Seanad Éireann debate -
Wednesday, 31 May 2000

Vol. 163 No. 12

Health (Miscellaneous Provisions) (No. 2) Bill, 2000: Second Stage.

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

Minister for Health and Children (Mr. Martin)

The Health (Miscellaneous Provisions) Bill will amend the Health Act, 1970, the Tobacco (Health Promotion and Protection) Act, 1988 and the Health (Nursing Homes) Act, 1990. In brief, this composite Bill sets out the Government's proposals to improve and update the statutory basis for the supply of drugs, medicines and medical and surgical appliances under the general medical services and community drugs schemes; to raise the age at which tobacco products can be sold to young persons from the present age of 16 years to 18 years and to raise the maximum fine on persons convicted for selling tobacco products to under age persons from £500 to £1,500; to empower the Minister for Health and Children to prescribe any necessary administrative and technical details to facilitate the efficient administration of the scheme for the payment of subvention in respect of patients in nursing homes and also to empower the Minister to make regulations governing standards in private convalescent homes under the Health (Nursing Homes) Act, 1990.

For reasons of clarity, as this is a composite Bill, I propose to speak about each of the three distinct elements of the Bill and then to outline the detailed contents of the Bill as a whole.

My purpose in amending section 59 of the Health Act, 1970, is threefold. In essence, section 59 is the statutory basis for the supply of drugs, medicines and medical and surgical appliances under the general medical services and the community drugs schemes, the schemes which allow the reimbursement by the State of medicines taken by patients in the community. As the legislation is 30 years old and the increasingly complex pharmaceutical issues facing us in this millennium could not have been foreseen when the Health Act, 1970, was drafted, it has been necessary to review the legislation with a view to improving and updating the regulation of the supply of drugs, medicines and medical and surgical appliances under the general medical services and community drugs schemes, promoting an equitable and more accountable service in this regard and making better provision for the delivery of community pharmacy services.

Under present arrangements, drugs, medicines and medical and surgical appliances are provided without charge to persons with full eligibility, that is, medical card holders, in line with criteria for reimbursement. Traditionally, these items are supplied through community pharmacies or, in cases where there is no local pharmacy, by the patient's general practitioner who in these circumstances is known colloquially as a dispensing doctor.

The position with regard to the provision of drugs, medicines and medical and surgical appliances for persons with limited eligibility – non-medical card holders – is that community drugs schemes have been in operation over the years whereby the State meets a proportion of the cost of prescribed products. Under the current scheme, the drug payment scheme, an individual or family pays the first £42 in respect of expenditure on approved prescribed drugs, medicines and medical and surgical appliances and the balance of the cost is met by the State.

A third arrangement, known as the long-term illness scheme, is in place for persons suffering from a prescribed disease or disability of a permanent or long-term nature whereby drugs are made available without charge in respect of the treatment of the primary condition.

The provisions of the Bill will continue present arrangements and, as in the current situation, drugs will be supplied without charge to persons with full eligibility and expenditure incurred by persons with limited eligibility in respect of themselves or their dependants will be recouped in part, as prescribed by regulation. Broadly speaking, "dependants" is defined as spouse, children under the age of 18 years or under 23 years if in full-time education, or children of any age with a mental or physical disability to the extent that it is not reasonably possible for the child to maintain himself or herself fully and who are living at home. The crucial or pivotal point with regard to a scheme such as the drug payment scheme, as is borne out by the definition of dependants, is that it is not means tested and is open to everyone. The Bill also continues to provide for the long-term illness scheme.

My concerns are to ensure that arrangements for the supply of drugs, medicines and medical and surgical appliances in the community are equitable, all arrangements meet accountability requirements and the service to patients is a quality service. Section 59 of the Health Act, 1970, does not facilitate a clear and transparent approach to reimbursement, does not explicitly provide for accountability and is not adequately structured to promote a quality driven community pharmacy service. In other words, time and expectations have moved on but the legislation underpinning the supply of drugs, medicines and medical and surgical appliances has not. Steps must therefore be taken to bring the legislation into line with current demands and requirements.

The Bill provides for the making of regulations concerning the granting of approval of drugs, medicines and medical and surgical appliances for reimbursement purposes and the withdrawal of this approval for stated reasons. This will ensure an equitable, transparent and coherent approach to reimbursement. As I mentioned earlier, section 59 of the Health Act, 1970, is concerned with the supply of drugs, medicines and medical and surgical appliances in the community. The Bill therefore provides for the supply of reimbursable products through community pharmacies as the most appropriate dispensing arrangement in most instances for medicines taken in the community. This reflects current practice and policy regarding the provision of community pharmaceutical care in line with the contractor agreement for the provision of community pharmacy services under the Health Act, 1970, which was introduced in 1996 and which is pro-active in promoting a quality driven service to the patient.

I have no doubt that the service to patients has been enhanced as a result of the new contractor agreement which imposes obligations not in place before. A central and innovative element of the contractor agreement is a clause providing for a review by the pharmacist of the medicine therapy of the patient, including screening for any potential drug therapy problems, therapeutic duplication, drug to drug interactions, incorrect drug dosage or duration of drug treatment, drug allergy interactions and clinical abuse or misuse. The review also includes an examination of the rational and cost effective use of the medicine prescribed, including the choice of medicines and the potential for wastage. In addition, the contractor agreement is designed to improve the quality of services by encouraging greater investment in the pharmacy and facilitating the involvement of a greater number of pharmacists in a given pharmacy.

In this context, the Bill makes specific provision for the making of regulations in regard to agreements between the proprietor of a community pharmacy and a health board pursuant to which community pharmacies supply drugs and medicines and medical and surgical appliances under the general medical services and community drugs schemes designed to foster the best possible community pharmacy service. However, the Bill also takes account of the fact that, in the absence of a community pharmacy service, some medical card patients in remote areas will rely on their general practitioners, dispensing doctors, for the supply of medicines.

In addition, the provisions of the Bill acknowledge the dramatic pharmaceutical advancements which have taken place in recent years and which are likely to continue, perhaps at an even faster pace. In some circumstances, it may be appropriate for patient safety and monitoring purposes for certain sophisticated drugs to be dispensed in a hospital or clinic setting on an out-patient basis. The Bill, therefore, provides for the reimbursement of products provided by an institution that provides a specialist service under the direct supervision of a medical consultant, where approved by the Minister in accordance with regulations.

In terms of supply and value for money, and in some cases patient convenience, it is recognised that community pharmacies may not be the most appropiate source of some non-drug items and that expertise in this area may lie elsewhere. On this basis, the Bill will also allow the reimbursement of some non-drug items supplied through other outlets approved by the Minister in accordance with regulations.

From the point of view of value for money and accountability, the Bill will empower the Minister to make regulations to provide for the manner in which payments to community pharmacists and others who supply items under section 59 of the Health Act, 1970, are made by the relevant State agencies with responsibility in this matter and for the furnishing of information on items supplied, services provided and the costs involved. Regulations may also be made for the furnishing of information the relevant State agencies may require by suppliers of drugs, medicines and medical and surgical appliances to those dispensing these products. The Bill, therefore, provides a good legislative basis for verification of claims on the State by those supplying products reimbursable by the State.

I will return to the amendment of section 59 of the Health Act, 1970, when outlining the contents of the Bill but I now move on to the amendment of the Health (Promotion and Protection) Act, 1988.

I regard the battle against smoking as one of the most important public health challenges facing us in the new millennium and this area is one of my main priorities as Minster for Health and Children. The adverse impact of tobacco consumption on public health is enormous. Smoking-related illnesses account for about 7,000 deaths each year in Ireland. Within the European Union the tobacco epidemic is killing over half a million citizens each year.

Work is under way in my Department to prepare a new comprehensive tobacco Bill which will take on board a range of issues relating to tobacco and health. I hope to have this Bill ready for the autumn session. I am particularly concerned by the reported increase in the level of smoking among children and teenagers. One of the most disturbing facts about smoking is that for the vast majority of smokers the addiction begins in their childhood or teenage years. The tobacco industry has targeted children in their marketing campaigns and has sought to get them hooked at an early age. The sale of tobacco products to children and under age persons in particular is a most reprehensible practice and is one that has to be tackled aggressively.

The report, Towards a Tobacco Free Society, launched by me on 7 March this year recommends, among other things, raising the age limit at which tobacco products can be sold to young persons to 18 years, as does the report of the Joint Committee on Health and Children on smoking and health, published in November 1999.

The proposed amendment to the Tobacco (Health Promotion and Protection) Act, 1988, before the House today will have the effect of raising the age at which tobacco products can be sold to young persons from 16 to 18 years and will raise the maximum fine on persons convicted of selling to under age persons from £500 to £1,500. The increase in the maximum fine to £1,500 is the highest amount that can be included in this type of amendment and will act as a further deterrent to retailers. I take this measure on legal advice.

Section 3 of the Bill amends the Health (Nursing Homes) Act, 1990. This Act, which came into effect on 1 September, 1993 has two principal objectives. The first is to ensure high standards of accommodation and care in all nursing homes registered under the Act and the second is to provide a system of subventions for dependent persons in need of nursing home care.

With regard to subventions, section 7(2) of the Act provides that the Minister may by regulations prescribe the amounts of subvention that may be paid, and such amounts may be specified by reference to specified degrees of dependency, specified means or circumstances of dependent per sons or such other matters as the Minister considers appropriate.

The rates of subvention were duly specified in the Nursing Homes (Subvention) Regulations, 1993 (S.I. No. 227 of 1993). In order to facilitate the operation of the subvention scheme, provisions relating to the administration of the scheme are required. These provisions would cover areas such as making of applications for subvention; onus on the applicant to furnish infomation; assessment of degree of dependency; assessment of means and circumstances; calculation of amounts payable; notification of decision on applicants; review of subventions decision; death or discharge of patient; services to be covered by subvention; appeals against decisions; and recoupment of subventions.

It is proposed, therefore, to amend section 7(2) to provide the powers to prescribe any necessary administrative and technical details. In addition, a further amendment of the Act is required to take account of the introduction by the Minister for Finance of a scheme of tax allowances in respect of capital expenditure on private convalescent homes in the Finance Act, 1999. The allowances apply to expenditure incurred on or after 2 December 1998 on the construction, extension or refurbishment of a convalescent home as well as the conversion of an existing building into a convalescent home. To ensure that the standard of care in convalescent homes is satisfactory, it is proposed that such homes be required to be registered under the Health (Nursing Homes) Act, 1990.

Regulations have been made under section 6 of the Act for the purpose of ensuring proper standards in nursing homes. It will be necessary to make similar regulations governing standards in convalescent homes, which may include provisions requiring convalescent homes to have adequate medical, nursing and para-medical staff and facilities, consistent with the patient profile of the home. I propose to amend section 6 of the Act to give ministerial power to prescribe different requirements for such homes.

I will now outline some of the contents of the Bill. Section 1 amends section 59 of the Health Act, 1970, by the substitution of a new section for the existing section. Section 1(1), (2) and (3) provides for the supply of approved, prescribed drugs, medicines and medical and surgical appliances to people with full eligibility and people with limited eligibility and their dependants.

Section 1(4) provides for the supply of approved, prescribed medicines to medical card holders by dispensing doctors and also for the supply of non-drug items to people with full eligibility and limited eligibility by other persons as approved by the Minister. Section 1(5) provides for the supply of approved, prescribed drugs by an institution that provides a specialist service under the direct supervision of a medical consultant and stands approved by the Minister. Section 1(6) provides for the making of regulations specifying the terms and conditions upon which and the extent to which health boards may defray the cost of supplying a particular drug or drugs or drugs for the treatment of a particular condition or conditions.

Section 1(7) provides for the granting of an approval by the Minister for the purposes of the previous subsections and for the withdrawal of an approval for stated reasons and in accordance with regulations. Section 1(8) is a standard provision to the effect that the Minister may make regulations for the purposes of this section.

Section 1(9) provides that regulations may provide for the manner in which payments may be made in respect of drugs supplied by community pharmacies and persons referred to in section 1(4) and (5) and in respect of fees for services. The regulations may also provide for the furnishing of information required on drugs supplied and services provided and for the refusal of payment if a request for information is not complied with.

Section 1(10) provides for regulations in relation to agreements between the proprietors of pharmacies and health boards pursuant to which community pharmacies supply drugs for the purpose of this section. Section 1(11) provides that where a supplier of drugs to community pharmacies fails or refuses to comply with a request under regulations, the supplier shall be guilty of an offence and liable to summary conviction to a fine not exceeding £1,500. Section 1(12)(1) is a standard subsection defining words or phrases in the section. Section 1(12)(2) is a standard provision for regulations made under section 59 of the Health Act, 1970.

Section 2 amends the Tobacco (Health Promotion and Protection) Act, 1988, by substituting a new section for section 3 of that Act to raise the age at which tobacco products can be sold to young persons from the present age of 16 years to 18 years and to raise the maximum fine on persons convicted for selling tobacco products to under age persons from £500 to £1,500. It also provides that it shall be a defence for a person who is prosecuted for an offence under this section to establish that he or she had taken all reasonable steps to assure himself or herself that the person to whom the tobacco products were sold, offered for sale or made available had attained the age of 18 years.

Section 3 amends the Health (Nursing Homes) Act, 1990, by the insertion of a new subsection after subsection (6) of the Health (Nursing Homes) Act, 1990, to provide for regulations to make different provision for different classes of nursing homes and prescribe different requirements for different classes of nursing homes. In section 7 of the Act a new subsection is substituted for subsection (2) in regard to the making of regulations prescribing any necessary administrative and technical details in relation to the operation of the subvention scheme.

Section 4 is a standard technical provision setting out the title of the Bill and providing that it and the Health Acts, 1947 to 1999, may be cited together as the Health Acts, 1947 to 2000, and that the Tobacco (Health Promotion and Protection) Act, 1988, and this Act may be cited together as the Tobacco (Health Promotion and Protection) Acts, 1988 and 2000. It also provides for the making of orders in regard to the coming into operation of the provisions of the Bill.

These are the provisions of the Bill. I know everyone in this House is committed to fair and transparent arrangements for the supply of drugs, medicines and medical and surgical appliances under the Health Act, 1970. There can be no doubt that the House is committed to appropriate anti-tobacco strategies in view of the effects of tobacco on the nation's health. I am sure there is commitment to necessary changes in the Health (Nursing Homes) Act, 1990. The Bill contains a range of measures in regard to its three distinct elements to strengthen and underpin existing legislation. We are prepared to listen to the debate and will consider any amendments which Senators table on Committee Stage with a view to bolstering the provisions of the Bill.

I commend the Bill to the House.

Mrs. Jackman

I welcome the Minister to the House and assure him that we welcome fair and transparent arrangements for supplying drugs and medical and surgical equipment under the Health Act, 1970. We are aware that this is a tidying up process to ensure we are kept up to date.

I hope the Minister will include asthma in the long-term illness scheme. There has been a big increase in the number of people suffering from asthma, across all age groups, and it is a very expensive illness. At this stage, it should be included in the long-term illness scheme. Will the Minister keep the individual or family payment at the £42 rate? It is still a relatively large amount for people with ongoing medical expenses.

The amendment to the Tobacco (Health Promotion and Protection) Act is an important element of the Bill. Having considered the report of the Oireachtas Committee on Health and Children, spearheaded by Deputy Shatter, the Minister proposes to make it an offence to sell tobacco products to people under 18 years of age. I was glad he took the report on board when it was debated in the Dáil last year and accepted the anti-smoking strategy. The Minister mentioned the 7,000 tobacco related deaths per year. The figure could be even higher. I was speaking to two visiting Americans today who had been here three years ago. I asked what they thought had changed in that time and they said that there was an extraordinary increase in the number of smokers, particularly in areas where one should not smoke.

We know death related to tobacco product consumption is the most preventable cause of early mortality in Ireland. Research has shown that 80% of adult smokers start before the age of 18. That is a staggering statistic. Of adult smokers, 50% had started by the age of 14 and the addiction had begun by age 12 for 25%. My experience as a teacher was that first year female students were often already addicted to smoking, a trend that is accelerating. The figures for young men are lower because of their interest in sports. It is difficult to get picked for the squad, let alone play, if one is puffing and panting. For young girls, however, there is pressure to look slim and many believe in slimming by smoking cigarettes. I am appalled by what is happening among that age group.

The other age group about which I am concerned is the 25 to 30 year olds. Some of my daughter's friends have no intention of giving up smoking but when they reach 35 they will not be able to give it up. We must do something about smokers of that age.

The Minister is attempting to increase the age limit for buying tobacco products to 18. I am concerned about how we will monitor the sale of cigarettes. This is the same as the anti-drinking laws – who will ask a 14 year old who looks 20 for identification? Shop owners could be penalised for any sale to an under age person by an employee. How will that be implemented? It will be extremely difficult to do so. I hope the Minister will take account of the fact that it should be an offence to have a cigarette vending machine on any premises where a person under 18 years of age is permitted to enter or to be present. If the product is available where young people gather it is obvious they will buy it. The issue of vending machines must be taken into account also.

There is a reference in the Bill, of which I hope the Minister has taken account, that a person prosecuted for the sale of cigarettes to a minor should not be able to rely on the defence of having taken all reasonable steps to assure himself of herself as to the age of the alleged under age purchaser unless the seller satisfies the court that he or she sought and obtained an appropriate document of age verification inclusive of an identity photo of the purchaser which attested to the purchaser being over 18.

There are specifics of the anti-smoking strategy which have to be dealt with. The newly enacted measure requires that specified and prominent notices be in place at the point of sale of tobacco products in retail outlets warning of (a) the addictive and health dangers posed by cigarettes and (b) detailing the age restriction on sale and the vendor is obliged then to ask for age verification. I presume the Minister has all that in hand. I hope he has the detail in hand.

I know from this document that fines of £500 to £1,500 are proposed and the Minister has stated that is the maximum with which he could deal under this legislation but the recommendation from the committee was a sum not exceeding £2,500.

Mr. Martin

That is the legal advice I received.

Mrs. Jackman

I do not know about the legal advice. A sum of £1,500 these days is nothing to many people. People talk in terms of millions. It has to be a harsh deterrent and it must be implementable. I will be proposing on Committee Stage that we examine this again. I do not know the relevance of the legal advice. Is it that it cannot be done?

Mr. Martin

It cannot go higher than that.

Mrs. Jackman

Relating to tobacco only?

Mr. Martin

Relating to an offence of this kind. We receive advice from the Attorney General on these matters. That is only by way of clarification on these matters. I would go higher if I could but that is what I am told.

Mrs. Jackman

Yes, I think the Minister would but I would like to know about fines in the context of other European countries. We have German parliamentarians visiting us. I wonder what sort of fines there are outside this country. I presume they are higher than £1,500. The Bill proposes that on conviction for a second offence the court should have jurisdiction to impose a fine of up to £5,000. Deputy Shatter has a legal mind and much experience and he would not go very casually into this area. He must have done his research and he has done tremendous research in the United States and Europe. The Bill proposes that on conviction for a second offence, the court should have jurisdiction to impose a fine of up to £5,000 and/or require the offender to do community service. This would be a major deterrent which I would love to see in other areas or, as an alternative to community service, to have jurisdiction to impose a term of six months imprisonment. If we were to take that harsh route, we would not have the vendors selling. The Bill, in addition to banning the sale of cigarettes to persons under 18, states that it should be an offence for persons under 18 to have cigarettes or any other tobacco products in his or her possession. That is also important.

I emphasise this because we have not been able to arrest the increase in smoking. We know that the number of women has outstripped the number of men suffering from lung cancer. These are such serious issues for women's health that we must have these deterrents and we must be seen to implement them.

On amending the legislation for the nursing homes, we are now very aware of convalescent homes and even convalescent wings within nursing homes. I am glad to see that the quality of care which the elderly will receive will be under examination. However, over the past eight or nine years, since 1991, subventions, which we will address on Committee Stage, have not risen from £120. The Minister knows that. He has had letters from every young or elderly person or families who have had to pay quite an amount of money to ensure that their elderly parents are looked after. The subvention of £120 over an eight or nine year period is relatively little and must be reviewed in line with inflation. It rose from £70.95 to £120 and has stayed at that amount over a number of years.

My next question is more appropriate for the VHI. Coverage for two weeks after a serious illness is minimal and I hope the VHI takes into account the need to provide coverage for a longer stay in convalescent homes. That would free up beds in hospitals that are very necessary for people on waiting lists, which I hope the Minister will tackle. If the State cannot provide the necessary supports, there should be nursing homes countrywide. I welcome the fact that the Minister will take the quality of care into consideration, that it will be open, transparent and open to visitation and assessment on a regular basis and that the same will apply to convalescent homes. I am glad there will be funding available to people who open convalescent homes. Some people in my area are changing from nursing homes to convalescent homes but they are finding that if they have a nursing home and they put in a convalescent wing, they must have separate dining quarters as requested by the VHI and also separate corridors and entrances. This is expensive. We probably will be taking the option of providing more and more convalescent units. It behoves us to ensure that, for the money people pay and for the investment by the proprietors in nursing homes, they would all welcome assessment, evaluation and visitation from our health boards to ensure that standards are high.

My interest in the killer diseases arising from tobacco consumption by young people, who for some reason we do not seem able to reach, is from a teaching viewpoint. The Minister is aware that teachers are making little or no impact in this area; perhaps they are within the confines of the school but certainly not when the students leave the school environs. We need to adopt more dramatic measures. With other members of the Oireachtas Joint Committee on Health and Children, I have examined this matter in Canada. We gleaned from other countries that they seemed to be able to get to grips with this problem but somehow here it still is, to use a pun, a burning issue. It creates havoc with the health of our young people. All it will do is place a heavier burden on our health services in the future when we will have to deal with so many tobacco associated illnesses.

I welcome the increase in the age to 18 years but I would like the Minister to look again at the fines and check with the Attorney General whether we can make it more prohibitive for those who sell cigarettes illegally and who apparently slip through the net. Another issue we need to examine again are sweeteners, the molasses and other products which the manufacturers are including in cigarettes and which are aimed at young people. The Oireachtas committee is dealing with the compellability of witnesses and openness and transparency from the cigarette manu facturers as to what they put in their products. We are entitled to obtain that information and we will be pursuing it with the Minister in the Oireachtas Committee on Health and Children.

Dr. Fitzpatrick

I welcome the Minister. This Bill is non-contentious. On Committee Stage we may have different interpretations on certain sections but on Second Stage we all agree on its principal aim. I will not take too long to deal with the drugs items. There is a publication called MIMS circulated to doctors on a monthly basis. It is a list of prescribed medications, most of which would be available in the general medical services system. One will find there are many of what I would call “me too” drugs. These are similar drugs made to a standard specification by different companies but one finds there is very little price variation in these medications. The pharmaceutical industry is very important, especially in the south and in the Minister's constituency, but the level of competition in prices is more apparent than real for many of these drugs. Perhaps that might be examined in greater detail in the coming months.

The Minister is pushing an open door with the section dealing with the sale of tobacco drugs. By coincidence this morning I read in one of the newspapers that the Canadian Government is looking at ways to bring home to the population the dangers of tobacco. It will probably move in the direction of ensuring that 60% of a cigarette packet will show the effects of tobacco on the person. There was a charming picture of cancer of the lung which, if put on a cigarette box, might make people change their views.

Even in my profession I find quite a few people who indulge in smoking even though they would advise their patients to keep away from the dreaded weed. An ancillary profession, nursing, has a very high number of smokers. These are people who would be closer to the effects of tobacco than doctors, because they see them on a daily basis, yet they do not seem able to kick the habit.

The Minister mentioned that he was constrained by advice from the Attorney General in the amount he could fine people for selling tobacco to those under 18 years of age. The Intoxicating Liquor Bill, which is being put through the Dáil by the Minister for Justice, Equality and Law Reform, contains fairly draconian penalties for selling to those who are under age.

Another problem mentioned by Senator Jackman was the control of vending machines, which is very hard. If I had a vending machine in the foyer of my hotel, I could plead that I cannot stop someone under 18 years of age putting money into the machine to buy cigarettes. It is a difficult problem and I do not know how the Minister will tackle it. It lets the vending machine owner and the owner of the premises in which the vending machine is situated off the hook. We will find it very difficult to prosecute in such circumstances. There were successful prosecutions last year under the old tobacco legislation in the Western Health Board area but there does not appear to have been any follow up. Those cases got much publicity but it seems to have died down.

Another problem the Minister will have will be with his colleague, the Minister for Finance. He gets £686 million per year in the tax take from the tobacco industry. That is not an insubstantial amount of money. The Minister may have difficulty there with his colleagues in the Department of Finance.

As Senator Jackman said, nursing home patients have different degrees of requirements, varying from the high-tech, high demand homes to homes, although not convalescent homes, in which people are cared for in a non-medical manner with some nursing care but mainly home care in a nursing home ambience. We will have to look at this again because the Minister will have to apply different criteria for different but appropriate standards of care to the people who need it.

Recently, the health authority came into a nursing home in my constituency, which cares for about ten or 12 elderly people who do not require a great degree of nursing care, and gave it a list of improvements which must be made but which will result in the closure of that home. The State will have to find places for these people. The inspector is within his or her rights in applying these criteria; he or she is applying the law. However, the criteria being applied are not appropriate to the degree of care being given. I welcome the Bill.

Mrs. A. Doyle

It is my first opportunity to welcome the Minister to the House in his new ministerial role and I wish him well. I welcome the topics under discussion in this Health (Miscellaneous Provisions) (No. 2) Bill, 2000. It is opportune that we commemorate or acknowledge world anti-smoking or world anti-tobacco day with this debate in the House, and I would like that to be recorded as such. It is but a small move in terms of increasing the age of youngsters to whom cigarettes can be sold legally from 16 to 18 years of age and increasing the fine correspondingly for those who sell to under 18 year olds. It is a small move but it allows us to state, particularly those of us with very strong views in this area, exactly what our feelings are on it.

We recently had a debate in the European Parliament on the new regulation in terms of tobacco marketing issues generally. A relatively tame and modest tightening up is being suggested at this point in time in Europe and, as many commentators have said, perhaps world opinion has moved even faster than the European Parliament in terms of legislation in this regard. I suggest the Minister looks seriously at the Canadian model. I have learned from interaction with various colleagues in Europe that graphic displays of health warnings, such as the lung of the smoker compared to that of the non-smoker, rather than just a sentence indicating that smoking will kill, endangers the unborn child or that smokers die earlier, has a far greater impact.

Can it be that the best brains in politics, medicine and marketing cannot come up with a message that will be heard and acknowledged, particularly by young people? I do not accept that it is not possible to get the no smoking message across. We have not done it to date – maybe the tobacco companies are far more powerful or maybe Governments have become far too dependent on revenue from tobacco. It is a legalised drug that is far more harmful than many of the so-called illegal drugs, although I carry no brief for those.

I feel extremely strongly that if one is hooked on alcohol or heroin, the State will help in one's rehabilitation. One will be taken in, dried out and there will be all sorts of rehabilitation programmes. If one is hooked on nicotine in Ireland and elsewhere, there is no help. What do we do? We effectively make all nicotine replacement therapy available on prescription only. Why does the Minister not put cigarettes on prescription only if the replacement therapy to help people get off this awful drug is not accessible except on prescription? I cannot understand the logic of cigarettes being freely available. Smokers can overdose every day of the week, each week of the year – they can smoke 100 cigarettes – and yet a nicotine replacement patch is available on prescription only in case they put two on together or have a cigarette while they have the patch on. I do not know what the logic is but there must be an issue to address. One cannot get a replacement patch if one is trying to get off cigarettes.

Would the Minister accept an amendment to this Bill on Committee Stage whereby, at the very least, GMS card holders could get all nicotine replacement therapy free on their medical card? Will he please consider that as our way of recognising world no smoking day? It is a small step. Will the Minister look at the reasons and ensure all nicotine replacement therapy is not prescription only and that it can be freely sold anywhere that sells cigarettes? I do not understand the logic of not selling it alongside cigarettes. Nobody but the addicted will want to buy it and they will only do so if they genuinely want to get off cigarettes. Why not have it available?

Perhaps I am missing something in this, but it is one of the areas which has frustrated me for years. My colleagues know how almost irrational and less patient I have become with this subject over the years.

Mr. Ryan

Worse than ever.

Mrs. A. Doyle

I introduced a no smoking rule at our parliamentary party meetings years ago before the legislation came in. I have little patience with this matter and our consistent failure over the years to get the message across. It is a tragedy that our young people are smoking in even greater numbers, particularly young girls. Where are we going wrong? Surely the best political, medical and marketing brains can come up with a clear message that will be heard by and impact on our young people. I do not accept that it is beyond us to get the message across in the political and marketing world of today. I ask the Minister to accept an amendment which I will table on Committee Stage to say that all nicotine replacement therapy should be available to medical card holders free of charge. If they need a prescription, they need one. I will possibly also table an amendment to remove the necessity for prescriptions and pharmacy only sales of the rest of nicotine replacement therapy for those in a position to buy it. I cannot understand the logic in this regard. By tabling an amendment we might get into the detail of this issue, which defies explanation to the lay person at least. Perhaps the Minister has more information in this regard.

The environment committee of the European Parliament voted that the primary health warning should cover 60% of the front of a cigarette packet and should be in the form of a black border and black writing on a white background. There will also be an additional warning covering 40% of the reverse side of the packet. This proposal must go before a plenary session of the Parliament. The smokers' lobby telephoned me and I said: "Please do not even waste your time on me; I do not want to know; I may not be rational. I will be polite but do not waste your time. I do not want to carry a brief for the cigarette industry." The tragedy caused by cigarettes over decades is only now beginning to be recognised. The State has had to bear an enormous cost together with individual families in terms of the premature deaths of main income earners, mothers dying young and the effect on children in the womb. The effects of cigarettes have also been brought into the debate on cot death. I do not know, I only read what is written in this area.

I refer to the damage caused by passive smoking and the attempts of the tobacco industry to deflect any serious debate in this regard and to deny there was scientific evidence in terms of the damage done by passive smoking. The industry still tries to justify its case that nicotine is not addictive. Nicotine is addictive but the other constituents in cigarettes are carcinogenic and there is little talk about them. The European environment committee, which also covers public health and consumer affairs, voted last week not to allow tar yields, ingredients and terms such as "light", "ultra", "low tar" and so on to be printed on cigarette packets so that they will not deliver any false messages in terms of less likely damage to the health of the smoker and the community around him or her through passive smoking. It is a live debate in Europe and perhaps we can plug into it or the EU could tighten up and learn from what member states have done because I am not sure that Europe is leading. Europe may just be reacting, taking a common denominator and then going further afield. The Minister has my support in anything he wishes to do in this area. We failed as politicians. We should have got together with the medical profession and the marketing people to get our message out to our young people.

The previous speaker has a medical background. Approximately 20 years ago an elderly doctor who was wringing her hands in desperation because of the state of general practice at that time and the little time that general practitioners had to spend with their patients to counsel and advise them on various issues said to me, "Frankly with MIMS in one hand and the pill in the other you are an established GP today". That was 20 years ago but the climate is changing again and the need for one to one consultation and for GPs to spend time with their patients is recognised.

There is a useful book relating to drugs and pharmacies for those who are interested in what they are prescribed. I am frustrated in people's lack of interest in the drugs they are prescribed. The contract referred to by the Minister is excellent but perhaps there could be an effort to explain to people exactly how drugs work in a user friendly way. We need to examine that urgently.

I support the Minister fully in regard to nursing homes but we need to go further. The demography of the EU is changing rapidly. In ten years there will be 37 million more old people than today. They will still be primarily cared for in the home but with more women at work full time and the reduction in fertility rates, there will not be enough primary carers left in the home to look after the older generation. A new intergenerational contract will be urgently necessary so that we can contribute and provide financially during our productive years for the pensioners who worked hard and long to rear us and other generations in much more difficult times than we live in today. Such a contract will provide for the elderly and support those who can care for the elderly in their own homes properly.

I do not have the time to raise the issue of the carer's allowance. Let us help those who can care for their own at home in every way we can and then let us ensure it is not put beyond the means of the average person or even pensioner who has worked hard all his or her life to avail of necessary care in nursing homes. Nursing homes should be treated in such a way that acute beds can be vacated and their residents should get the same care with the same support from the State as the convalescents.

Mr. Glynn

While this is a short Bill, it is nevertheless important because it makes a number of provisions in health legislation which are welcome. I refer to section 59 of the Health Act, 1970, which was innovative legislation. The fact that it has not been amended very much in the interim reflects the thought that went into it. I congratulate the Minister for updating section 59 regarding the supply of drugs, medicines and medical and surgical appliances under the GMS and community drugs schemes. As somebody who worked in the health services for a number of years, I have always seized the opportunity to speak on health legislation, especially that relating to the prescription of drugs.

My colleague, Senator Fitzpatrick, is an experienced general practitioner and I appreciate his views not alone on this Bill but also on past health legislation. However, I regret that in regard to prescribing drugs too often a patient attends a doctor's surgery or a hospital and a prescription is written, especially in the case of antibiotics, and the antibiotic might be worth a tinker's curse to the patient. If he or she has a respiratory condition or urinary tract infection, who is to say that the organism causing the infection will be sensitive to the antibiotic? I believe the employment of the old culture sensitivity test before medications are prescribed would be beneficial in certain circumstances, especially in regard to UTI, respiratory conditions, etc.

The Bill contains an amendment to the Tobacco (Health Promotion and Protection) Act, 1988. This is one of my pet subjects. I have the honour, with Senator Fitzpatrick, of being a member of the Oireachtas Joint Committee on Health and Children and representatives of tobacco companies have appeared before us. When drug addiction is discussed, the denial and delusion stage is mentioned, especially as it pertains to the addict. In this case it applies to the drug barons, who are the tobacco companies.

Mr. Ryan

Hear, hear.

Mr. Glynn

Having listened to the representatives of tobacco companies the concept of denial and delusion springs to mind but it does not refer to the unfortunate addict who cannot help himself or herself. Members of the public appeared before us, one of whom was in a wheelchair, and even though their health was in a deplorable condition they still were not able to help themselves; they could not kick the habit. The tobacco companies denied all the way to hell and back that nicotine was addictive.

My colleague across the floor of the House said the message was not being got across. Legislation is in place and I congratulate the Minster for increasing the fines. However, he should send a clear message from this House today that the Tobacco (Health Promotion and Protection) Act will be enforced. There is no point in introducing legislation without enforcing it, as we have done so often in the past in many areas that cause problems for public health. The increase in the maximum fine from £500 to £1,500 is a step in the right direction. Those who knowingly supply tobacco products for consumption to people under the age of 18 years, as prescribed in the Bill, should have their licence revoked. I have no sympathy for them.

The taxpayer contributes hugely to fund the treatment and care of those suffering from respiratory and the other illnesses arising from the smoking of tobacco. Seán Citizen is paying the bill to cover the numbers who are submitted to care institutions for treatment and care. Taxpayers have a vested interest in ensuring that tobacco companies are hauled into line.

Reference was made to advertising. It is not too long since television advertisements would show a man walking along the seashore at perhaps 1 o'clock in the morning looking the picture of desolation and loneliness. He would then be depicted taking a box of cigarettes from his pocket, there would be a whirl of smoke and the caption would read: "You are never alone with a strand." The message was that a cigarette was the answer if one was alone and lonely. Another advertisement would show a man eating his nails with frustration, then a caption would appear suggesting that a hamlet would solve all his problems. While we have got away from that, the real villains are the tobacco companies who have rebutted every suggestion and proposal made to them during their attendance at the hearings of the Oireachtas Joint Committee on Health and Children. I told one person who attended that if the evidence bit him on the nose he would still deny it. Those are the people we must get to.

I commend the Minister for introducing an amendment to section 7 of the Health (Nursing Homes) Act, 1990. Section 7(2) of that Act provides that the Minister may by regulation prescribe that the amounts of subvention that may be paid may be specified by reference to specified degrees of dependency. That is very important. Not long ago a difficult approach was taken to the payment of subvention to those unfortunate enough to require nursing home care for themselves or their dependants. These new provisions progress matters considerably, which I welcome.

The monitoring of nursing and convalescent homes is very important. While they provide a very important service, it is also important that they provide medical cover. For a long time nursing homes were run on a shoe string and, regrettably, the appropriate level of care was not provided. I welcome the Minster's pro-active approach to the matters before us and I echo his sentiments in commending the Bill to the House.

Mr. Ryan

I welcome the Minister to the House. It is the first time I have been in the House with him since he took up his onerous new job. If not geographically, we share a constituency in that I have a political interest in the constituency he represents. I do not say he represents it well, but ably. I do not dispute his ability but I must dispute how he does his job. That is part of my role in politics.

I agree with Senator Avril Doyle that no Government will ever be able to do enough when it comes to dealing with tobacco. I am married to a habitual smoker.

Mrs. A. Doyle

So am I – quadruple by-passes later.

Mr. Ryan

I am also married to a doctor and since they are the same person it is something of a contradiction.

We must begin to put those who make and sell tobacco products into the place in society where they fit, which is an atmosphere of disapproval. It is wrong to sell tobacco products and it ought to be said with the full force of society. There can be no ambivalence about this. It involves the Government realising and being prepared to accept that it has a strategy to replace the £650 million it currently gets from tax on tobacco products by raising it elsewhere if necessary. I therefore welcome the increase in duty on tobacco products in the last budget.

We are concerned with a product that kills, I believe, approximately four million people a year on the planet. That is probably a conservative underestimate because as we all know, the drug barons of the tobacco industry are currently involved in a huge campaign to increase smoking in the developing countries where we have not yet got the proper mortality figures to identify the scale of death being brought about there. They did that deliberately and cynically once pressure was placed on them in the developed world and they are continuing to do so.

There is no doubt that these companies, like the breweries, are targeting young people with an intensive level of lobbying. I have no disapproval of drink, but the targeting of young people in these areas is very dangerous. According to the figures I have seen – I am sure the Minster has better figures – we have amongst the highest levels of drug and alcohol abuse among teenagers in the EU. I suspect we are rapidly moving to a situation where we will have levels of smoking among teenagers, especially among teenage girls, that are among the highest. Aesthetics should matter to teenage girls, but giving smoking glamour or appeal is one of the great achievements of the tobacco industry. Persuading young girls, who are otherwise so sophisticated about appearance and appeal, that having a cigarette trailing out of their mouths is supposed to improve one's general appeal is a sinister achievement of profoundly effective marketing on the part of the tobacco industry. There is a need to address it with the full resources of the State. Given our capacity to allow our young people to abuse drugs and alcohol to an alarming extent, we should not be surprised at the level of abuse of tobacco that is beginning to develop.

I welcome the measures in the Bill but I wish to make a number of suggestions. It is time that committees of the House stopped meeting tobacco lobbyists. We should say that we know what they are doing is wrong. We do not invite the Fellonis or the Meehans to tell us about the drugs problem because we know what they are doing to society. It is time to tell the tobacco industry that its days of getting a hearing and taking up the time of Members of the Houses of the Oireachtas are over. It should be told that we do not need it any more, that it should go away and find a way to do something useful with its resources and that it should stop harming society. There is a need for the Houses of the Oireachtas to say that there should be no more tobacco lobbyists around the place and that the Oireachtas has no more interest in them.

People in the State who are managing investment portfolios should be encouraged either through specific taxation or other provisions not to invest in the tobacco industry. This may mean a specific revamping of the taxation provisions for pension funds or other areas. One could cynically suggest that pension fund managers have a vested interest in the tobacco industry because it reduces their liabilities substantially. Nevertheless, we should begin to consider that limited move. I have had an interest in ethical investment for some time but it should be said to anybody who wants to benefit from the tax provisions governing various pensions funds, etc., that it is conditional on them not taking any shares in companies involved in the manufacture and sale of tobacco products.

This is a statement of values. We would be outraged if pension funds were involved in the drugs industry. I am outraged that some of them are probably involved in the armaments industry, but that is a separate issue. It is time to recognise that they are involved in an industry which does nothing but harm. There is no upside to cigarettes. It only becomes of some benefit once people are addicted because it relieves the symptoms of the addiction. However, beyond that, there is no upside to tobacco and, therefore, we should not be involved in it.

If these measures were taken, it would begin the process of recognising that the existing situation is a form of legalised drug pushing and that the people who do it are legalised drug pushers. This is what it is all about, although I am sorry to say that about small shopkeepers. As well as making the moral position of society clear, practical steps must be taken to reduce demand, such as the elimination of advertising. Another suggestion is that the sale of tobacco products should be banned in places where people congregate, such as pubs, clubs and elsewhere. Tobacco products should not be available anywhere that young people might congregate.

Availability should be restricted and selling cigarettes from slot machines should be stopped because it is uncontrollable. While penalties could be introduced, in most pubs there is a slot machine in the corridor on the way to the toilets which cannot be supervised. This should be made illegal. People should have to sell cigarettes over the counter and only in restricted outlets.

Mrs. A. Doyle

Prescription only.

Mr. Ryan

The problem with a prescription only system is that it would involve people getting items on prescription and the State could end up paying for them. That would concern me.

Mrs. A. Doyle

I am being sarcastic.

Mr. Ryan

Cigarettes should only be sold in off-licences in the same way as the sale of alcohol is restricted to a limited number of premises. Cigarettes should not be sold anywhere that families or children might be. I do not believe in prohibition, but ease of access should be reduced to the maximum possible extent.

The price of cigarettes should be increased. I make no apologies for saying that it should be made prohibitively expensive to smoke. A specific health tax on premises that are prepared to sell tobacco should probably be introduced. If people want to sell tobacco, a specific health tax, in addition to the normal taxation rates, should be imposed on them. I want to discourage places from selling tobacco. It should be made as difficult and inaccessible as possible. I do not believe in prohibition – it has not worked in any area – but those measures would be useful.

Any area to where the public has access should have, at a minimum, a legal requirement to make a non-smoking area available. I do not care how much the vintners whinge. The institute of technology where I work has one little area in one student canteen where people can smoke. Smoking is not allowed in any other place. I remember when people were allowed to smoke in cinemas. That is now prohibited and the quality of the atmosphere in cinemas has been transformed. I remember when people tried to get away with smoking in theatres.

Mr. Martin

And bingo halls.

Mr. Ryan

I suspect they still smoke in bingo halls.

Mrs. Jackman

Absolutely.

Mr. Ryan

Any place in which the public congregates either for leisure or commercial purposes should have a predominantly non-smoking emphasis. The biggest centre of recreation in Ireland is the pub, but that is the one place where there has been no attempt to restrict smoking. Pubs should not be allowed to sell cigarettes; they do not need to sell them. In addition, they should have to make provision for an area for non-smokers which is proportionate to the size of the population that does not smoke. Approximately 60% or 70% of the adult population does not smoke now and that is the proportion of the space which should be available in any premises. These measures need to be taken. Although I do not blame the Minister, my only argument with these provisions is that they do not go far enough.

Mr. Martin

We know that.

Mr. Ryan

That is my only complaint. I am the ultimate liberal in many ways, but the imposition of smoking on society is horrendous.

Mrs. Jackman

That is true.

Mr. Ryan

I may not be as positive about other provisions of the Bill. The health service in general is in tatters. It is lacking in vision and philosophy. It is a health service that was imagined when Ireland was poor. It has not developed the vision to deal with the idea of a health service of the quality that should exist when a country is rich. One example is the so-called improvements in the drugs scheme. I agree with Senator Doyle's point that nicotine replacement therapy is not available to medical card holders, but the State is happy to spend thousands of pounds on them once they get cancer from cigarettes.

Mrs. Jackman

That is true.

Mr. Ryan

It is ridiculous that nicotine replacement therapies are not available on the medical card scheme. Our priorities are confused at times.

As the Minister is aware, there are two problems in this area. In terms of the GMS, there is a question about what is available under it and it is a matter of continuing controversy. It is time to move on. We can afford to do better and it is time that was done. With regard to the drugs refund scheme and a single person with an income of £160 a week, a GP now charges £25 per visit.

Dr. Fitzpatrick

Where?

Mr. Ryan

On the north side of Cork. My GP has many medical card patients and he charges £25 a visit, although a plumber charges £40 just to come to one's door. Perhaps Senator Fitzpatrick should move to Cork.

Dr. Fitzpatrick

I am reviewing the situation.

Mr. Ryan

They are obviously more affluent there. The maximum amount payable under the drugs refund scheme in that case is £10 a week. On an income of £160 a week, that is one sixteenth of one's income. If one adds other sums for other items, it could amount to close to 10% of the person's income. The irony is that the State spends 5.5% of GDP on health care but we are prepared to say that someone on a low income should spend 10% of it on their health care. We in the Labour Party have endeavoured to come up with the proper figure to provide a decent public health care system but all we got from the Minister was an inadequate and under-researched response, which was not up to his standard – I am sure the Minister saw the letter in The Irish Times last week from Dale Tussing – and it deserves a good deal better and a more in-depth response. It may not be the only way but it will be a lot better than what we have at present.

While I am glad the Minister is rationalising this and regulating nursing homes, an area which needs fundamental and major resourcing is the provision of nursing home care for our increasing elderly population. It is a nonsense, only capable of being thought up by the Department of Finance, that anyone can afford to pay £400 a week indefinitely in a nursing home. Some £20,000 a year is what the John Byrnes and Dermot Desmonds of this world can afford but most people cannot afford the cost of a nursing home. I have no objection to people paying a reasonable contribution out of their income but we should not turn the elderly in our society into a burden on their children.

The Minister has a problem with the ideology of the Minister for Finance. In his previous Ministry, the Minister for Finance believed in spending money on what he was doing, but he does not believe that in this ministry. The Minister's biggest challenge is to change his mind.

Dr. Henry

I welcome the Bill in which I have a great interest. I will not indulge in a diatribe about why the hospital employers are involved in brinkmanship with both the nurses and the non-consultant hospital doctors because it would not be productive. I hope the Minister will be able to come into the House as soon as possible to address the serious staffing issue in hospitals. This debate has an impact on that issue because if nursing and convalescence homes were used as step down facilities for hospitals, it would help to unblock the beds in the acute hospital service.

I do not want to inflame the situation as regards the non-consultant hospital doctors but I am extremely worried by the lack of progress within the Labour Relations Commission and the fact the psychiatric nurses have decided to take strike action again next week. It must have been the Leader's influence and that of Senator Glynn that St. Loman's in Mullingar is not included in the first group of psychiatric hospitals to be hit by the strike. The psychiatric nurses say they will attack the flagship hospitals first, so I do not know how pleased those in Mullingar will be to hear that. It is a serious situation, as I am sure the Minister is aware, because some of the most vulnerable patients in the health service will be affected by this action.

I was disappointed with a reply to a parliamentary question last week, which the Department must have given to the Minister of State at the Department of Health and Children, Deputy Hanafin, who is a truthful person, which suggested there was no problem with staffing in hospitals. However, that is not true. There are last vain advertisements in the past few weeks' medical journals for staff throughout the country, including Portlaoise, Tullamore, Galway, Castlebar, Sligo and St. Luke's. Those jobs have been advertised for 1 July. If they do not have staff for them now, they will not have any on 1 July. There are no locums for June.

This is a useful Bill which deals with three separate topics. I hope the Department will try to seriously address the problem of patients who believe there is no cure without a pill. The medical profession needs to be educated about it but so does the public. We have a big problem with multiply resistant staphylococcus aureus in the hospital service. There is not a hospital in the country which does not have a problem with it. This has arisen from the overuse, and some would say abuse, of antibiotics.

Litigation in the medical profession is a serious problem. A doctor is more likely to be sued in this country than anywhere else in the world, including the United States of America. For reasons of defensive medicine, there is an over-prescription of antibiotics. The public must be made to realise this is not in their best interest. The Department should introduce an initiative because we are talking about preventative medicine to prevent more serious infections.

The prescription of antibiotics for upper respiratory infections, which are mainly viral, is well known. I am sure Senator Fitzpatrick read the recent interesting articles about the inadvisability of prescribing antibiotics for children with an initial middle ear infection and indicating that perhaps they would be better to wait for 24 hours to see how they are doing. If the child does not do well, the doctor is in a serious position because it will be said that it would have been better to have prescribed antibiotics for the child in the first place. However, that might not be true.

The over-prescription of antibiotics by medical practitioners as a protective mechanism has been influential in the development of multiply resistant staphylococcus aureus. We need to resist the pharmaceutical companies and to remember that some of the narrow spectrum older antibiotics may be the ones of choice. I am sometimes astonished to see patients on something I would have regarded as a hospital antibiotic which should not be given except in a hospital as a last line of defence. Just because an antibiotic is broad spectrum and will hit a lot of bacteria and is the newest does not mean it is the best thing to prescribe.

We must also look at the problem of the availability of antibiotics without a doctor's prescription and on Internet sites. We heard this morning about the deaths from Viagra of two Irishmen who had heart conditions and 14 others had adverse effects. The last time I sought information on the prescription of Viagra I found 83 sites in the United States where it could be obtained without a prescription. It is as easy for someone here to look for it as it is for someone in the United States. We have a serious problem regarding the supervision of patients on antibiotics or any potent drugs who may be getting them without seeing a medical practitioner. The Department should make a major effort to address the problem of the overuse, if not abuse, of antibiotics for the medical profession and with a view to informing the public of the risks involved.

The direct advertising of drugs is useful because patients may bring to one's attention the availability of a particular drug. However, a drug may appear to be a cure-all for certain conditions but the downside of its use may not be made sufficiently clear. Pharmaceutical companies need to be extremely careful in the way they promote products which are aimed at the general public.

I am glad that renewed efforts are being made to restrict the sale of cigarettes to people over the age of 18. The only difficulty is that existing legislation governing this area is not being enforced. I do not know how the new provisions will be enforced because it will be extremely difficult to ascertain whether a person is over 18 years of age. It will also be easier for shopkeepers to plead that they did not know a person's age. This restriction on the sale of cigarettes is welcome but I do not know how we will encourage environmental health officers and others to police the legislation.

I was in a shop recently when a child of approximately eight or nine years of age purchased cigarettes. When I objected to the shopkeeper, I was informed that the child's mother was known to them. I stated that I did not care whether the shopkeeper knew the child's entire family and pointed out that it was illegal to sell cigarettes to the child.

A useful survey, one among hundreds of its kind, was recently published by the Southern Health Board. It shows that children as young as eight or nine years of age, particularly boys, drink alcohol at least once a month and smoke on quite a regular basis. It is clear that our attempts to reduce the consumption of cigarettes and stop young people from taking up smoking must focus on providing information to children in primary school. We must adopt a multi-faceted approach to trying to prevent children taking up smoking because, unfortunately, those who smoke or drink at a very early age are much more likely to become involved in the abuse of illegal drugs. It is vital that we address this problem.

A number of representatives from the tobacco industry in Ireland recently complained that restrictions on tobacco advertising are becoming even tougher. I have no sympathy for these people because approximately 90% of those who smoke want to stop but it appears to be extraordinarily difficult for them to do so. Regardless of what one might say about alcohol, no evidence can be provided to show that there are benefits to be gained from smoking cigarettes or any other form of tobacco.

When advising people not to smoke, emphasis is placed on the dangers of contracting chest conditions, lung cancer and emphysema. However, it is important to note that people who smoke can develop terrible cardiovascular problems. Evidence which shows an earlier onset of heart disease among women who smoke and of their deaths from heart attacks is remarkable. I do not believe adequate emphasis is placed on informing women, particularly those who smoke, about the dangers of heart disease.

I have never known a non-smoker, unless he or she was a severe diabetic, who lost a limb. However, I am aware that numerous smokers have had limbs amputated. Such people have lost limbs at quite an early age, perhaps when they were only 50 or 60 years of age. We must continue to stress the problems which may result from smoking.

I am familiar with a number of surveys which indicate that 40% of teenage girls smoke. I am inclined to believe this because I recently chaired a meeting in Trinity College and, despite the presence of huge "No smoking" signs, I was nearly asphyxiated and I thought I would have to be carried out on a stretcher. Those present at the meeting obviously possess some form of high intelligence because they had managed to gain entry to third level education. However, regardless of the emphasis that has been placed on warning people about the dangers of smoking and despite my strong objections, many of those at the meeting were puffing away on cigarettes.

We must adopt a different approach to warning young women about the dangers of smoking. New surveys have shown the effects of tobacco consumption, particularly in terms of the thinning and ageing of skin. At 17, 18 or 19 years of age one does not think that one will be covered in wrinkles by the age of 40. However, it might be an idea to use "before and after" photographs to illustrate the position. In that context, I recall that, in the past, the "Toni Twins" television advertisements used to employ such photographs and inquire whether people could identify which model had dyed her hair. Perhaps we could try to make young women aware of the effect smoking will have on their physical appearance.

I wish to comment on the sale of smuggled cigarettes. I work in a part of the inner city where I frequently see people selling cigarettes on the street at prices well below those charged in the shops. I accept that customs and excise officers and the Criminal Assets Bureau have enjoyed a degree of success in tackling this problem but there is a need to deal with it in an even more enthusiastic manner. I understand that it is more profitable to deal in smuggled cigarettes than in illegal drugs because people do not have to pay as much for them, the turnover is excellent and those involved in their sale are not as enthusiastically pursued as those who deal in hard drugs.

There is a need for a full debate on nursing homes, an area where major growth has been experienced. Convalescent homes and step-down facilities could be used more extensively and provide great assistance to the acute hospital service. However, like the hospital service, such institutions are encountering difficulties in attracting staff. Perhaps the Minister will address this matter on another occasion.

Mrs. Taylor-Quinn

This important Bill is an attempt to update the legislation relating to smoking and convalescent and nursing homes. However, on Second Stage one is entitled to speak on wider health issues.

I concur with Senator Jackman's comments on the provision and distribution of drugs through the various drug refund schemes which have provided relief to a considerable number of people. However, there is a need to expand the existing system. Statistics have increasingly shown that the number of people suffering from respiratory and lung diseases has increased dramatically. This may be due to changes in the environment which have been caused either by the release of various gases into the atmosphere or by global warming. However, the incidence of such diseases among young people cannot be denied. I am sure Senator Fitzpatrick encounters such people at his medical practice on a daily basis.

People have been campaigning for a number of years to ensure that those suffering from asthma are included under the drug refund scheme. However, the Department, for whatever reason, has refused to accept proposals in that regard. This is most unfortunate because a large number of young children are affected by asthma. Many families come under huge financial pressure and incur major costs as a result of their children contracting asthma. The Department and the Minister have a responsibility to give serious consideration to this matter.

Public representatives are aware of the financial hardship incurred by families in this regard, particularly by young couples with mortgages and other major financial responsibilities who perhaps have two or three young children suffering from asthma. Such people find it extremely difficult to meet the financial cost of drugs and other support services. At a time of economic boom, I urge the Minister to consider the needs of these people, allow them into the drugs refund scheme and provide them with the financial support they require. That would be a huge relief to the families of severe asthma sufferers. The Minister is progressive in a difficult Department but people have confidence that he will respond to these issues and show his ability to deal with them in a forward-thinking manner.

On the Tobacco (Health Promotion and Protection) Act, 1988, I welcome the introduction of legislation in regard to revised policy in this area. However, I am very disappointed that in view of the amount of work undertaken by the Joint Oireachtas Committee on Health and Children in this area, in which Members of the Oireachtas from all parties researched the national and international situation and published a conclusive report, this legislation has not taken any of the report's recommendations on board. I am particularly disappointed that the legislation does not encompass the report's recommendations on fines. It is imperative that fines would become so frightening and prohibitive that they would prevent people from selling cigarettes to underage people. The increase from £500 to £1,500 is not adequate; the fine should be increased to £2,500, as recommended in the committee's report. That would be far more prohibitive and effective. I urge the Minister to introduce an amendment on Committee Stage or to accept Members' amendments to address this matter.

The report also includes recommendations in regard to advertising, promotion and monitoring. There is a huge onus on the Department, together with the health boards, to ensure that the sale of tobacco in health board areas is monitored closely. The Department must provide the health boards with the funding required to employ people to ensure that regulations are being complied with by manufacturers, traders and distributors. Such monitoring cannot be carried out effectively unless the Government provides the necessary funding to the health boards.

Although I will not refer to any specific campaigns conducted by the Department of Health and Children, we have seen very successful advertising campaigns in the past. The Minister has an opportunity to promote an attractive, anti-smoking advertising campaign in the national broadcast and print media to encourage young people not to smoke. Some tobacco manufacturers sponsor major sporting events in which young people have a particular interest and, in doing so, subtly encourage young people to smoke. The Minister must counteract that influence.

There has been a dramatic increase in the number of nursing homes throughout the country over the past ten to 15 years. There has been a further increase since the Minister for Finance introduced the special tax incentive scheme in the 1999 Finance Act due to the attractiveness of investment in this area. I commend and support the thinking behind the scheme. However, those seeking tax relief through investment in the scheme will approach projects from a business point of view and it is very important that the Minister and the Department ensure that the standards in nursing homes built under the scheme are up to scratch. I recognise that this legislation will ensure that nursing homes built under the tax incentive scheme will be registered and I commend the Minister for that. I urge him to ensure that additional personnel are provided in the health boards to monitor these homes to ensure that they are properly managed and that a proper standard of care is provided.

When nursing homes were built here initially, some of them left a lot to be desired and were closed down. It should be compulsory for any nursing or convalescent home to be registered in order that they or their patients could receive assistance. I note that the legislation distinguishes between convalescent and nursing homes.

I suggest that the Minister should consult with his colleague, the Minister for Social, Community and Family Affairs, as carers and nursing and convalescent homes are closely inter-related. If carers were given more serious consideration and if better provision were made for the carer's allowance, fewer people would have to go into nursing or convalescent homes. There are some cases, particularly with very elderly people, where it is impossible for people to remain at home because of inadequate finances. There is room for manoeuvre in this area between the Departments of Health and Children and Social, Community and Family Affairs.

The Minister recently visited County Clare and we were delighted to welcome him to the county at such an early stage in his term of office, although we were somewhat disappointed that he was only there to put an initiative announced three years' ago by the then Minister for Health and Children, Deputy Noonan, on a solid footing. Nevertheless, we welcomed his visit. However, the Minister did not manage to visit the mammography unit in Ennis General Hospital. That unit was established in 1984 as a result of voluntary fundraising carried out by a group of people drawn from throughout the county. A private fund was set up at that time and people continue to raise funds on a voluntary basis. I understand that a report was commissioned and is possibly on the Minister's desk—

Mr. Martin

The report was prepared by the Cancer Forum, which was established by the Senator's colleague, Deputy Noonan, when he was Minister for Health.

Mrs. Taylor-Quinn

Although the report has not yet been published, I understand that it contains a recommendation that such units should be centralised. There would be a huge degree of dissatisfaction with that. People from Dublin and other large urban centres may automatically think that major hospitals should be centralised but people living in counties Cork or Clare know how far away west Cork and west Clare are. If these units were to be centralised, the number of people who would avail of these facilities would be reduced. Middle class, mobile people would be in a position to travel to the centralised units to avail of the services but less privileged people who do not have cars would find it impossible to do so.

Regarding the centre in Clare, a number of the specialists in Limerick are not happy with the recommendations in that report regarding centralising in Limerick. The people of Clare who have been using this service, and particularly those on the periphery of the county, are most dissatisfied at the idea of its being transferred, particularly given that it continues to be funded from voluntary sources with a little subvention in recent years from the Mid-Western Health Board.

I ask the Minister to undertake a close examination of this matter when the report becomes public. I am sure he has had it examined in detail already, but he will recognise that there is a social dimension to all of this and it is essential that services be provided near those who require them. Services 60, 70 or 80 miles away are not adequate for a high percentage of the population and I urge the Minister to look at this with a view to retaining the mammography unit in Ennis General Hospital.

Minister for Health and Children (Mr. Martin)

I thank the Senators for their constructive contributions to the debate. I am greatly encouraged by the convergence and the unanimity of views on adopting the strongest and most stringent anti-tobacco measures possible.

Senators Fitzpatrick, Doyle, Glynn and Jackman and all the Senators spoke strongly on the tobacco issue. The Bill raises the age at which tobacco products can be sold to young persons to 18 years and increases the fines. I have been advised that that is as far as I can go on the fines issue and I must accept the advice available to me.

Mrs. Jackman

The Minister should check again.

Mr. Martin

There is legislation of a much more substantial nature on the way. I am currently preparing a tobacco Bill. The Office of Tobacco Control has been established and a chief executive and board have been appointed. The next step is to appoint a tobacco-free council. The Office of Tobacco Control, in conjunction with my Department, is currently preparing the heads of the Bill. I look forward to bringing that Bill before the Oireachtas in the autumn session – that is the timeframe towards which I am aiming. Many of the issues raised here will be covered in that Bill. For example, we are looking at providing that 60% of the cigarette packet will show the effects of tobacco on the person. We are looking at the availability of cigarettes in retail units and the degree to which they are advertised in retail units. We know, for example, that when children go into shops to buy sweets they see packets of cigarettes adjacent to the sweets. I agree with Senator Ryan that we must change the climate to one of intolerance of cigarettes in society.

As a newcomer to the Department of Health and Children, I am somewhat taken aback by the statistics and the research. People complain rightly about waiting lists and about the accident and emergency service. The reality is that health is a simple equation and the health status of the Irish people is poor relative to that of our European partners. Ireland has the highest instance of coronary disease in Europe and is highly placed on the cancer table. Accidents and injuries apart, these are the three main causes of illness and death in Ireland. One of the single greatest determinants of death and illness is cigarette smoking. If we focused our efforts on cigarette smoking, we would do the health status of the Irish people now and in the future an enormous amount of good.

There is a moral imperative on me, the Minister for Health and Children, to attack this issue with everything at my disposal. Some people have accused me of becoming a fundamentalist overnight. I am not. I never smoked, although I tried it once. There is a downside to that in the sense that one can be overly intolerant of smokers because one has never been addicted. We must understand that it is an addiction and smokers need help to quit the habit. It is estimated that about eight out of ten smokers want to give up smoking and have tried time and again.

Mrs. A. Doyle

Why do we make it so difficult?

Mr. Martin

The issue of nicotine replacement therapy was raised by Senator Doyle. The policy decision has been taken to introduce nicotine replacement therapy for medical card holders. The issue is how we will do it. The report of the tobacco-free policy group, which I launched in March, recommended the introduction of NRT for medical card patients in the context of cessation programmes. In other words, it did not want smokers simply going in and grabbing the NRT without anybody talking to them or without proper programmes. There is a dilemma in that obviously there is a lead in time before one can establish cessation programmes in all locations.

The tobacco-free policy group's report was significant in that for the first time the Government stated that it accepted it had to do more than just campaign against cigarettes and state that people should not smoke, and that it must help people to get off cigarettes. The NRT is a factor in that process.

The cardiovascular forum, which is advising on the cardiovascular strategy, was asked some time ago to tease out this issue with a view to advising Government on how best to introduce NRT in the context of the GMS scheme. That is happening at present. I am awaiting the recommendations of the cancer forum regarding the mechanics of doing it and the context in which it should be done. Obviously that will lead into the Estimates process also, but the bottom line is not so much the decision to do it, which has been taken already, but how we will do it. That is an issue because there could be a considerable amount of wastage. There is a necessity at some stage in the process to link it with a proper cessation programme. We are working on a number of different settings to develop that. Only yesterday we launched the minimum standards for public hospitals in terms of smoking and cessation programmes. Interestingly, Beaumont Hospital has a cessation programmes facilitator, whose function is to co-ordinate the smoking policy within the hospital but also to develop cessation programmes for staff, patients and families. There is a great deal of work to be done on that, but we recognise the importance of NRT.

Senator Doyle raised the apparent absurdity where a person has no difficulty buying 80 or 120 cigarettes but cannot buy NRT over the counter because it is a licensed drug. We need to tease out that matter a little further. If one takes NRT off the list of licensed drugs, then there remains the issue of dosage.

There are other issues coming down the tracks. One ought not to be surprised if in five years the tobacco industry states that it will not sell cigarettes anymore. Some of the pharmaceutical firms have pointed this out. There is no regulatory framework, for example, to distinguish between NRT and whatever else may emerge. The tobacco industry is one of the most resourceful industries in the world. We are facing a very tough opponent here.

Senators Jackman and Fitzpatrick made interesting points about young smokers. We actually succeeded in making good progress from the mid-1970s to 1993, when we reduced the number of tobacco consumers from about 50% to 28% on average. Unfortunately in recent years it has risen to 31%. It seems that a significant proportion of those are young women and young people generally. That suggests to me that the tobacco industry has regrouped, refocused and redirected its marketing strategies to get people hooked again.

That said, the proposed tobacco Bill will look at the issues of passive smoking in terms of where and how, and will give strong powers to the Minister to introduce regulations in all the areas identified by the Senators. This legislation is an interim step in line with what was said in the Dáil on Ash Wednesday, which was anti-smoking week. I thought I would use the opportunity available in this Bill to make this provision because I know about the volatility of the Legislature and the difficulty in getting provisions through. Legislation can take time and therefore I decided to take the opportunity of the Health (Miscellaneous Provisions) (No. 2) Bill at least to increase the age at which a person can purchase tobacco products and to increase the fines, in accordance with the advice available, to the upper limit. I will seek clarification on the advice in accordance with Senators' wishes.

I accept the point raised by Senators about the rate of nursing home subvention. Over the years the Department of Health and Children has actually secured an additional increase in the Estimates for nursing home subvention. It started off at about £4 million in the early 1990s. This year the bill for nursing home subvention is £40 million. Last year my predecessor, Deputy Cowen, secured an increase of £3 million or £4 million. He thought that this would facilitate an increase in the rate, but what happened was that the demand grew. The increase merely pays for the increase in the number of people coming into nursing homes and reflects the demographic changes in Europe and of Ireland.

Shortly after coming into office I instructed my officials to prepare a strategic action plan for the elderly. This is currently being prepared in the Department, in consultation with the health boards. I want to move quickly on this plan because the timeframe presented by our aging population may cause difficulties and because there are significant gaps in services between acute and community care services. We have much to do.

Approximately £200 million has been earmarked in the national development plan for a range of services for the elderly in the community, including community nursing units, res pite care, day care centres and so on. I suspect that the bill will be higher before the strategy has been put in place. We will then have to go to the Minister for Finance. We have increased current expenditure in the health services by 56% in the last three years and the capital programme of £2 billion is very significant. However, I suspect we will need more.

We also need reform. I note Senator Henry's point about industrial disputes. We need reform of what we are doing in hospitals. We must reform the hierarchical nature of the medical professions. Investment coupled with reform will give us a world class health service.

The question of long-term illnesses, particularly asthma, was raised by many Senators. This is an issue of concern to me. How we define certain illnesses as long term must be decided. There is also the issue of Estimates. I will explore the feasibility of defining asthma as a long-term illness over the next number of months because asthma medicine is a costly item for many people.

We are working with the Department of Social, Community and Family Affairs on the issue of carers and the continuum between nursing homes, convalescence and care in the home. The point made in this regard is a very fair one. I have already had discussions with the Minister, Deputy Dermot Ahern, on the question of taking an integrated approach to care and of giving carers greater support. Carers will be vital in assisting the elderly and others who are in receipt of community care, in ensuring that people retain independence in the community and in delaying recourse to acute services.

People may not be aware of the Walk Tall programme, a substance abuse programme which is being comprehensively introduced in all primary schools. The programme was prepared by a team of psychologists and others in the Department of Education and Science in consultation with the health promotion unit of the Department of Health and Children. It is a very good programme and in-service for teachers who will provide it is now under way. The programme was introduced in 1,500 schools last year and will be introduced in another 1,500 this year. This will give complete coverage of primary schools. Its fundamental philosophy is to give children self-esteem and self-confidence so that they can withstand peer pressure. All the recommendations are that this is the key way to give young people the means to withstand the pressure to take a drink or to smoke. It is not enough to tell children to say no. We must arm them with self-esteem and respect for their bodies and for their health and well being. If we can do this we will prepare them to make the right decisions in the future. This programme is under way in all primary schools and over time it will have an impact on the educational aspect of the debate on smoking and substance abuse.

Senator Henry raised the issue of MRSA. This is not totally relevant to the contents of the Bill but I am very conscious of the seriousness of the issue. It raises very basic questions about hygiene in hospitals and the over-use of antibiotics in society generally. We are working with the World Health Organisation, and the National Disease Surveillance Centre now has responsibility for developing a policy on MRSA in hospitals. A consultant will be appointed to spearhead that campaign.

I note Senator Taylor-Quinn's comments about the mammography unit in Ennis. I am examining the situation. When I was in Ennis I did not hear a great deal about this issue. Because I gave the grant to the control team to build the hospital and to do everything else I was asked to do, the agenda appears to have moved on very quickly. We must balance availability and accessibility with quality of care and concentration of the best service in one location.

Question put and agreed to.

Committee Stage ordered for Wednesday, 7 June 2000.