the policy to which Professor Drumm is committed. A site is now in the possession of the HSE. Will the money be forthcoming to provide the nursing home, long awaited by the people of Ballinrobe and those in the catchment area of Mayo General Hospital? Will there be a subvention for contract beds and for the provision of additional long-stay beds in my own town of Castlebar? I note Professor Drumm visited Sacred Heart Hospital, where there has been a significant cutback in the number of beds in recent years. They have been increased in the acute hospital and decreased in public long-stay facilities so it is inevitable 13 people will be on trolleys in accident and emergency units this week.

Is it the intention of the HSE to enhance subvention for the west and will it be on the basis of need, as identified in the document? The Minister made reference to BreastCheck in the west, about which I am very concerned. She said it would happen in the spring but when exactly? Is 1 February not the start of spring?

I also want to raise the issue of orthodontics. I have been a member of this committee for ten years, in which capacity I have seen two reports on orthodontic services. As a result of the second report the Minister established a review group on orthodontics. Mr. Healy was present at the last meeting so he is getting a double dose of the discussion on orthodontics. Since then the report has been published and was presented to us on 13 February. While some of the recommendations were excellent, particularly on the introduction of new guidelines replacing those of 1985 with an international standard, it also made the point that significant additional resources would be needed because 7% more children in Ireland will fall within the new guidelines, which are to be introduced in May. What provision is the Minister making for additional resources for that purpose?

Is it normal to publish a report in which there was a dissenting voice? There was also a minority report which was not included in an appendix to the main report. The report came before the health service management team on 29 January and was accepted. Did it accept it without sight of the minority report? That seems unusual, particularly when the minority report related to the main recommendation of this joint committee, which was considered by the review group.

I will raise a small matter on the subject of prosthetic clinics. What system operates in Ireland for the fitting prostheses? Do we contract the work out to other companies? People have raised the issue with me and I understand that the UK NHS used to contract out the work but it was very costly and now the health service employs people directly. Does the Minister envisage Ireland going down a similar road?

I will ask a question on the IPU. I presume other countries operate similar competition law but they are still able to negotiate through unions acting on behalf of pharmacists. Why can they do that but we cannot? Is it possible or advisable to amend competition law in this country to facilitate it? Given that we are in something of a legal minefield, which will have consequences for other health service areas, how do other countries in the EU deal with the issue?

Senator Henry

I welcome the Minister and Professor Drumm. Two worrying reports came to light recently regarding cancer. One was a survey carried out by the Irish Cancer Society in conjunction with the Irish College of General Practitioners. It concerned the views of general practitioners on access to diagnostics, for example, if they suspect a person has cancer, and to specialists in the area. There appeared to be an unacceptable delay, particularly for public patients, and almost 50% of GPs surveyed said they felt private patients had better access to both diagnostics and consultants, which is not a good state of affairs. I gather the Minister intends to give access to general practitioners to diagnostics in private hospitals but has this been costed in comparison with the option of extending the hours in which facilities would be available in public hospitals?

The second report was published in the Annals of Oncology and Professor Peter Boyle was one of its main authors. It concerned the outcome and incidence of cancer in OECD countries. Ireland did very poorly on five-year survival rates, all being below the EU average. It was said that the outcomes in childhood cancers are now very good but that is certainly not the case in adult cancers. The national cancer strategy was launched in September 2006 and made recommendations for specialised centres for every 500,000 people, eight in total. Has there been any progress in implementing the national cancer strategy because it is important to put such facilities in place as soon as possible?

Deputy Cooper-Flynn raised the question of orthodontics. I have been very concerned about the development of the maxillofacial unit in St. James's Hospital. It appears that, because of the level of road accidents and cancer cases, the present facilities are incapable of dealing with serious orthodontic cases, particularly in children with an intellectual disability where there are real problems. Mr. O'Brien might be able to help in this regard.

I am glad Deputy Connolly raised the screening of newborn babies for hearing disabilities. This very important area is another in which we are shamefully behind the rest of the EU. Having seen the ease with which my own granddaughter was screened in London, the difficulties cited for failing to introduce it simply do not exist.

The final point I wish to raise is the secrecy of the National Treatment Purchase Fund, which cannot tell us what anything costs because of commercial confidentiality. Can the Minister not be relied upon to look privately at its pricing and compare it with the deals the VHI manages to get with private hospitals. There is considerable anecdotal evidence that the VHI strikes better bargains and it would be deplorable it we found that the unfortunate taxpayer was paying even greater fees. Deputy McManus referred to consultants who are being paid to work in the public service and, when the facilities are not available, operate on the same patients in private health authorities, which is most unfortunate and such cases should be minimised.

Senator Browne

Does the Minister accept that people have been infected with MRSA while in hospital? Why has she ruled out a redress scheme for those people? I understand that people may have MRSA before entering a hospital. However, if a patient was swabbed on admission and again on leaving and can prove he or she caught the bug while in the hospital, is there not a clear case entitling him or her to some compensation? If one got food poisoning in a restaurant one would be entitled to compensation. This issue must be examined. The Minister for Justice, Equality and Law Reform, Deputy McDowell, has spoken of tribunals wasting €1 billion and paying lawyers massive fees. It looks as though we are heading down the road of litigation and unfortunately solicitors will now get involved on behalf of patients. The Minister for Health and Children, Deputy Harney, could save taxpayers and patients, time and money by setting up a redress scheme to acknowledge the fact that patients were badly treated in hospitals and hospitals breached the duty of care, as outlined in the Health Act.

I cannot understand why it takes the Health Service Executive, HSE, so long to fill staff vacancies. We discovered in a previous meeting that only a month's notice is required for staff to leave. However, when I was teaching it was necessary to give three months' notice and one could only be released when the vacancy was filled. Would it not make sense for the HSE to change this rule so that staff can only be released after three months' notice or when the vacancy is filled? One month is a very short time for an employer to advertise for a job, recruit somebody and have them start in the post. Meanwhile the patient suffers because service has stopped without regard to him or her. In life, people are promoted, resign and retire so I suggest this change be made to allow the HSE fill vacancies and ensure continuous service is provided to the patient.

Was a decision reached in the court case listed in the High Court last week, on patients who went to private nursing homes because no beds were available in public nursing homes? Are funds to be made available in the event that a decision is made against the Government? This would mean the nursing home refund scheme would have to be increased substantially. I know the State is contesting the matter.

We have heard about the lack of nurses, consultants and doctors and the lack of general practitioners, GPs, in north County Dublin. Would it not make sense for the Minister for Health and Children, Deputy Harney, and the Minister for Education and Science, Deputy Hanafin, to formulate a plan to double or treble the intake of students at the relevant institutions? I was amazed to learn that many of the students at the Royal College of Surgeons are from the Middle East. They are attractive because they pay huge fees that keep the college going but when they qualify they go back to their home countries and we are left with a deficit. Foreign students are very welcome here but we need to substantially increase the number of people we recruit and competition is the best way of doing this.

Even in Carlow, the lack of GPs is a major problem and the town has grown so much that people are finding it difficult, if not impossible, to make appointments with doctors. There is more pressure on the health service nowadays and we must see that more doctors and consultants are fed into the system.

I spoke to Professor Drumm and Mr. O'Brien about post mortem facilities during holiday periods as I know of a neighbour whose 19 year old son died suddenly at Christmas. There was a delay in the post mortem and the release of the body, though, as it happened, it did not take as long as was originally envisaged. The process was to take a week, which was very upsetting for the family involved and they were not allowed to talk to the hospital authorities except through the undertaker. I will give the details of this case to Mr. O'Brien after this meeting and I ask that during the holiday period the families of people who die suddenly come first though I appreciate people will be on holidays.

Deputy O’Connor

I appreciate the opportunity to speak today and I extend my welcome to the Minister, to Professor Drumm and their teams. It is a pity the Minister was not here a couple of weeks ago because Deputy Connolly referred to issues in border areas. We had a very good meeting, under Deputy Moloney's chairmanship, with the Social Democratic and Labour Party group. Its spokesperson, Ms Carmel Hanna, said some very nice things about the Minister's work that I hope were repeated to her.

Deputy Harney

I have more support from outside the jurisdiction than within.

Deputy O’Connor

Deputy Twomey took careful notes at the meeting so if the Minister has not heard Ms Hanna's comments I will have him write to her.

Deputy Twomey

I question whether she received the correct information.

Deputy O’Connor

I do not wish to repeat everything said already this morning and there have been many good contributions on issues of concern to me. My colleague, Deputy Cooper-Flynn, referred to the issue of orthodontics and I was a member of the sub-committee — chaired by Deputy Fiona O'Malley — that examined the matter. I point out to Professor Drumm that people do not believe they are receiving the kind of service they should in this regard, despite the best efforts being made.

The difficulties facing the Irish Nurses Organisation, INO, and the Psychiatric Nurses Association, PNA, have been mentioned and I would like to be associated with this matter. Like others, I have met the various groups involved and think what was said earlier regarding the unanimous decision of this committee to back the relevant motion is significant. We have raised these issues as members of various parliamentary parties and it is important that the Minister understands the feeling of public representatives in all parties that this should not be allowed to manifest itself as a real dispute.

Many of us have had contact in recent weeks with the Irish Pharmaceutical Union regarding the difficulties its members are experiencing. We all have pharmacies in our constituencies. I do not wish to be parochial but on the Springfield estate where I live three pharmacists provide very good services. They have issues and I would like guarantees from Professor Drumm that they will be heard and that actions will be taken in this regard.

Other colleagues referred to out of hours GP services and we hear a great deal about this as it applies to north county Dublin. I have raised this issue with the Minister on several occasions in respect of Tallaght Hospital. I stress that this is still an issue and I hope the Minister asks her officials and the HSE to continue to study ways of addressing the subject.

I mention Millbrook Lawns health centre again, though I drew vexed reactions last time. We are all talking about the importance of primary community services and are very proud of developments in the constituency. In Tallaght a tremendous service is being provided in the Mary Mercer health centre in Jobstown and in GP centres around the estates. Millbrook Lawns health centre is still blighted as it was damaged by fire eight years ago and has not yet been redeveloped and this is a shame. I pay tribute to the local manager, Mr. Adrian Charles, and his team for his efforts in this regard. Comparisons can be made with other services. I, along with others, will be taunted by people who should know better, as we approach the end of this Dáil, suggesting the centre will be fixed up as part of the election campaign. This is not true and I will defend myself on this point on every street in Tallaght and Dublin south-west.

I point out to Professor Drumm that we need to see builders on the site. This is nothing to do with the election. As anyone who looks at my record will know, I have raised this matter at every opportunity. It is time the facilities were improved as this has gone on for far too long and would not have been allowed to happen elsewhere. If this had happened anywhere else people would storm the gates of the Department and the HSE.

I will briefly and clearly refer to the Minister's comments on children's services in Tallaght. The decision on the National Children's Hospital and the Mater Hospital has been made, though many views are still circulating on the issue, including a suggestion that it should be located in Mullingar. As the Minister travels around Clondalkin, as she regularly does, and I travel around Tallaght, we see posters of candidates of whom neither of us has hardly heard, and their stated position on an issue. I have been consistent in my defence of Tallaght Hospital. I was first appointed to the Tallaght planning board in 1988 by the Ceann Comhairle who was then Minister. I was involved in the AMNCH board which set up the services in 1998. I am clear that, irrespective of the decision made on the siting of the new children's hospital, children's services at Tallaght Hospital must be retained. That is the decision that must be made, having regard to HSE examination of urgent care centres and so on. It is time that the future plans were made clear for the people of Tallaght and its immediate catchment area, which is vast. I am aware that people in Clondalkin have raised this matter with the Minister. I hope what I have said will turn out to be the case.

With regard to the current proposal that the new children's hospital could be located on two sites, I suspect the Minister might have a view on how that might work. I want to be clear in pointing out that I have consistently said that the children's services in Tallaght Hospital, which were established under charter on the setting up of the Adelaide, Meath and National Children's Hospital in 1988, which the Taoiseach strongly supported, must be retained. I hope that an announcement to that effect will be made sooner rather than later.

I compliment the Chairman on the manner in which he has conducted this meeting. We are dealing with important issues. We may not have another opportunity in this type of forum to deal with these issues as the election may be called within 100 days.

Deputy Cooper-Flynn

If a decision is made to proceed with one hospital located on two sites, one of the sites would surely have to be located in the midlands. I am sure the Deputy would agree with that.

Deputy O’Connor

These issues are important. I thank the Minister and Professor Drumm for their co-operation.

Deputy Twomey

It is great to see the Deputy backing Fine Gael policy.

Chairman

We will have to go and see Tallaght some time as I have heard so much about it.

Deputy O’Connor

Professor Drumm might visit Tallaght some day. If he is able to do so, I will be happy to host such a visit.

Chairman

We must move on as we have business to conduct. We can see Tallaght at our leisure.

Deputy Harney

I am very familiar with Tallaght Hospital which is, if I could describe it as such, my constituency hospital. Deputy O'Connor spoke of one hospital on two sites. If we could have one hospital on 53 sites, thus located on the sites of all the hospitals, I am sure somebody would also advocate that. We have read the findings of the experts, examined best practice internationally and the HSE board and the Government endorsed the recommendation made.

For so many years, for whatever reason, we always back away from doing the right thing. That is what has bedevilled the health services for far too long. When I visited Chicago at the end of last October I took the opportunity to visit the Children's Memorial Hospital. Its location in terms of proximity to Chicago city can be compared with the location of RTE in Donnybrook to the centre of Dublin. The hospital had an opportunity to secure a 12-acre greenfield site for a new hospital on the outskirts of Chicago or to locate it in the heart of the city just off Michigan Avenue, which is to Chicago what O'Connell Street is to Dublin, and co-locate with an adult hospital, which it what it has decided to do. If one saw the size of that site, one would wonder at its decision. It is infinitely smaller — I cannot remember the size of the site off the top of my head — than what we propose for this new hospital.

Regardless of whether the children are my constituents or any other Member's constituents, in my strong opinion the parents of sick children want their children to be in the best possible facility. It is not only about a building, it is more about the expertise within the facility. That is what parents want.

One of the most informed contributions in this debate, which has not received much attention, was made by Ms Linda Dillon, who is involved with the New Crumlin Hospital Group, and whose daughter, Alice, tragically died last year. I remember her sitting in my office with others and her saying "Get on with it, don't let us have delays, we want a new hospital". She also said that publicly.

A proposal for a new site at Corkagh, which has been acquired by Mr. Farrington, has received considerable media backing. There are major issues surrounding that, including the problems related to zoning and access. If the hospital were to be located there, Tallaght Hospital might as well close because it is within two miles of the location. We need to know what it is we are pursuing. Many people have difficulties once a particular site is chosen. If we decided to locate the new hospital at St. James's Hospital, I have no doubt many people would have been unhappy with that decision and likewise if it was decided to locate it at Tallaght Hospital. The group examined all the potential sites and while I am not an expert or a clinician, I strongly buy into its recommendation. We must move on and get on with the business and that is what we will do. I strongly oppose the proposal for one hospital on two sites.

The transition group, which is made up of the HSE and the Department, will make a determination on urgent care facilities over the new few weeks. I understand that of the 29,000 children who went to Tallaght Hospital in 2005, 25,500 were dealt with and went home the same day. Bed occupancy in Tallaght children's hospital is about 40%. That is the reality. The bulk of experience with sick children involves them coming in in the morning and being discharged in the evening, and those facilities will be provided at the urgent care centres.

On Deputy Connolly's point, I saw the three Sir Gerry Robinson programmes. I told Professor Drumm they should be compulsory viewing for everybody who works in the health system, including the Minister for Health and Children, because Sir Gerry Robinson made some simple findings. First, people were not talking to each other. There was one clinician who thought if he did not have a first class honours degree he could not manage anything. The doctors thought managers were the problem and the managers thought the doctors were the problem. Available capacity was not being used. They were very simple issues.

Deputy Connolly

It is not rocket science.

Deputy Harney

The health service needs somebody who has vision and the intellectual capacity to understand the issues but, above all else, the courage to see it through because it is a not popular job being the Minister or the chief executive officer of the Health Service Executive driving reform. They will not win many friends but people do not do it for that reason; they do it to put in place the best possible health care system this country can have.

The north east is a case in point. I am a Member of the Oireachtas 30 years this summer and for as long as I have been in Leinster House there have been debates about the north east. Every time we almost achieved something we pulled back because it did not suit this or that or did not look good. In almost every election some new initiative was introduced in the north east.

I understood Professor Drumm to say earlier that the rate of hospital admissions in the north east was 5.9% compared with 1.7% in the United Kingdom. Some 50% of the elective work and 30% of the medical work from the north east comes into Dublin hospitals. We know we have to make changes in the north east. The patients are voting with their feet and going elsewhere. That is the reason we are putting in place a new state-of-the-art hospital for the region. That will not happen overnight, however, and in the meantime we must beef up the existing service, based on patient safety because whatever is required for patient safety will have to be put in place.

The HSE will deal with the operational issues around Drogheda and Monaghan and all those issues. I strongly believe the time has come to make the right thing happen wherever it is throughout the country and to have services provided as close as possible to where people live, provided that can be done safely and in accordance with best practice.

That brings me to the issue of cancer care mentioned by Senator Henry. It is one of the areas where we have greatly strengthened our investment——

Deputy Connolly

Does the Minister consider she has dealt with the issues I raised with her?

Deputy Harney

One of them was the nurses' pay claim with which I will deal.

Deputy Connolly

The issue is the commitment the Minister and Professor Drumm gave on Monaghan General Hospital on the previous occasion.

Deputy Harney

I did not give any commitment. I let the HSE deal with that. It is an operational issue.

Deputy Connolly

The Minister gave a commitment that the vast bulk of services would remain at Monaghan General Hospital and Professor Drumm gave a commitment that no service would be removed from Monaghan General Hospital until better, safer services were in place. The Minister can check the Official Report.

Deputy Harney

That is my understanding of what is happening.

Senator Henry mentioned cancer care and access for public patients to services. We have made very significant investments in that area in recent years. I understand we have 100 additional consultants in cancer care. I heard Professor Boyle say on a radio programme that Ireland is implementing the right policy for cancer. The HSE will deal with the implementation of that policy, including the new cancer director and so on. First, we must ensure that people have access to cancer services, both screening and treatment services. That concerns the roll-out of BreastCheck which, to answer Deputy Cooper-Flynn, will be in April. Second, we must provide the facilities in cancer centres even though there is no doubt they could be delivered in smaller facilities. That is the policy that will be implemented. In Ireland, a large percentage of breast surgery was carried out by doctors who did fewer than five operations in a year. That is very dangerous and the outcome was terrible. All that is changing, however, and while I wish it could happen overnight, it will take time. We are certainly on target concerning that and the HSE will deal with the actual implementation.

Senator Henry asked about access by GPs to diagnostics, which is a matter for the HSE. Clearly, if we cannot reform the public health system fast enough we must use whatever capacity is available in the private sector for patients because they need the treatment. That was the reason the National Treatment Purchase Fund was established. It was not modelled on any American fund but on what happens in Norway. The irony is that we seem to have more private work in some of our public hospitals, while public patients are going to private hospitals. I do not know if there are different rates. I will have to check what the National Treatment Purchase Fund is paying the various hospitals. I know that some of the work is done on Saturdays, so perhaps there are issues there as regards its being more expensive. I will revert to the Senator on that issue.

On competition law and the IPU, it would not be a good thing to change competition law to facilitate price-fixing, which is one of the provisions that hinders negotiating with people who are not one's own employees. There are innovative ways around it, however. The HSE will be in a position to negotiate contract details with the IPU but there will have to be an independent process for setting fees. There is a way around it and we hope to find such a process soon.

Senator Browne referred to medical training and we have already agreed to double numbers. We are moving from 327 per year to 725. In 2006, we provided 70 extra places, while this year there will be 100 extra places: 40 at undergraduate level and 60 at graduate level. Over the next few years, therefore, we will have more than doubled the number of doctors in training. The Minister for Education and Science and I have agreed to that and funding is being provided.

I will let Professor Drumm deal with the issue of vacancies. I am always astonished at how long it takes to find consultants in particular because of the disengagement and re-engagement involved. One would wish that the process could be speeded up because it seems to take an incredibly long time.

We had a debate on MRSA in the Seanad yesterday. The preliminary results from a project by Irish hospitals together with hospitals in Northern Ireland, England and Wales show that Ireland has the lowest rate of health-acquired infection, which is encouraging. It is 4.9% compared with an average of almost 8%. I do not take any solace from that and we still have to reduce it further.

Last week, I met the HSE team that is driving this matter forward by recruiting surveillance scientists and infection control nurses. There will be a major public information campaign and a phone line through which people can make complaints if they are not satisfied with hygiene standards. As we know, however, the main issue surrounding MRSA is the over-prescribing of antibiotics. This is an international issue. The countries with the lowest rates are those that have worked with general practitioners and patients on the issue of prescribing. For example, the Netherlands has low rates. It had a very intensive programme of education, training and awareness involving both general practitioners and patients. That programme is also planned for Ireland.

Senator Browne

What about the redress scheme?

Deputy Harney

Every day, people litigate against the health service and these matters must be dealt with on a case-by-case basis. There is no question of a redress scheme being established. People can vindicate their rights through the courts. The reason I am establishing a redress scheme for some of Dr. Neary's patients is because the files were destroyed. They have no way of vindicating their rights through the courts and that is why I believe the State has a moral obligation to compensate those people financially, but it is only in those exceptional circumstances.

Senator Browne

If I went to the Minister's constituency clinic and tripped over her chair, I would be entitled to lodge a claim for damages.

Deputy Harney

Of course.

Senator Browne

I know of a 16 year old who broke his leg playing rugby, which is a routine occurrence. He contracted MRSA and ended up spending much longer in hospital as a result. He was very sick after that. If I were going to hospital tomorrow morning, I would insist on being swabbed on admission. I would advise anyone going to hospital to do the same for MRSA, clostridium difficile or any other infectious blood disease. In those cases, people are beginning litigation.

Unfortunately, solicitors will now get involved and it will cost even more. I do not know why the Minister is refusing point-blank to establish such a redress scheme. Having gone through the trauma of becoming infected in hospital, as a result of which their condition is made worse, people will now be faced with hefty legal bills. It will cost the State more in the long run. The Minister should not rule out such a redress scheme.

Deputy Harney

As we know, adverse events happen in hospitals every day in Ireland, as they do elsewhere. We cannot have a redress arrangement to compensate people where there has been negligence on the part of the hospital or the health authority. These are matters that have to be dealt with——

Senator Browne

We had one for Dr. Neary.

Deputy Harney

I have already told the Senator the reason in Dr. Neary's case — it was because the women had no way of vindicating their rights because their files were destroyed. There is no record and they could not win in any court proceedings. They could not even take a case without the basic information. Unfortunately — and disgracefully, as the judge said in her report — the files were interfered with and destroyed in many cases. That is the main reason the State intervened. Some of the women successfully sued where records existed. Clearly, however, if such records do not exist, other women are not in a position to do that.

The Senator asked about a case concerning the private nursing home sector that was due in court last week. The HSE may know more about it but I understand that the case was settled. The management of any case is dealt with on a case-by-case basis, taking the best legal advice available concerning the circumstances or the facts in a particular case.

Deputy Cooper-Flynn

Will the Minister address the nurses' pay claim and the motion passed by the committee in particular?

Deputy Harney

Believe it or not, I was not aware that the committee had passed a motion which is clearly in contravention of the Government's public pay policy.

Deputy Cooper-Flynn

The committee did so and it was backed unanimously.

Deputy Twomey

I would like to add that the Fianna Fáil backbenchers on the fifth floor are also making their views known.

Deputy Harney

I am sure they are. I hear everybody's views all the time and I listen to them, of course. Government pay policy is determined by the Government. We have had a social partnership agreement which provides for a 10% pay increase for nurses and everybody else over a 27-month period, although the INO has not accepted that. I do not think the INO has actually rejected it, but it has not accepted it. Nurses in SIPTU, for example, have voted to accept the agreement. The Labour Court adjudicated on the nurses' eight claims and suggested resolving two of them through benchmarking. One of them concerned the issue of people with low skill levels reporting to nurses in the mental health area, who get about €3,000 more. There is an anomaly there and we will express a positive reaction to that if we can go through the appropriate process. I would encourage the leadership of the INO and the Psychiatric Nurses Association to resolve the issues through the process we have put in place, which has served this country well.

Deputy Cooper-Flynn

Does the Minister accept that benchmarking has been set aside in other instances? Why would that not be considered in the nurses' case? The Minister mentioned the 10% pay increase but what will happen to members of the INO and the PNA? Will they receive that 10% pay increase when it is awarded?

Deputy Harney

Since they have not accepted it, I presume they will not.

Deputy Cooper-Flynn

Even though they have not rejected it?

Deputy Harney

They have not accepted it.

Deputy Cooper-Flynn

Does that mean they will not get it?

Deputy Harney

I would imagine so but that is a matter for the employers. That is normally the case — that one does not get it. If one is pursuing a claim in another way, obviously one does not benefit from the provisions of the agreement. Unfortunately, some things are being settled in a different way and that is regrettable, but we are where we are and must deal with that.

Nurses make up 35% of the workforce in the health care system. Nobody wants to empower nurses more than I do. I have recently provided for nurses prescribing in certain care settings. There is no doubt that we want to empower nurses to do more in the health care system. In terms of public pay policy, however, we have processes in place and we need to abide by them. That is the message from the Irish Congress of Trade Unions as well as from Ministers.

Deputy Twomey

The Minister is essentially saying that she is offering nothing in this dispute with the nurses. If the benchmarking process is not altered in some respect, it will not give nurses anything

Deputy Harney

They got 8% the last time.

Deputy Twomey

Frontline nursing staff got 8% and administrative nursing staff got more than that.

Deputy Cooper-Flynn

The issue surrounded the working week.

Deputy Harney

I am not here to adjudicate on the appropriate pay levels, rates or otherwise. We have processes in place to do that — namely, the Labour Court and the Labour Relations Commissions — and we have benchmarking.

Deputy Twomey

They have been rejected at all those levels. There is no avenue open to them.

Deputy Harney

I believe all but two of the issues have been rejected.

Deputy Twomey

There is no avenue open to nurses.

Deputy Cooper-Flynn

A precedent has been established.

Deputy Harney

I have suggested it would be a good idea — there is goodwill from some organisations working in the health care system — to have a wider process involving all health care professional representative bodies to see how we can change work practices and bring more innovation to the way we work. The Government, the HSE and others are very positive about that. Perhaps that would be a forum in which nurses could discuss these issues.

Deputy Cooper-Flynn

A precedent has been established. Other health care workers have had their claims dealt with outside benchmarking. The benchmarking process has failed to deal with some aspects of their claim. Why not adopt a similar approach to nurses?

Chairman

I call on Professor Drumm to respond to Deputy Twomey's queries.

Professor Drumm

Deputy Twomey raised one of the big challenges we face, namely, MRSA. The big challenge there, which has been raised by the Health and Safety Authority, is infrastructure-related. We are working very closely with the Health and Safety Authority. We must put a huge effort into making relatively simple changes in our infrastructure. Obviously, we would like new hospitals everywhere. If there is a deficit in our system at a hospital level — we are dealing with our acute bed issues again — it is the quality of the infrastructure we have that really needs huge improvement. That is obvious from the issues on which the Health and Safety Authority is focusing. We really need to focus on improving the quality of the infrastructure.

There is the continuing issue, which came up in Deputy Twomey's question and in others, that MRSA is highly prevalent in our community at large. The two issues are its prevalence in the community at large and the risk of picking up that infection when one is seriously ill. I was misquoted when I raised this issue before here. The prevalence of MRSA in the community is driven by the use of antibiotics in this society over many years. It is much higher than it is, for instance, in northern European countries. It happens to be somewhat lower than in the UK which, obviously, adopted very similar antibiotic approaches to us. That high prevalence of MRSA clearly exposes people who become sick in the community to greater risks than if they get sick in a community with a low prevalence of MRSA. We must take that responsibility seriously and accept we have generated much of this problem ourselves as a community in terms of our demands for the use of and our prescribing of antibiotics.

If one ends up in hospital, it increases one's risk of getting MRSA. We are working with the Health and Safety Authority to reduce that risk. As the Minister pointed out, we can take no solace from the fact our rates are somewhat lower than those in Northern Ireland or in the UK because their rates are extremely high. We really need to focus on bringing our rates down very significantly.

Senator Browne touched on the issue of hospital-acquired infections in general. For example, clostridium and pneumonia are at a high level in hospital systems. Interestingly, they are as high in northern Europe as they are here — they are higher in some northern European countries which are not affected by antibiotic prescribing. The same practices prevail in those countries apart from antibiotic prescribing. These are huge risks that exist in our hospital system. We are trying to focus on dealing with those with which can deal

There are two main issues when dealing with MRSA. The first is the medium- to long-term issue which is the appointment of more pharmacists to control the prescriptions — not only to give out the prescriptions but to control the prescribing of antibiotics in society. We are in the process of recruiting them. That has the potential to have the biggest impact. It will not, however, have an immediate impact. MRSA will not disappear by simply changing prescribing patterns now. That develops over years.

The second issue is basic hygiene, namely, basic hand-washing. While we will continue to focus on the cleanliness of our hospitals, the evidence shows that the cleanliness of the hospital itself will not significantly affect MRSA but that how we wash our hands when moving from patient to patient will do so.

The next issue is how it comes about in our community. I said before there is no doubt that two people shaking hands can spread MRSA. It will affect us if we bring it into a hospital by shaking hands with a patient who is undergoing major surgery. That patient may get MRSA in the hospital or from somebody bringing it into the hospital. These are not simple issues. They are issues in respect of which we must take up the challenge. They will not be solved immediately, nor would I suggest that. We must take our responsibility seriously in terms of issues such as hand-washing, a simple issue. That is where our focus lies.

We have set up a group similar to our winter initiative group which will set hard measurable performance standards across the system to try to reduce MRSA. It will be the first time we have a system in place which is focused on the specific figures. We will not see immediate responses but we will see them over a period of time through the changes in pharmacy. One hopes that we will see some immediate changes through improved hand-washing.

Deputy Connolly

Professor Drumm said MRSA is prevalent in the community. Does the HSE have any plans to screen patients on admission to hospital? Interhospital transfers and nursing home admissions are screened.

Professor Drumm

There is great debate about this internationally. Some hospitals are doing this already. The Deputy and I could be screened for MRSA today. Screening will not necessarily confirm that I have MRSA because one swab on my arm might be positive while another swab on my nose might be negative. How many swabs does one take?

Deputy Connolly

How can one say it is prevalent in the community?

Professor Drumm

We know it is highly prevalent in the community from looking at the swabs we take. We would like to be able to say that by swabbing everybody coming into hospital, we could assure those who do not have a positive swab that they do not have MRSA. The problem is we cannot do that, nor can any system. It is not quite as simple as swabbing everybody who comes into hospital. A person can be in hospital for 12 hours and somebody can come in and give him or her MRSA. I accept that a person may get it from the patient in the next bed or perhaps from someone who came in to visit. It is not as simple as saying that if we swab everybody, we will have the answer. It would be great if it were.

It is the same as rapid diagnostic systems. There are huge arguments about how reliable they are. We need to be very careful about that in terms of making sure what we do is right and accurate. We need to do simple things in regard to MRSA. If everybody in the system — myself included when I was in clinical practice — washed their hands extraordinarily carefully 100% of the time and if we could get all those who prescribe medicines to think very carefully about the prescriptions they write, we would have the biggest impact on MRSA. It is our responsibility to focus on all those issues.

Deputy Twomey

On the question of the Health and Safety Authority and the fact there were 12 major incidents, MRSA is considered to be a bio-hazardous agent and, as Professor Drumm said, it can be spread quite easily. Does Professor Drumm have any idea of the number of frontline staff in our hospitals who have been swabbed for MRSA?

Professor Drumm

No. We have not swabbed staff at large in the hospitals. The Deputy has raised what could be a huge fear. If we swabbed everybody in the system for MRSA, how many staff would immediately be taken out of the system? This has come up in regard to other infections as well.

Deputy Twomey

I have also been made aware that patients known to have MRSA were put into wards with at least four to six beds.

Professor Drumm

That should not happen. Some hospitals are now running MRSA units. That again raises questions about whether one is segregating people and demonising them in ways——

Deputy Twomey

It is not that.

Professor Drumm

We fully accept that what the Deputy said should not happen.

Deputy Twomey

We consider MRSA to be a bio-hazardous agent even under the health and safety legislation, not to mention the health legislation. We are supposed to protect patients if workers might have MRSA. The HSE is not testing the workers. When I was a student in the Meath Hospital, the matron used to swab students, doctors and nurses to identify the levels of MRSA yet 15 years later, we have stopped doing that.

The Minister said a surgeon performing ten breast cancer operations per year should not do so. In some respects, it is a borderline case when somebody is doing 80 or 90 cases, and we think 100 is the optimal target. When someone is doing ten to 20 cases Professor Drumm should issue clear directives that it should stop, not state when he is before the committee that it should stop. There is clearly a problem with someone doing ten cases of breast cancer a year. Such a person should be told to stop. The same goes for any other number of operations. Where someone might be doing 80 or 90 cases and we think 100 is the optimum, I agree we can say we will wait until we get the expert report. When something is clearly not working correctly, we do not need to wait for an expert review group.

As I stated, there is a plan for wild birds and chickens if avian influenza comes into this country, and yet we are operating with MRSA endemic in our communities and hospitals rather than acting like it is an emergency as we should be.

Professor Drumm

I agree with practically everything Deputy Twomey stated. As he knows, these staphylococcus organisms are present on everybody's skin. The question is how many are resistant. It looks like up to 40% of isolates for staff in this country may be multiply resistant. If we are to swab everybody, it certainly would have enormous implications. It goes back to the question of whether that will turn out to have a more deleterious or beneficial effect.

Deputy Twomey

I feel the same. There seems to be much talk about setting up task forces and guidelines, but the HSE is not really doing anything about MRSA. It states that there is over-prescribing, but I have never received a letter and to the best of my knowledge GPs do not get fully focused on the over-prescribing issue

One could probably wipe the top of many of those alcohol plungers in the hospitals and find that they are gathering dust. For instance, has the HSE employed a security guard at the door of every hospital asking people entering to use the alcohol plungers in front of them? These are the sorts of measures which must be taken. There must be a genuine, clear commitment to stop MRSA.

I accept that one cannot swab every person in the hospitals but, for instance, we should swab everybody in the orthopaedic theatre and anybody who is operating where there is poor blood supply to the zone of operations, as is the case with spinal and hip operations, so that we could at least ensure that everybody who is standing around the patient in the operating theatre is MRSA-free.

There is a need for us to stop talking about this and to show that there is a clear commitment to take on MRSA. It is what happened in other jurisdictions. It is not just about hand-washing and over-prescribing. There are issues of capacity. Given that our hospitals are working at 100% capacity, MRSA patients are being put into wards with other patients. There is a need to face up to our responsibilities in this regard and put a stop to it.

Professor Drumm

As I stated earlier, first and foremost, infrastructure is critical but it does not appear overnight. The first point I made was that it is our type, not the amount, of structure that is critical to these infections and that is the number one issue. That will not be resolved. We can deal rapidly with hand-washing and over-prescribing, although the latter will not have as immediate an effect.

Deputy Twomey is correct. We have narrowed our focus. That is why we are imposing performance targets. For instance, he mentioned how much information goes out to GPs. There is now a group in the GP department at UCC which is definitely communicating with GPs and getting out the information on the risks of prescribing. That is not to say that GPs have generated it because many of the antibiotics that have generated this are used specifically for very sick patients within hospitals. Those things are happening.

Nobody can argue with Deputy Twomey's suggestion that this is a significant challenge to the system and we must meet performance indicators that show we are improving, but we must accept that it is not an issue that will go away and vigilance is necessary. Perhaps some of the issues he raises are ones we should adopt. I accept his suggestion that door security makes people wash their hands. That is a good one, in terms of cutting down on MRSA coming from the outside. We must maintain that focus.

Occupational therapy is a significant issue that arises time and again. I will ask Mr. Healy to address that challenging issue.

Mr. Pat Healy

It is recognised that occupational therapy staff, and other multidisciplinary staff such as those in physiotherapy, are needed within the system. Occupational therapists are being employed in all of our development programmes — primary care, the elderly and mental health.

An important element of it in the past identified by the Bacon report was to develop training schools. That has been done and people are graduating from those. As we develop our services and putting additional resources into them, these staff are graduating and will be able to take up the posts.

An indication of the success of that is shown in our employment statistics. By the end of 2004 there were 705 occupational therapists employed while at the end of 2006 there were 928 employed, an increase of 222 or 32%. There is clearly a push to take on more occupational therapists and that will continue.

Professor Drumm

Mr. Healy will also address the issue of the inspectorate for elderly care and the primary care teams.

Mr. Healy

It is not the case that the 87 primary care teams in place have merely been written to. These teams are up and running. All the teams have met. A number of the teams around the country will have met on many occasions at this stage. For example, in my area of Cork city, and in west Cork, teams have been meeting for some time. Teams have been meeting in Clare and in both Dublin north and Dublin south. Obviously some of the teams will be at different stages of development and that was envisaged. Some began earlier than others.

The important point is that the GP response to the initiative was positive. From the outset over 1,000 GPs expressed an interest in participating. Obviously, while there were concerns about that, there has been discussion with both the ICGP and the IMO as well as with other stakeholders over recent months. That has certainly improved the buy-in to that and that was reflected in recent medical news coverage.

On the nursing home inspectorate, the inspections are taking place. We have implemented a national standardised approach to that. While there have been some difficulties which were covered in the media, we within the HSE, in advance of the arrangements being taken up by HIQA later in the year, are advancing the standardised approach with dedicated teams and that is intended to continue until the HIQA takes up responsibility in line with the new legislation.

Professor Drumm

Mr. O'Brien will deal with the CT scanner in Louth, the DEXA scanner and Wexford and Letterkenny hospitals.

Mr. O’Brien

Deputy Twomey will know well that the CT scanner is not a toy which is plugged into a wall and functions on the day it arrives. In my experience, one needs approximately a three-to four-month period to install a CT scanner. This CT scanner was delivered in December last. One cannot even begin construction to install it until one knows which company's device one will take in. This will be installed well within the timeframe appropriate for a CT scanner.

I will check the position on the DEXA scanner in Sligo. I do not know what the issue is.

The Wexford and Letterkenny issues get us back to this position of making global statements about beds and capacity. What we have done in approaching difficulties around emergency departments is to localise to a great degree and focus on what the issues are within the individual hospitals that require to be addressed to enable them meet their requirements for emergency departments and other areas. Wexford and Letterkenny are two of the hospitals which have come out on case mix as being efficient. They are two of the hospitals where we have expanded and are in the process of expanding capacity, and they will be going into position over the coming months

I can probably point to several individual hospitals where over a period of a year cancellations occur and, invariably, where in other instances they do not. The main issue around cancellations is that we treated more elective cases in 2006 than in 2005. That was in circumstances where total attendances at hospitals — in terms of both emergency and elective cases — increased. The numbers attending accident and emergency departments actually increased by 3% to 4%. In the circumstances, hospitals should be applauded for their response. On the basis of the evidence, they managed to absorb and deal with this increase in activity better than in previous years.

Deputy Twomey

That is the point I am trying to make. The hospitals are increasing their level of work. No one enters hospital for the fun of it. There have been increases in both turnover and the type of work being done. This means that hospitals have become more efficient in recent years. However, major difficulties continue to arise in the context of procedures being cancelled regularly, a high number of patients on trolleys and the fact that there are huge numbers of people waiting to see consultants. As a result, we must again consider the issue of capacity. According to Government policy, resolving that issue is dependent on the new private hospitals. Do our guests have any difficulties with the new co-location hospitals? Will the contracts be signed in April and, if so, will this happen in the absence of a new consultant contract?

Mr. O’Brien

The HSE has clearly outlined where it stands on co-location. We have undergone a procurement process in respect of this matter. The device we used for that procurement, competitive dialogue, is novel and was brought into effect largely because the specificity with which one can determine one's requirements at the earliest stages is limited and, therefore, one must engage in dialogue with potential providers to reach the point where everyone is clearly aware of what should go onto the site and the conditions on which this should happen. We set out target dates for accomplishment of the various stages of the process and these really have not changed. If anything, they have kicked back ever so slightly.

Having shortlisted a number of providers for a number of different sites, we are continuing dialogue with them. That dialogue is scheduled to cease in early March, at which point we will finally be in a position to issue an invitation to tender to those remaining companies. The date for receipt of final bids on those tenders, as is now targeted, would be towards the end of March. We should be in a position to make appointments in respect of successful bidders around mid-April. Those dates have not changed since the outset

Deputy Twomey

I am of the opinion that it is inappropriate to proceed with these projects without changing the contract relating to consultants because public and private patients will be penalised. Is the HSE just going to adhere to Government policy and do what it is told? Is it of the view that the projects in question should proceed in the absence of a new consultant contract? If they proceed in the absence of such a contract, we are wasting our time discussing that contract and we will merely perpetuate the existing system to the detriment of all patients.

Mr. O’Brien

I will not comment on the policy issue because it is the Minister's responsibility to do so. The issue is clear in my mind. At present, approximately 2,000 to 2,500 beds in public hospitals are designated private. The purpose of this exercise is to make available 1,000 of those beds to public patients. The actual net increase in stock will be to the public rather than the private sector because the bed numbers in the latter will not increase. Under the exercise in which we are engaged, the number of public beds will increase. If we agree that our health system should be run on a public-private mix basis, the approach we are taking of leveraging the public and private aspects in a way that will contribute better to the system in overall terms would be best delivered in the context of what we are trying to do.

Professor Drumm

The contracts that exist are clear. People who have category 1 contracts work for us. Those with category 2 contracts work for us but they can also work elsewhere, including at co-located sites. That is the contractual system as it exists. That is the way it will remain in the absence of a renegotiated contract.

Deputy Twomey

The point I am making to Professor Drumm and Mr. O'Brien, director of the National Hospitals Office, is that the co-location project will reinforce the status quo. When we discuss changing the consultant contract, we are concerned with extending consultants’ working days and the number of outpatients with which they deal, reducing the numbers of junior doctors by encouraging those who hold senior positions to become consultants. In the absence of a new consultant contract, the policy of co-location could, as already stated, reinforce the status quo vis-à-vis the existing category 1 contract. The first consultant contract was negotiated by Charles Haughey and what is happening now will copperfasten that contract and discourage consultants from changing it. For example, it would make no sense for them to change the contract because they would thereby be prevented from moving between and working in the public and private hospitals at co-located sites. Not only will this lead to the premiums paid by private patients increasing dramatically, it will also have significant effects on patient care.

Professor Drumm

People with category 1 contracts, namely, the majority of consultants on these sites, will not be working at co-located sites.

Deputy Twomey

They will not be working in the new private hospitals.

Professor Drumm

Not under HSE policy.

Deputy Twomey

That is not Government policy.

Professor Drumm

It is.

Deputy Harney

Category 1 doctors cannot work at these facilities under the current contract.

Deputy Twomey

They can do so because the land is only being leased and is, therefore, still technically considered to belong to the HSE.

Deputy Harney

No, that is not the case.

Deputy Twomey

I will wait to see if it proves to be the case.

Professor Drumm

From the HSE's perspective, that is clear.

Deputy Twomey

They are off-site.

Professor Drumm

Yes.

Deputy Twomey

Does the current consultant contract not allow them access to 20% of the beds? Those beds cannot simply be appropriated.

Professor Drumm

There will always be a significant amount of work that must be done in a public hospital in respect of all patients.

Deputy Twomey

I am talking purely about the consultant contract as it exists at present. Professor Drumm is stating that there is no such thing as moving private beds. However, the contracts relating to consultants working in public hospitals stipulate that they have access to 20% of public beds for private practice.

Professor Drumm

HSE policy is that category 1 consultants will work in the public hospital system as they are contracted to do. I do not expect that it will change because the board has adopted a definite view in respect of it.

Deputy Twomey

We will have private hospitals but there will be no question of moving private beds out of public hospitals.

Professor Drumm

Under the new consultant contract that we hope to negotiate, I hope we will reach an agreement that will allow the creation of a system in which people will be able to work in a measured way across the public-private divide. That seems to be the demand that exists in the context of our policy of a mixed system. The HSE board stopped appointing category 2 consultants, which it was perfectly entitled to do because decisions relating to the contract one gets have always rested with the employing authority. It did not break any contractual agreements because it was always within its remit to decide what contract to issue. The HSE simply decided to stop issuing category 2 contracts.

Deputy Twomey

I do not wish to extend the debate on this matter. For the first time, however, I have obtained from our guests some clarity on this matter, in respect of which I have tabled a number of parliamentary questions. Professor Drumm may contradict me if what I say proves to be wrong. In the case of these new private hospitals on the grounds of public hospitals, consultants will work exclusively in those hospitals and will not be permitted to work in the public hospital on the same site. This seems to be the point which Professor Drumm has clarified.

Professor Drumm

There may be people with category 2 contracts which we can do nothing about.

Deputy Twomey

Is it the case that no one appointed in the future can work in both hospitals?

Professor Drumm

On a current contract the HSE is only offering category 1 contracts——

Deputy Twomey

So they cannot work?

Professor Drumm

——which would preclude a person from working elsewhere.

Deputy Twomey

With regard to the consultants working in public hospitals, their contracts clearly state that they are entitled to 20% of the public beds to carry out their private practice. If these new public hospitals are built, the present group of consultants in the system have a contract which states clearly that they are entitled to use those beds for their private practice so those beds will not transfer to the new private hospitals. This is a complete contradiction of what the Government has been telling me in replies to parliamentary questions for the past year. There is no such thing as transferring private beds to the private hospitals. The private beds remain in some respects the property of the consultants under the present contract.

Deputy Harney

I wish to answer. The right to engage in private practice is not a guarantee. What we are seeking to do——

Deputy Twomey

Is the Minister 100% clear on that? What about the contract?

Deputy Harney

——is to have a new contract of employment.

Deputy Twomey

Under the present contract.

Deputy Harney

The present contract does not guarantee access.

Deputy Twomey

Can the Minister take private practice away from those consultants once the public hospital is open?

Deputy Harney

The consultant earns a fee for every patient going into the hospital with private health insurance, with the exception of the accident and emergency department. This could be 50% of the patients.

Deputy Twomey

The hospital gets——

Deputy Harney

No, the doctor gets a fee if the patient has private health insurance. The doctor gets the appropriate fee for treating the patient and this includes pathologists and radiologists.

Deputy Twomey

What will happen when the private hospital is built?

Deputy Harney

That is an unsatisfactory situation because it gives one group——

Deputy Twomey

I know it is unsatisfactory. Reading between the lines, what the Minister is saying publicly is not what is going to happen. Can she take private practice out of the public hospitals?

Deputy Harney

The intention of these new negotiations——

Deputy Twomey

The Minister cannot do it.

Deputy Harney

Of course we can.

Deputy Twomey

Is this what is going to happen? This is the first time in a year that I have asked the Minister questions on this subject. I was always given the impression that the private practice would cease in the public hospitals and that private hospitals would be built on the same grounds.

Deputy Harney

Obviously that will not happen in the case of every hospital in the country as there are eight proposals. The intention is to have a new public hospital contract.

Deputy Twomey

Will these hospitals be built before the contracts have been sorted out? There is something seriously amiss here.

Deputy Harney

The expectation is that the contracts will be sorted out by the end of March and that is the hope.

Deputy Twomey

And if that is not the case?

Deputy Harney

I understand there are three days set aside next week for talks. One would hope, and I remain hopeful, that we can have a new contract of employment agreed in the timeframe that is being suggested. I have said before that Governments can be put together in two weeks and all kinds of things can be done in a couple of weeks——

Deputy Twomey

We have waited three years for this contract.

Deputy Harney

I agree that we have waited a long time. One could say we have waited since 1979 or whenever. One thing is certain: we need a new contract of employment that meets the needs of the public health care system and one that delivers what Professor Drumm and Mr. O'Brien have spoken about: flexibility, 24-hour cover where that is required and a consultant-delivered service.

Deputy Twomey

They are the matters on which I supported the Minister this time last year but nothing has happened in the intervening 12 months.

Deputy Harney

This is what we are hoping to achieve in these negotiations which are resuming next week. The Deputy will know that because the category 2 contract dominated the talks over the past year and a half and led to the collapse of the talks on two occasions. We have not been able to discuss the contract of employment.

Deputy Twomey

There is a fudge. It is quite clear that what I have been led to believe for the past 12 months with regard to private beds in public hospitals is not at all the situation.

Deputy Harney

It is the situation. We have in our public hospitals 2,500 private beds which are 100% funded by the taxpayer. The nurses, diagnostics, administration and management are all paid from the public purse yet insured patients have access to those beds. There may be exceptional situations where they are converted to deal with an emergency situation. This is not a fair situation and it is not in the interests of all patients and neither does it guarantee equity of access to the public hospital facilities. This is what we want to address in the new contract of employment.

Deputy Twomey

Will the Minister address it with this co-location plan? I have serious concerns that she will sign contracts and give away her trump card before these negotiations are completed.

Deputy Harney

I do not accept that.

Deputy Twomey

It might be worse for the taxpayer and the private patient, especially in the long term.

Deputy Harney

The Deputy seems to want us to build private hospitals 15 miles away instead of close by.

Deputy Twomey

I want to see competition and not to give things away.

Deputy Harney

There is no question of giving anything away, as the Deputy knows.

Professor Drumm

I will address Deputy Connolly's questions. He asked about suicide prevention. I will ask Mr. Healy to comment on the Vision for Change programme and the issue of suicide prevention.

Mr. Healy

The national strategy for action on suicide prevention, Reach Out, was published in 2005. This listed 26 action areas and 96 individual actions which were identified. Progress is being made on all these areas. One of the actions was to establish a national office and this has been done. Mr. Geoff Day is heading that office and is leading the progress on these actions.

I wish to refer to a number of specific areas as there is differing progress on each of the 96 actions. Some of the priorities include the provision of €1.5 million last year and an additional €1.85 million this year. One of the critical areas is accident and emergency response to deliberate self harm. The involving of psychiatric nurses in accident and emergency departments to respond to and follow up on deliberate self harm presentations was commenced in 2005 and will be continued in 2006 and prioritised in 2007. There is a need to focus on primary care for those who deliberately self harm and general practitioners are looking for additional support. A pilot initiative is underway in the Cluain Mhuire service in south Dublin where local GPs are becoming involved and are working with the community team. We will learn from this pilot project and hope to progress it elsewhere.

One of the priority areas identified in the report was the national mental health promotion campaign. A tender process has been commenced and this will be concluded shortly. The intention is to engage on a national multimedia campaign to impact in particular on the stigma of mental health and to encourage help-seeking by individuals in the community. This campaign will be initiated and it is in conjunction with our voluntary partners. I hope it will progress significantly in 2007. Many of the other actions will also be progressed but I have referred to the specific actions which I believe are important to highlight.

Deputy Connolly

I know of a programme in the west where people in the community are trained to recognise and to act as advocates for people who might be considering suicide. This seems to be a good plan. Is there any possibility of nationalising that plan?

Mr. Healy

This action is happening in a number of areas. One of the initiatives is to standardise our approach and roll it out across the country.

Deputy Harney

It is not privatised at the moment. Does Deputy Connolly mean whether it is being rolled out nationally? He used the word "nationalising".

Deputy Connolly

Yes.

Deputy Harney

Just in case anyone thought it was privatised.

Deputy Connolly

Anytime a talk is held on suicide awareness in any hotel in the country such as those started in Dromahair, County Leitrim, there is a response because the people want to know about suicide. They feel so helpless after a suicide has occurred. If people were trained, if young people knew they could go to somebody who would listen to them and if they were able to take that first step, it would go a long way towards resolving some of their difficulties.

Deputy O’Connor

I refer to a project called Teen Line in my town, Tallaght. They have been very critical recently of the lack of help. I wish to signal this to the delegation and I hope for a response.

Professor Drumm

Deputy Connolly raised an issue about which I have to hold my hands up, namely, universal newborn hearing screening. There is no doubt we must accept this has not been implemented with the desired speed. This is a HSE issue rather than a Department of Health and Children issue. There is widespread acceptance that children are screened much later for hearing and by a public health nurse who does a distraction test. There is a body of evidence that we would be better off rolling out newborn hearing screening. Earlier this week I received a letter from the National Association for Deaf People again bringing this issue to my attention. It asked us to take a dedicated view of the matter. We need to accept responsibility for the matter and we need to move.

Deputy Connolly

In 2004 the HSE acknowledged the benefits to such screening, which represents fantastic value for money. I ask that it be given serious consideration.

Professor Drumm

It came to the HSE in 2005. However, it would have come from the older system. However, we are not standing here to say the Deputy is wrong. We must accept it is an important issue and one with which we should be dealing. The Deputy's representations today add to that.

Deputy Cooper-Flynn

It is taking place in the hospital I attend. I want to put that on the record. The last time I attended this committee I got a letter from a consultant in Galway complaining and pointing out that both of my children had been screened. It is happening in some hospitals and is continuing.

Professor Drumm

Much of that comes down to a local paediatrician who would have considerable knowledge and might be one of the pioneers promoting it nationally.

Deputy Cooper-Flynn

It is nice to know a consultant took a personal interest in me.

Professor Drumm

He is one of the people who promoted this at national level. It is an issue with which we need to deal.

Mr. O'Brien has been very involved in Monaghan General Hospital and I ask him to speak about it.

Mr. O’Brien

I return to the issues the Deputy raised and the commitments given regarding not reducing services until something better was in position. We have done nothing that has run counter to that. What the Deputy cited is a case in point. The on-call service the Deputy mentioned is still in position and will remain in position until we can produce something that is better. The Deputy knows the process, which was articulated to him and other public representatives at a meeting scheduled with the Minister. It was articulated again at a meeting set up by the Taoiseach with the Monaghan alliance group and that commitment has been given. All that has happened is a change of person but the service is still there and it has not changed.

Deputy Connolly

The general manager made a public statement to local councillors that he would remove emergency medical services by March. To coincide with that there was a consultant contract due for renewal at the end of December. He refused to renew the contract. Part of that was to discontinue the on-call service at Monaghan General Hospital. That raised great concern that services would be removed before better alternative services are introduced.

Mr. O’Brien

I repeat, that issue of the threat to remove on-call services from Monaghan in March was raised at the meeting held with the Minister, who gave a very clear indication. Eilis McGovern, the project director on the implementation of the north-east programme, gave a very clear statement that there was no intention to remove the on-call service from Monaghan in March. It is not the intention that it be removed in March. What we have said to the Deputy holds. The issue regarding the consultant he mentioned is simply a change of person. There has been no discontinuation of service and it continues to be as it is. We have indicated to the Deputy the current position in medicine there. We have indicated to him what interim arrangements will go in position on medicine over a period of approximately two to two and a half years and also the long-term position. This has been articulated to both the group that met the Minister and the alliance group that met under the aegis of the Taoiseach just before Christmas. That is the position and we have not wavered from that.

Deputy Connolly

I know we will not get an all-singing all-dancing hospital in Monaghan as we have been regularly accused of seeking. We want patients whose lives are under threat to be stabilised at Monaghan General Hospital and to have an opportunity to get to a further hospital. We seek reassurances about these kinds of services.

Professor Drumm

Deputy Connolly raised the issue of advanced nurse practitioners. For some reason there is a view, not held in Monaghan, about moving people from what is an advanced nurse practitioner and the tremendous level of skill they can bring as against a junior hospital doctor cohort in training. The accident and emergency unit in Monaghan General Hospital has a superb lady who is a real leader as an advanced nurse practitioner. She needs more people trained and she is very focused on getting that resource there and in other places. We see her as a true leader in that area. Not just in Monaghan but also throughout the country people like her represent the future of driving emergency services of which the Deputy speaks because of the continuity of care they can provide. We are absolutely committed to providing that.

I grew up in a town that was the first to see a county hospital changed dramatically. We all have the fear that the service will be somewhat less. We need to make it clear to people that the service we are trying to put in place will be superior and will be better linked to community services. We can consider the St. Davnet's site, with which the Deputy will be very familiar. Some of the best services in the country exist in Monaghan town, if considered as a health service as a whole. I have quoted several examples in the St. Davnet's site as being exemplars, for example in the area of child services, etc., from which we could learn. Some of the elderly services in places like Oriel House are exemplars. This is what we need to try to do. I accept we need to play our part in reassuring people that is our aim.

Regional centres of excellence have developed. I know these are large centres. If one were to consider the development in Cork and Galway over the past ten years, those centres have come a considerable distance. Historically much of the work they now carry would have come to Dublin. These have developed as huge centres of excellence in many cases with very big international reputations.

We continue to consider the North-South issue. I know Government is interested in it. As the Deputy is probably more aware than any of us there has been a decision for a major hospital development in Enniskillen, which was not ideal from some people's perspectives. It led to an enormous battle between Fermanagh and Tyrone. We are open to consider North-South initiatives. There are some that are operational including ENT services in Donegal with very significant input from the North of Ireland.

On outside hospital managers, while I did not see it, the issue on the "Late Late Show" was relayed to me. However, I did see one of the programmes that was outlined. I had a small smile to myself because everything the man was saying was exactly what I have been saying since I came to the job. He talked about throwing resources at it without resolving the problem. He talked about throwing beds at it without resolving the problem. He spoke about the need for changed practices and processes. I was surprised at the suggestion of Mr. Kenny. I could see why he might suggest that Mr. Robinson should do the job rather than me if he was totally at odds with where I was coming from. I did not hear him say one thing that I have not said constantly and indeed get criticised for in this system.

Deputy Connolly

Why did he get the result and Professor Drumm did not?

Professor Drumm

We have got the result. We have seen several situations, for instance in accident and emergency units, where we have had dramatic results. If I sent anybody from RTE to what by UK standards would be a small hospital with a camera talking to surgeons and asking them whether they would do extra work next and cut down and start taking on extra lists, I have no doubt that any man going in there would get the same result going in under those circumstances. It is not fair to suggest that somebody going in with a BBC camera behind them got the response "Of course I'll do extra work. In fact you're the first man ever to ask me to do it. I was just waiting for someone to come and ask me." It may have some reality.

Mr. O’Brien

The notion of managers coming in from outside was dealt with in the UK health service in the mid-1980s. They came and lasted six months. They could not hack it — they had to go. There is a very short memory span on their part. It is a very difficult form of engagement. I did not see the programme, although my CEO tells me that I should look at it.

Professor Drumm

Mr. O'Brien needs to get himself a television camera so he can go in.

Mr. O’Brien

I know the hospital he was in — we are talking about a very small-scale institution. It is not too difficult to do something like that in such a hospital. It is much more difficult to do it on a broader base.

Deputy Harney

Some people say the Minister for Health and Children should be a doctor — Deputy Twomey would qualify, but not many other Deputies would.

Deputy Connolly

Is the Minister announcing her successor?

Deputy Harney

I do not think so. I believe Deputy Twomey intends to run everything from Hawkins House.

Professor Drumm

I have to defend the HSE. It has delivered a balanced budget and it has exceeded its service plan requirements, on that budget, by several percentage points over the past year. I will move on because there is a little paranoia in that regard. If I have not responded to all the issues raised by Deputy Connolly, I will come back to them if he reminds me of them.

Deputy Connolly

I asked about inappropriate patterns of work. I refer to doing minor and intermediate procedures over five days, for example.

Professor Drumm

That is a good point. Most such procedures are dealt with by means of day surgery. The bulk of our work — the treatment of inguinal hernias, for example — is done in that way. An endless amount of that work can be done in Monaghan General Hospital, for example. A little more difficulty arises when such matters are dealt with over five days because surgeons are needed to cross-cover sites — the question is whether they can do that. The amount of five-day work is minuscule when compared with the amount of day work. The level of day work is growing constantly. The HSE agrees that hospitals should work with such a model.

Deputy Connolly

Should day procedures be taken from regional hospitals and given to hospitals like Monaghan General Hospital, where bed costs are more appropriate?

Professor Drumm

We are doing that already.

Mr. O’Brien

That is where we are heading. Our Lady of Lourdes Hospital in Drogheda, which was mentioned by the Deputy earlier, is extremely busy. Significant issues need to be dealt with if we are to relieve the pressures on the hospital. Work on the physical expansion of the hospital that is needed will start later this year. When the new accident and emergency department is finished, capacity will be freed in other parts of the hospital to give it more flexibility. We are starting to adopt Deputy Connolly's suggestion of moving work that does not need to be done in the main hospitals away from those hospitals. Such work should be done in the hospitals in Monaghan, Navan and Dundalk, for example, and that is the thrust of what we are doing, in effect. The movement between the two types of hospitals is an important issue. Certain types of work need to be taken from the smaller hospitals as well, but that cannot be done until hospitals like those in Drogheda and Cavan are capable of taking that extra work. As those hospitals are unable to take on such work at present, we are talking about putting infrastructure into the larger hospitals over a two-year period. We are concerned about patient health, rather than hospitals. We are looking at the whole package.

Deputy Connolly

Mr. O'Brien spoke about the construction of a new accident and emergency unit in Our Lady of Lourdes Hospital in Drogheda. I understand that a new regional centre of excellence, which will include such a unit, is being developed.

Mr. O’Brien

Absolutely.

Deputy Connolly

Is the HSE building a new accident and emergency department, or is it merely expanding the hospital in Drogheda? Can Mr. O'Brien clarify that?

Mr. O’Brien

I can clarify it very easily. Deputy Connolly mentioned that the hospitals in the north-east — certainly Our Lady of Lourdes Hospital — will not be able to continue to do what they are doing, given that the level of hospital activity is likely to increase rather than decrease. It would not be sustainable or even possible to keep things as they are for the next five years. We have to invest in trying to make the hospital capable and fit for its purpose, which is to deal with the expansion it will face over the coming years.

Chairman

We will try to move on if we can at all. Some people are waiting to get away.

Deputy Connolly

My last point is——

Chairman

I have to try to move on. Can I come back to the Deputy? I want to allow Deputy Cooper-Flynn to get a response. I will come back to Deputy Connolly later so he can ask a final question. I ask the delegation to respond to Deputy Cooper-Flynn's questions. She is anxious to go to another meeting.

Deputy Cooper-Flynn

We have all been here a long time. It is not fair that some people get all their questions answered, and can then depart. If Professor Drumm and I are here at the end, perhaps we can resolve the nurses' dispute. Maybe everyone else should go so we can do that.

Chairman

There is no other system I can use. People come and go, unfortunately. There is nothing I can do about it.

Deputy Cooper-Flynn

I do not want to labour the point, but the same pattern is evident every time. Deputy Connolly and I are both Independents, but I am always called to ask questions after him. Perhaps the Chair will bear that in mind for future reference.

Deputy Connolly

We are different.

Chairman

That is not the way——

Deputy Cooper-Flynn

Are there different types of Independents?

Chairman

Not at all. We are all members of the Joint Committee on Health and Children.

Deputy O’Connor

I have to speak in——

Deputy Harney

Deputy Connolly has to ask about Monaghan General Hospital. He was elected on that basis.

Deputy Connolly

Absolutely. I hope to be re-elected on that basis.

Deputy Cooper-Flynn

I was elected as a multi-issue candidate.

Deputy O’Connor

I also have a re-election agenda.

Chairman

We should not mention politics. This is totally above politics.

Deputy O’Connor

I just want to say that I have to speak in the Dáil.

Deputy Harney

Elections are not compatible with reforming the health system — that is for sure.

Deputy O’Connor

If I miss the section of the meeting in which my issues are dealt with, perhaps someone will write me a nice big long letter to reassure me about them.

Chairman

Fine.

Deputy Harney

I think we responded to the issues Deputy O'Connor raised about the hospital.

Deputy O’Connor

Professor Drumm has yet to reassure me about some issues. I ask him to look after Deputy Cooper-Flynn first.

Deputy Cooper-Flynn

I thank the Deputy.

Professor Drumm

The Minister has dealt with many aspects of the pay claim about which Deputy Cooper-Flynn asked. As one of the biggest employers in the State, the HSE has to work within the infrastructure for making decisions on public service pay, such as the benchmarking process and the Labour Court. The HSE cannot undermine institutions like the Labour Court, which has heard the claims and made recommendations. It is not within the remit of the HSE to work outside those structures, so it would not choose to do that. While I do not want to be in conflict with our 35,000 nurses, who clearly represent a hugely important part of our system, we have to manage the organisation in a manner that is consistent with public policy, as outlined in the rules and regulations of the State. I have outlined the current position and how we intend to proceed. The HSE has to be consistent in how it deals with the many people, including nurses, who work for it. That is how we are dealing with it.

Deputy Cooper-Flynn

I could accept that if it were not for the precedent that was established when benchmarking was set aside in 12 separate and identifiable cases. The nurses' claims cannot be dealt with fully under the benchmarking process. The Minister and the Labour Court have acknowledged that two issues — the 39-hour working week and the child care pay discrepancy — need to be dealt with. The Labour Court said 26 years ago that the 39-hour working week is too long. This committee has spent ages talking about the contracts of consultants and other people in the health service who seem to be seen as more important than the nurses, who have worked the system as best they can. Although nurses constitute the biggest group of people in the health service, the exceptions that have been made in other cases do not seem to apply to them.

Professor Drumm

Yes. The Labour Court was presumably established to cater for everybody. It is not within my remit to decide to ignore the Labour Court. The HSE will work within the recommendations it has been given by the court. I do not see how the HSE can go beyond that.

Deputy Cooper-Flynn

Would any decision to set benchmarking aside have to be made by the Minister?

Professor Drumm

Absolutely. The HSE, which is a huge organisation with many employees, could not make such a decision — it is not empowered to do so — because it would have a potentially huge effect on that wider group of employees, as well as on the specific group in question. I ask Mr. Healy to comment on the enhanced subvention in the HSE western area, which Deputy Cooper-Flynn has asked about previously.

Mr. Healy

I will put it in the context of the Minister's remarks in her opening statement about the new nursing home scheme that was to be introduced in 2008. Additional resources were specifically provided in 2007 to do two things — to provide for the €300 standard cost and for enhanced subvention, both of which are now being implemented. We have issued a standardised set of national guidelines to ensure consistency, which perhaps was not evident in the past. We are also trying to work towards greater equalisation of the level of support for people in those parts of the country where differing levels of nursing home prices are charged with some of the allocation provided by the Minister. In Deputy Cooper-Flynn's area, from the work we have done, the allocation of €300 will result in a significant improvement, given the cost of private nursing home care in the area. In the guidelines we make provision for an enhanced subvention to be provided where appropriate. There is plenty of scope for individual cases to be looked at, if necessary. The east of the country deserves greater priority for an enhanced subvention owing to the far higher cost of nursing home care, but there is provision for a standardised approach across the country. The new guidelines provide for an enhanced subvention to be considered in individual cases.

Deputy Cooper-Flynn

That worries me. I was afraid that would be the response. There is no great difference in setting the base subvention at €190 and then providing for an enhanced subvention but still leaving us with a figure of roughly €300 in the west and €700 in the east and then changing it to have the base subvention at €300. That means the figure is still €700 in the east and only €300 in the west. It is all the same to the person placing a relative in a nursing home. Nursing homes in the west have been told there will be no enhanced subvention available. I have a copy of the guidelines and accept that provision is made for them but the bottom line is that people will not receive an enhanced subvention. Is Mr. Healy saying the difference in cost in the east and west is €400 per week?

Mr. Healy

The key factor is not the enhanced subvention, but the level of support required by an individual in order to pay for nursing home care. What we are trying to do is ensure standardisation in so far as we can across the country in the current year. Obviously, we cannot achieve this fully in the current year but with the resources we are providing there will be a significant improvement. In the west, given the average nursing home price in each of the local health offices and with the provision of a base figure of €300, the situation will improve significantly. The issue of an enhanced subvention will only come into play in those cases where there are exceptional circumstances. Provision is made in the system to allow for this. As we roll this measure out across the system, it is our intention to monitor it on a quarterly basis. We regularly meet representatives from all the nursing home units and if adjustments have to be made, we will take account of this.

Deputy Cooper-Flynn

I appreciate what Mr. Healy is saying. There has been a significant improvement in the HSE's approach since our last discussion but I still do not accept the difference is €400. The base subvention should have been set at €400. The cost of private nursing home care in my area is still €650 or €675 per week. A base subvention of €300 plus the pension payment still leaves a significant shortfall to be made up by families.

Mr. Healy

I can talk to the Deputy separately on this matter. Many of the prices payable in the west are lower than the figures outlined by her. However, I accept there are differences. The initiative taken by the Minister is targeted at supporting individuals and their families. We do not want to bring about a situation that would lead to an increase in nursing home prices.

Deputy Cooper-Flynn

I accept that point.

Mr. Healy

A balance must be struck. We are trying to introduce the measure in a sensitive way but which also meets the needs of individuals. We provide sufficient scope within the guidelines and regulations to take account of difficult individual circumstances. We will monitor the situation and if the measure is not working well, we will take account of this.

Deputy Cooper-Flynn

There is no policy decision that an enhanced subvention will not be paid.

Mr. Healy

No, absolutely not.

Professor Drumm

Not only have I been to Castlebar General Hospital but Mr. O'Brien was also there in the not too distant past. Clearly, we are experiencing problems there. Following our visits there in recent days, we will be providing for an intense evaluation in terms of an outside review of what needs to change to deliver a much better service. Let us be clear: I visited the surgical services which I suggest are among the best in the country. Waiting times for controversial treatments such as an endoscopy and colonoscopy are down to practically zero. This is an example of leadership driving a hugely performing service where everybody working in the day unit such as nurses, etc., is being superbly innovative. We need to deal with the areas that are not working but I would prefer not to go into the detail today. However, I will be happy to discuss them off the record. In the coming weeks we will get people from the places where the services function well to work with people in Castlebar to achieve the excellence across the board one currently experiences in only a couple of areas.

Deputy Cooper-Flynn

Will the people concerned come from outside Castlebar but from within the health service?

Professor Drumm

From within the health service, including one person who has come from the United Kingdom to help us with this issue. A number will come from within our own system. We will use the people in Castlebar to spread what is a superb example of best practice. However, we need to extend this approach more widely within the hospital in Castlebar. One could make a fascinating DVD to show how leadership can drive superb performance and, equally, how its absence affects performance. I would be happy to talk to the Deputy later about this if she has a few minutes.

Deputy Cooper-Flynn

Sure.

Professor Drumm

I was in the Sacred Heart Hospital in Ballinrobe where, as the Deputy is aware, beds are being closed. It is a remarkable example of a building built in the 1970s where there is subsidence. There is a stark contrast between the superb mental health facility which has probably been in place for 200 years and a building which is 30 or 40 years old where the floors are subsiding. That is one of the challenges with which we are faced. It raised for me a question with national implications, whether we should continue with 150 bed units taking people in from distant communities or have smaller more localised units. When I was in Cork the other day I came across a 50 bed unit that keeps people in their own community. The unit in Ballinrobe is probably another example. Does Mr. Healy know if we have any information on it?

Mr. Healy

The proposal is for a 40 bed unit. The land is provided and provision is made for it in the HSE capital plan 2007-11. It has been prioritised. Work will go ahead in terms of choosing a project team, etc. for planning but priority this year was given to St. Patrick's Ward in the Sacred Heart Hospital and Swinford Community Hospital where development work is also needed. Health centres in Ballycastle and Newport are also included in the capital development works that will go ahead this year. Planning will continue in Ballinrobe.

Deputy Cooper-Flynn

Does the HSE have any interest in a sale and lease-back arrangement?

Mr. Healy

Currently, no decision has been made on the detail of how it intends to progress the project. I am not sure whether it has reached that stage or whether a sale and lease-back arrangement was on the cards. That is something which may emerge for consideration when the development stage is reached.

Deputy Cooper-Flynn

Therefore, nothing is planned for this year.

Mr. Healy

Not in that regard, but it will be considered in the planning phase this year and into the beginning of next year. The key factor from the Deputy's perspective is that the project has been prioritised.

Deputy Cooper-Flynn

Will any money be allocated this year?

Mr. Healy

Not this year.

Professor Drumm

On the dissenting voice in orthodontics, from my reading of the matter, it came down to one issue——

Deputy Cooper-Flynn

A relationship issue.

Professor Drumm

Yes. I do not know if anybody expressed a dissenting opinion in writing.

Deputy Cooper-Flynn

They did.

Professor Drumm

Somebody dissented from——

Deputy Cooper-Flynn

No. There is a written opinion approximately 13 pages long.

Professor Drumm

I have not read it.

Deputy Cooper-Flynn

It is unusual that it was not included as part of the report. Any time people have come before the committee and dissented, for example, there was dissension on the issue of assisted human reproduction, it has always been included in the appendices.

Professor Drumm

I do not know. Perhaps issues were raised in which people were named. If an individual was named, it would probably preclude it being included.

Deputy Cooper-Flynn

I do not think there was.

Professor Drumm

In those circumstances I do not see any reason we would not be happy to have it included in the published report.

Deputy Cooper-Flynn

Is it not interesting that it came before the management executive of the HSE which accepted the report but Professor Drumm does not even know there was a dissenting opinion? Would that not worry him?

Professor Drumm

I knew there was a dissenting opinion. I was clear on that point but I was not aware there was a dissenting opinion in writing. It is an ongoing, drawn-out issue and we need to find out whether it can be resolved by mediation. This was a proposal and I was quite aware there was a dissenting opinion.

Deputy Cooper-Flynn

I suspect we will return to that issue on another day.

Mr. O’Brien

The national prosthesis service is delivered through the National Rehabilitation Hospital in Dún Laoghaire and it is run in conjunction with a private company called Opcare, which has approximately 17 clinics located across the country. I could not list these locations off the top of my head. The system is such that if somebody has lost a limb, through vascular disease, cancer, trauma or another condition with the exception of those requiring maxillofacial surgery, he or she is referred to the prosthesis service in the National Rehabilitation Hospital. Over six weeks, he or she meets a full team of consultants, physiotherapists, occupational therapists, chiropodists and psychologists. The patient's needs are established and he or she is then sent back to local clinics for reappointments and refitting when necessary.

In the case of maxillofacial surgery, which concerns pieces of jaws and teeth in need of replacement, prosthesis is carried out mainly at the laboratory in St. James's Hospital. It does most of this work and is assisted from outside.

Deputy Cooper-Flynn

Is the clinical work contracted to Opcare?

Mr. O’Brien

Yes.

Deputy Cooper-Flynn

It fits the prosthetics. Is there any reason for contracting rather than employing people directly within the health service?

Mr. O’Brien

Opcare has been operating in various guises within the health system since 1929. This is a long period and there is concern because the company is the only provider of the service.

Deputy Cooper-Flynn

A person who operated for a private company in the United Kingdom, but who is now working with the NHS, contacted me on this matter. I was informed that when the contracts were abolished and staff were employed directly a saving of 30% accrued.

Mr. O’Brien

That is being considered at present. There is only one company involved in Ireland. However, in the case of maxillofacial surgery there is a mix in that quite a few people are hired directly to create the prosthesis.

Deputy Cooper-Flynn

I may speak to Mr. O'Brien later to obtain further information.

Professor Drumm

Senator Henry raised the issue of the cancer strategy.

Chairman

She also referred to the maxillofacial unit at St. James's Hospital.

Mr. O’Brien

We have a €20 million allocation this year for advancing the cancer control programme. Some €8 million will be dedicated to advancing the screening services of BreastCheck and €5 million to cervical screening services. There will be a considerable focus on radiation therapy, to which €3.25 million will be dedicated. Six new consultants and seven specialist registrars are to be recruited. There is to be a training programme for physics in that area, which will be needed as the radiation therapy programme is expanded.

A major component will be the establishment of cancer services within the health service in a programmatic form. This means that, over the course of this year, we will appoint a director of cancer services who will take charge of cancer services nationally. The fundamental idea is that cancer services have tended to develop disproportionately under the aegis of health boards in geographical areas. There is not an equitable position on cancer across the country in any sense and the purpose of employing a director is to have him or her take charge of the resource or service and ensure development is equitable and structured.

We have accepted assistance from the British Columbian Cancer Agency, based in Vancouver. The programme will proceed very quickly over the course of the rest of the year.

Deputy Connolly

It is regularly reported of the north east that it has the highest patient admission rate per 1,000 members of the population. The delegates referred to 5.9 admissions per 1,000 and this raises a couple of issues. In the past, the health board for the region was traditionally the most underfunded in the country, yet the region has the fastest-growing population. Is the high admission rate because patients are being held longer for appendectomies or other procedures? What is the root cause?

Professor Drumm

The average length of stay for procedures such as appendectomies varies greatly across the country. There are hospitals in which practically every patient must stay overnight, in which hospitals they may have cataracts treated, and there are others where nobody needs to stay overnight. The length of stay for an appendectomy can vary from close to six days to above three days. This is a problem in the north east but it is also a problem elsewhere.

Deputy Twomey raised this issue already. It is not just a case of patients remaining in hospital who should go to long-stay facilities. There are significant variations in how long one spends in hospital for acute conditions. There are certainly enormous differences in the numbers admitted through accident and emergency departments depending on one's location. We must now deal with these issues and in this regard we are introducing our own performance measures. The first set of these measures will go live in the coming weeks and will begin to identify the very major differences in different parts of the system.

The same applies to attendance. Attendance at accident and emergency units in the north west is the lowest in the country because the two units are 70 miles apart. Attendance at accident and emergency units in the midlands is much higher because there are three accident and emergency units relatively close to one another, in Mullingar, Tullamore and Portlaoise. We must accept the regional factors and begin to shine a light on them.

Deputy Connolly

How serious is the problem in hospitals? Health insurance covers inpatients in hospitals. Technically, patients who are admitted the night before treatment are such. Is this a major issue? If a member of the public wants to get a CAT scan done independently, he or she cannot have it done quickly, but if a doctor admits that person to hospital he or she can have it done much faster.

Mr. O’Brien

It can be done outside hospitals; that is not an issue. Those who want the scan privately must pay for it if they are outpatients but do not pay if they are inpatients. Thus, behaviour affects incidence and I therefore do not believe the phenomenon is as prevalent as is sometimes suggested. I do not know the answer to the question and part of what we are doing is examining the matter.

Two broad factors affect the length of stay, namely, internal practice and external capability of handing. The latter covers factors preventing the patient entering hospital and the ability to receive the patient as he or she leaves the hospital.

Circumstances are not the same in every institution or every area because there is variability within institutions and in support services for patients outside hospitals. This is why the problem can only be tackled by examining individual institutions, which is exactly what we are doing.

When we spoke about the length of stay in the north east, Professor Drumm mentioned that the dependency study contained evidence that up to 50% of patients did not need to be in hospital on a particular day. The real question is to understand why this is so and address it; it is not a question of blaming the hospital. Different hospitals in the north east will have different lengths of stay. The rate pertaining to Our Lady of Lourdes Hospital is nowhere as high as in other hospitals in the region.

Professor Drumm

Even within one hospital.

Deputy Cooper-Flynn

Last year I was told a rheumatology consultant was included in the budget for Mayo General Hospital for this year. Then I got a letter telling me that we were fourth in line and that we had our wires crossed. When will the consultant be appointed?

Mr. O’Brien

We responded to the Deputy on that issue. The issue for us in the current year is that we are implementing one of five Comhairle na nOspidéal reports that covers rheumatology. We can only work our way through these on the basis of revenue as it becomes available to us.

Deputy Cooper-Flynn

It is unfortunate because I welcomed the announcement that the budget would cover it. Then I had to backtrack because I got a letter saying we were fourth in line in the national context.

Chairman

Could Mr. O'Brien outline the situation regarding the maxillafacial surgery unit at St. James's Hospital?

Mr. O’Brien

There are a number of issues related to maxillafacial surgery and I am not sure which the Senator wanted addressed. There was a change of personnel — three surgeons were working in the unit but one retired and the hospital is in the process of replacing the consultant at this stage.

A difficulty that was alluded to was the programme for children with orthodontic issues, which has been running for some time. The procedure is lengthy and involves orthodontists outside the hospital, then those inside the hospital and eventually surgery. The Senator referred to this obliquely.

St. James's Hospital has done a lot of work with Crumlin hospital to work through the issue and get access for a maxillafacial surgeon in Crumlin hospital. The post that was vacated is to be replaced with a different structure. Previously it was structured between St. James's Hospital and St. Vincent's Hospital. It will now be between St. James's Hospital and Crumlin hospital, which will allow the service to run more smoothly.

Chairman

I thank the Minister, her officials, Professor Drumm and his officials for giving us four and half hours to ask questions. I do not know if we will have the Minister back before the election or after it.

Deputy Harney

I would prefer to come back after the election, we might have a more rational debate.

Deputy Connolly

The Minister will be back asking Deputy Twomey questions.

Deputy Harney

I look forward to coming back in the same capacity.

Chairman

Two issues were raised at the committee some time ago. First, could screening and vaccination be carried out on the medical card? Second, what is the Department's position on the substitution of branded epilepsy drugs with generic drugs?

Professor Drumm

The cervical programme is being developed alongside BreastCheck and is progressing.

Deputy Harney

A story was published two days ago that we had decided not to provide for the vaccine on the medical card. That is not correct, our immunisation programmes are not done through the medical card but on a whole population basis. The national experts are examining this and I would be confident we will be introducing the vaccine.

We must decide the age group for vaccination, if it should be 12 and 13 year old girls, and if we should do it through schools, rather than inviting people to come to their GP, where there might be higher penetration. These issues are being examined in conjunction with the roll-out of cervical screening. I appointed a national screening board some weeks ago to look at cervical screening and BreastCheck to bring both together.

To the best of my knowledge only two or three countries, one of which is Austria, have introduced the vaccine through their insurance scheme. The French are about to introduce it and one or two others have made that decision. I am confident that we will make the decision although it has not happened yet. It is down to the technical issues of how it is done.

Dr. Philip Crowley

On the generic substitution for epilepsy drugs, when monitoring epilepsy, the blood levels of medications are monitored to ensure they are adequate to give maximum control against fitting. The Irish Medicines Board allows generic substitution around plus or minus 20% difference in circulating blood levels for many medications and there are disputes over the acceptability of that in the management of epilepsy particularly. I do not think there is any widespread practice in the community where people are substituting one medication for another. If someone is well in control under medication, it would not be substituted.

Chairman

Muscular Dystrophy Ireland asked a question about funding for research to identify people with MD and to develop the services available for them. This question is on the list we have given to Professor Drumm so we will get a written answer to it.

Professor Drumm

Funding research is not an issue for the HSE, it an issue for the Health Research Board. We could, however, make an application because there are significant funds. I do not know the Department's view of the matter.

Chairman

I thank the witnesses for their time.

The joint committee adjourned at 2.10 p.m. until 9.30 a.m. on Thursday, 1 March 2007.