Seanad Éireann debate -
Wednesday, 14 Jun 2000

Vol. 163 No. 17

Medical and Nursing Staff Shortages: Motion.

Dr. Henry

I move:

That Seanad Éireann deplores the lack of any sense of urgency on the part of the Government in addressing the medical and nursing staffing shortages in Irish hospitals.

I welcome the Minister for Health and Children, Deputy Martin, to the House. I am very sorry that I must raise this topic. I have asked the Government to debate this issue during its time for the past two years and I have explained, as someone working within the health service, the serious developments that I have seen regarding staffing. I get Private Members' time only once a year and on each occasion I have had to use it to debate something in the health service. The Government should have dealt with these matters in its own time because the situations were so serious.

I will address the nursing situation first because it is worse than the medical one. The Commission on Nursing which was chaired by Judge Mella Carroll produced a splendid report. A considerable number of people went before the commission and a great deal of work was put into the report. Three years ago next July it made its recommendations. The current Minister has been in his Department only a short time and I cannot blame him for the delay in bringing forward a solution to some of the problems which were elaborated by the commission. Nor can I blame him for the first nursing strike here which took place last autumn. It took a great effort for nurses to steel themselves to go on strike. They felt the situation, not just regarding money, but career structure and the treatment of their patients left them with no option and they went on strike.

I am concerned about brinkmanship by the employers within our hospitals. Last month psychiatric nurses almost went on strike in some hospitals because of the non-implementation of the agreements made last autumn. To my amazement I discovered that this dispute was mainly about seniority posts which had been agreed. Some 60% of psychiatric nurses agreed not to strike if another 20 were considered. The fact that we could have a strike on this matter is utterly ridiculous. It shows no sense of understanding the feelings of the people who are employed in these situations. I am very glad Senator Glynn is here because I want to say that we all know that there is a dire shortage of nurses in the psychiatric services. Some speed and imagination are needed to deal with this.

There are many inactive nurses on the register but this issue could be easily addressed. To do a retraining course nurses are obliged to travel to Dublin and support themselves for six weeks. Why can we not have regional courses? We are in such a bad state. Why can nurses who are inactive and on the register not be paid for going on these courses? If that was done we could get them back into the workforce.

Recently the Civil Service held a recruitment fair in the RDS. It decided that new recruits could bypass five grades and be admitted into the Civil Service. Why can we not let trained nurses bypass two grades? Instead of nurses joining at the £15,500 level they could join at the £17,000 pay level. If the Civil Service can recruit new people at higher levels, why then can it not happen with nurses joining the health service?

I know the Minister has agreed to recruit more nurses. Will we get people to fill these places? The recruitment situation is nearly as bad as retention. Student nurses have demonstrated outside of this House because they must pay their fees. In a very short time we will have to pay them not to stay outside of Dáil Éireann but to return to where they are studying.

I cannot separate consultants from the non-consultant hospital doctors problem. I was very depressed to see the Medical Manpower Forum mentioned in the amendment. The forum has not met for five months. A meeting was arranged for 4 April but it was postponed; a meeting had taken place quite some time before that.

I objected to the Medical Manpower Forum's make up in the first place. As 60% of medical graduates are women what was the point of starting off with a forum that consisted of 12 men? Surely some imagination could have been exercised within the Department to ensure that women were represented on that forum; the sub-committees included women as did the training committee. The people working in the workforce must be represented at the highest level. There is no reason this sort of thing should happen.

Deputy Gilmore asked the Minister about the Medical Manpower Forum on 24 May and he replied that the forum would produce a report shortly. Almost a month has passed without anything appearing. The Irish Hospitals Consultants' Association has not agreed to the first report. How on earth will we have a report shortly if half of the people involved in bringing it forward have not agreed to it at all? It is pointless to tell people that something is coming forward shortly unless "shortly" is next Christmas.

There is a huge shortage of consultants here. To bring us up to the Scottish level, which is not reckoned as being over-populated with consultants, we would need approximately 1,000 consultants. The North Eastern Health Board, the Midland Health Board and Mid-Western Health Board do not have a rheumatologist. Is there no arthritis in those areas? We know the problems with arthritis and other rheumatic conditions but there are only 12 such consultants in the entire State.

Scandals do occur in the health service but some of them arise in the areas which are most neglected. Monaghan and Dundalk are the last places in either Ireland or Britain with single handed obstetricians. There are a further nine two handed practices. Since 1 January, the Institute of Obstetricians and Gynaecologists has refused to recognise posts for juniors unless three obstetricians are working in the practice. That means 11 centres will not be recognised. How will they manage without the juniors who do much of the work?

There is a scandal now about the 78 year old locum pathologist who was employed. There are many single handed pathology practices in hospitals throughout the State. What are these people supposed to do when someone goes on holiday? How will they find locums for these positions? They are entitled to some time off. It is no wonder we end up employing locums with whom there are problems.

We are far below the medical staffing levels of most developed countries. I beg the Government not to introduce a screening programme for prostate cancer because there is no way there are enough urologists to deal with it. There are 12 in the State when it is estimated that we need 34. Those on waiting lists who are not there for operations – patients suffering multiple sclerosis, strokes and other serious neurological conditions – will never get to see someone. That is pitiful. In 1991 there were 13 neurologists and we in Comhairle na n-Ospideál asked if something could be done to rectify the situation. That was ten years ago. It is no wonder people are angry about the situation.

Currently, 1% of the population is on a waiting list for an operation. The waiting lists initiative is a good idea but who will operate on these people? Who will anaesthetise them? I was disappointed to hear the Minister say in the Dáil that anaesthesiology is a consultant-provided service. We have no choice but to do it. Gone are the days when there would be a consultant anaesthetist supervising two or three theatres.

Some people will ask what the non-consultant hospital doctors are doing when they are standing about. They are getting ready for people going into theatre or taking people when they come out of theatre into intensive care. They are going round wards. I do not want to hear that nurses will do these jobs because they are struggling to nurse, never mind trying to fill in for the medical profession. The anaesthetists need their staff. The anaesthetic situation is also appalling. I said sarcastically recently that it is still traditional in Ireland to anaesthetise people for operations but it seems we will soon forget about that.

When the Irish Medical Council changed its regulations to make non-EU doctors sit an examination which did not tie in with the British examination, I said that we would run into serious trouble. Everyone knew we would because the non-EU doctors could take their examinations elsewhere. The crunch has now come. The lack of training facilities means that non-EU doctors will not be allowed by the Medical Council to train in some hospitals. It has finally been decided that non-EU doctors will not train in Naas. What will happen as a result? Irish and EU doctors will have to go there as part of their rotations. If it is not suitable for training non-EU doctors, how is it suitable for Irish doctors?

Consultants are asked to continue in medical education and clinical auditing. We would be delighted to but when are we supposed to do it? Every year, 10,000 patients are admitted to hospital and 1,000 per hour, eight hours a day, five days a week are seen in hospitals. There are 1.3 million attendances at accident and emergency departments seen by only 14 accident and emergency consultants. There will be strikes next week because the talks have run into trouble again.

The Minister and Minister of State are truthful people but who told them there was no trouble with staffing? In the Dáil two weeks ago, ques tions were answered with replies which stated that there was no trouble filling consultant vacancies. Here I have an advertisement posted by Naas General Hospital asking anaesthetic registrars to submit curricula vitae immediately for two posts. Such advertisements are everywhere. Mallow General Hospital requires senior house officers, general medical staff, general surgery staff and accident and emergency staff for 1 July. St. Luke's Hospital requires senior house officers by 1 July. A locum consultant anaesthetist is immediately required in Ennis General Hospital. The south infirmary of the Royal Victoria Eye and Ear Hospital is advertising for a locum consultant radiologist. There are pages and pages of such advertisements in the newspapers. There are advertisements placed by Lettekenny General Hospital seeking obstetricians and gynaecologists, anaesthetists, a registrar in accident and emergency and a senior house officer at once. Sligo General Hospital is looking for medical and geriatric specialists. Maternity hospitals are short of 40 midwives and the Dublin hospital area is short of 1,200 general nurses. In spite of that, I am told there is no crisis.

Mr. Quinn

I welcome the Minister to the House. The motion states that Seanad Éireann deplores the lack of any sense of urgency on the part of the Government in addressing the medical, nursing and staff shortages in Irish hospitals. When Senator Henry first informed me of her intention to table it, I was not all that sympathetic. It is the same everywhere, there are signs for looking for staff in almost every window, whether it is a fast food outlet, a shop or a high tech Internet company. The nursing and medical situation is the same.

Then I did some study on the area and read that Ireland was among the lowest spenders on health care in the European Union as a proportion of GDP. I realised then that the answer to this is in our own hands, it is not just another shortage. I am at a loss as to how we got into this situation in the first place. If we compare our medical services to a normal commercial business, we expect higher standards from the medical services because they deal with life and death. That is not the case. When we compare the medical services with ordinary businesses, we find them lacking in even the most basic requirements for running a business which any company would accept without question. How can we put up with such a thing? In a normal business there would be imaginative and creative solutions to such problems. Management would not sit back and say that it is a shame it can do nothing about it. That can be seen in many areas of the medical service.

Senator Henry talked about staff shortages. The Mater Hospital was looking for nurses and was offering two, four, six, eight and 12 hour shifts. Others posts involved job sharing. Such efforts are commonplace in commercial outlets but very rare in the health service. We are not a Third World country, we are a rich nation with a growth rate higher than any other OECD country. It is not enough to sit back and say nothing can be done. The Government has enough money to do something about it but we are lacking imagination and creative management.

Senator Henry may be right that there is a lack of management training. We have medical services which can only be described as a disgrace. We starved these services of resources to the extent that no one is surprised when malpractice scandals arise. Why did we tolerate this? Was it because the standards on offer at the top level, which is accessed by the fortunate few, are impeccable? The standard of care and service provided at this level is extremely high because the best consultants are employed in private hospitals. As a result, the needs of important people are catered for while others are obliged to accept a level medical services which no advanced country would dare to offer its citizens.

I do not doubt that a multitude of excuses, which date from the period when the country was less well off, can be put forward to explain why the level of service available to ordinary people is so bad. In my opinion the apparently abysmally low standard of management in the health services dates from the period to which I refer when we could not afford to take action, but surely those days are gone. For many years we have taken a "poor mouth" approach to the difficulties which have arisen in respect of this and other areas. Now that we can afford to put matters right we should surely begin by improving the health services.

I am not as familiar with the health services as Senator Henry. However, I have enjoyed a number of good experiences when dealing with hospitals in recent months. On the past two bank holiday Mondays I have been obliged to attend the accident and emergency department in Beaumont Hospital because, on both occasions, I injured myself while working in the garden. I arrived in the hospital at 9 a.m. and I was very impressed by the level of care and attention the six people in the accident and emergency department, including me, received.

I am informed, however, that if one attends an accident and emergency department during peak hours one will see that they are obliged to deal with successive crises. However, that is no different from the situation which obtains in most other businesses. If a person is obliged to wait for six or seven hours in an accident and emergency department in order to receive treatment, their temper will become frayed and they will become angry or aggressive. The fact that people awaiting treatment may have taken alcohol or another substance means that there is a need to employ security personnel to maintain order.

These are the challenges faced by those involved in management in any business. However, the people who manage our health services have not adapted to these challenges. The crisis in the health service may not be due merely to a shortage of money, it may, perhaps, be due to a lack of management training. I wish to refer to three examples to illustrate my point.

First, a number of agreements reached in respect of non-consultant hospital doctors in 1997 have not yet been implemented. If that happened in a normal commercial enterprise chaos would ensue, employees would go on strike and there would be a breakdown in industrial relations. The second example involves the agreement reached in respect of the regrading of psychiatric nurses in October 1999. That agreement has not yet been implemented and a strike has been threatened in recent weeks My third example refers to junior doctors' rosters. It was agreed, perhaps three to four weeks ago, that responsibility for the these rosters would be assumed by a senior member of staff in hospitals. Apparently, however, the new system has not yet been implemented in a number of hospitals.

The examples to which I refer do not involve medical matters, they relate to normal management practices which must be put in place. Part of the problem is that those involved in managing our hospitals require advice and help and they should be encouraged to undergo specialised management training. These people should be able to run our hospitals and the medical service in general as if they were normal businesses.

Let us consider how technology might be used to improve matters in the health service. Mechanical aids such as the hoists used in geriatric wards and other technological developments could be used to allow a smaller number of people to do the job better. However, if we do not invest money with a view to providing such aids, the care people receive will not improve. The situation which obtains in respect of providing secretarial staff in our hospitals with word processors and modern computers is similar. In a normal commercial venture, an immediate investment would have been made in this regard.

The lack of investment in the health services was understandable in the past. However, it is no longer understandable, excusable or acceptable, particularly when one considers that we are discussing matters of life and death. Instead of proceeding with the Government amendment to the motion, I urge the Minister to state that there is a need to take urgent action in this area.

Dr. Fitzpatrick

I move amendment No. 1:

To delete all words after "Seanad Éireann" and substitute the following:

"noting that the Government established the Medical Manpower Forum to review the medical staffing in Irish hospitals; recognising that the Government is committed to implementing the recommendations of the Report of the Commission on Nursing, which are designed to address the underlying problems within the profession and develop nursing as a key profession within the health services; commends the Government on its efforts to address the medical and nursing shortages in Irish hospitals.

I have no desire to criticise the previous speakers but one could infer from their comments that we are living in a Third World country with a Third World medical service. That is not the case. Our best is as good as the gold standard offered in other countries. I have no desire to undermine the commitment of consultants, doctors and nurses to developing a quality service.

Mr. Quinn

I agree with the Senator in that regard.

Dr. Fitzpatrick

I am not trying to pick a fight with Senators Henry and Quinn and I accept that there are a number of problems in the health service. However, health services in every country encounter difficulties. One need only consider the manpower shortages and the lack of investment in the British health service. At least the problems faced by the Irish health service relate to a lack of money not manpower. That is the thrust of Senator Henry's argument.

Senator Quinn made a number of important points. He said that while hospitals should not be run as commercial entities, they should be managed in line with commercial standards. I have said previously that hospital managers should be trained in hotel schools and not by the IPA. The approach adopted by hotel managers is customer-oriented, while that of health managers is, by and large, systems-oriented. Many Senators are members of health boards and can testify that they receive a staggering number of reports on a monthly basis. They will also agree that they are expected to be au fait with each of these reports.

One of the problems with the health service is the tendency to focus on systems rather than people. Another is the fact that we are moving towards a consumer led environment. People are aware of developments in medicine and they want to avail of new treatments and services. They rightly expect these to be delivered, irrespective of their ability to pay for them. There are three areas – health, education and social welfare – where the services on offer should not depend on people's ability to meet the cost of those services. Such services should be delivered on the basis of need.

There has been a change in attitude among people joining the health services. Senator Henry will recall that there was an atmosphere of vocation when we entered the health profession. However, that has changed. Students sitting the leaving certificate require straight As in order to gain entry to medical school. I often wonder if such students are ideally suited to becoming doctors or nurses. In my opinion they may be extremely intelligent but they may not have the patience required to endure the daily grind of medical practice. This matter must be addressed.

People's entry to the medical profession is determined solely by the number of points they obtain – if they obtain the requisite number of points, they will be allowed to enter medical school. To interfere with that system might lead to charges of favouritism, etc. That issue must be examined.

I believe that in the near future people will receive a licence to practise medicine only for a certain number of years, after which they will be reassessed and re-licensed depending on their ability to practise and their level of training. This will have huge implications for staffing in the health professions from doctors to nurses to paramedics. People will not be licensed for life any more and will certainly not be licensed up to 75 years of age in the general medical services. I note that a consultant in England practised pathology up to 78 years of age; he was probably a pathology specimen himself at that stage.

The Minister for Health and Children and all future Ministers will have to deal with the huge vested interests in the medical and paramedical professions. Any move the Minister makes will have a domino effect on all grades throughout the health service. Although many people in the health service realise the value of change they, like all human beings, will be slow to change.

The Minister has probably not read the book by Professor McCormack and the late Dr. Skrabanek with which Senator Henry and I are familiar, although his officials may have brought it to his attention. The book is essential reading for anyone dealing with the delivery of health care. These eminent doctors – Professor McCormack is still practising – cast a cold eye on many modern medical fashions such as screening. People are screened for everything nowadays. A person could be screened for coronary heart disease, receive a clean bill of health, walk out the door and drop dead from a heart attack. Screening is not foolproof. The adoption of a mechanical view of medicine, as happens in America and Germany where doctors test for everything, may miss many important factors. The ability to deliver good medicine depends on the practitioners' experience, the years of grind in which they learn from their mistakes or failure to identify problems. That fact should not be underestimated when doctors are being employed.

I do not have any real experience of health board areas outside Dublin but the insistence that senior consultants should spend a number of years abroad, primarily in America, represents a serious waste of money. We can train our consultants to a very high standard here and can send them to good teaching hospitals for a few months if additional experience is required. It is not necessary to waste five good years of medical manpower by insisting that doctors go abroad. Those doctors apply for jobs, their CVs are full of papers which nobody will ever read and which most interviewers would find incomprehensible, and they are subsequently employed here.

Mrs. Jackman

I welcome the Minister. Senator Henry has raised over a number of months on the Order of Business the urgent need to address staffing shortages in the health service. I am disappointed that that urgency is not embodied in the amendment. Most of the Senators present are members of the Joint Committee on Health and Children and I had hoped we could have worked together to resolve this issue.

I acknowledge that the Medical Manpower Forum has been established and I understand that Departments and local authorities must set up various committees. Senator Henry's intention, in tabling this motion, was to get the Minister to acknowledge the existence of problems and to outline specific measures to address those. Perhaps the Minister will address these issues in his contribution. That is all the motion seeks to do.

We are not dealing with mere statistics here. The people who make up these figures are real people who are awaiting operations. Nurses are not under pressure because there are not any vacancies outside Dublin but because it is virtually impossible to replace nurses who are on sick leave or bereavement leave. Hospitals can deal with foreseen absences such as maternity leave. It is not the desire to create a better environment for nurses which poses problems, rather it is the day to day pressure and inability to cope because nurses are absent due to unforeseen circumstances. The urgency of this motion centres around what we can do to relieve the pressures which currently exist in the health service.

Due to the limited time available to me, I intend to concentrate on nurses. It would be cold comfort to them to hear that the Medical Manpower Forum has been established. Their eyes would glaze over on hearing that the forum was established to review medical staffing in Irish hospitals when they are already aware, from a succession of reports, of the problems which currently exist and which existed long before the nurses' strike.

We know there is a shortage of nurses in the Dublin area, although the same problem may not exist outside Dublin. There will not be a massive exodus of nurses from Limerick to Dublin because nurses do not want to work in Dublin. Many nurses who trained in Dublin will naturally want to return to their own areas and many will want to train in their own areas. Due to the lack of openings in nursing schools – I am referring specifically to Limerick – many nursing students have to go abroad. They will naturally want to go the regions when they return home. I do not know what the Minister intends to do about the shortages in Dublin, which are not confined to the nursing profession. The major problems and crises exist in Dublin.

Reviews are all very well but the Minister must address the reality. There is a need for a greater number of social workers and junior doctors. What will happen in July when new contracts must be signed? Perhaps there will be automatic replacements in July but the Minister must address this issue.

What has happened in regard to the medical professionals who were supposed to come here from the Philippines? Are these people already in situ? I understand there are 14 in St. James's Hospital and 70 in the Mater Hospital. I also understand that St. John of God's Hospital has certain missionary or other links with the Philippines and that up to 100 medical personnel may be employed there. I hope that this issue, which was raised in meetings of the Joint Committee on Health and Children in March, has been addressed.

There has been an improved intake of 30 people by the Daughters of Charity at St. Vincent's, Lisnagry as a result of the strong recruitment drive in the media. I stated previously that the campaign budget of £400,000 was very low and that a more attractive campaign could have been launched to attract young people into the nursing profession, particularly psychiatric nursing.

On the centralisation of nursing training and the proposal to bring this under the CAO system, what will happen in regard to points? The points required for nursing are relatively low at present. Students currently require two C grades on higher papers and four D3 grades on lower papers. Has thought been given to what may happen when nursing comes under the CAO system? I have been told that 1,500 of the 5,000 applicants have already been placed.

Many of those who take the graduate nursing diploma in the University of Limerick do not proceed to nursing careers but take up teaching or travel abroad. This does not improve the supply of nurses. Although the Minister has provided finance for those who opt to study for an extra year these students have not been incorporated in the student body. I know the Minister feels it would be difficult to balance between those who have gone through the apprentice scheme and those who have gone through a degree scheme, that there may be an inequity.

Rheumatoid arthritis is a major issue in Limerick. I receive many representations from people who wish to know why patients must travel to Galway or Dublin for treatment for this condition. Rheumatoid arthritis patients suffer dreadfully in the damp climate of Limerick and the west of Ireland.

I would need another half hour to talk about the problems of cancer treatment. An integrated cancer treatment service is needed, particularly for women. I recently travelled with Deputy Keaveney to see the integrated breast cancer service in London. In the Royal Free Hospital I was pleased to note that of the 1,300 beds dealing solely with breast cancer, only 12 were reserved for private patients. I would like to see our public patients having the same access to services as is the case in other countries.

I hope the nursing profession does not become one which does not attract young people. This would leave the medical service in a sad and sorry state.

Minister for Health and Children (Mr. Martin)

I thank Senators for raising this issue and for giving me an opportunity to make a comprehensive statement on medical and nursing staffing difficulties.

I have listened carefully to the contributions of Senator Henry and other Senators. Politicians and the general public must decide whether or not we accept regional statutory health authorities. The Government has been condemned this evening. Regional health authorities were established in 1970 with statutory powers to do certain things about which people are now complaining. The regional authorities are responsible for manpower and human resources. I do not condemn management at local or regional level but there is confusion on this question. Everyone wants the Government to take responsibility for matters, yet everyone loves the idea of regionalisation and trumpets the cause of regional authorities and the need for them. However, I am still asked parliamentary questions about why someone in Castlebar is waiting for an ENT procedure, for example. It is time we decided whether we want a regional approach to the health service or to have all power retained at the centre. We cannot have it both ways.

Senator Henry rightly asks where I get my information regarding the shortage of consultants and their recruitment. I do so by liaising with health boards. Structures of communication between the players in health boards are not satisfactory. Consultants tend to make statements to the medical press. I have often asked people who complain about situations if they have spoken to their health board on these matters.

I was in Mallow hospital last week to discuss a range of issues, particularly the expansion of the hospital. Many people still fear that hospitals will close as they did in the 1980s. It is no longer Government policy to close hospitals. Its policy is one of expansion. However, if a particular area of a hospital is changed, perhaps because of developments in Cork University Hospital, local people become defensive and fear that their hospital will close. There is a reluctance by major players in the health service to engage, even with the local or regional health authority. I stressed to those I met in Mallow that they must engage with their health board. They cannot demand that the Minister solves their problem because they do not wish to talk to their health board.

Progress has been made on the issue of medical examinations. The Medical Council is a statutory authority established by the Oireachtas to make recommendations to the Minister and to do certain work, yet the Minister is asked to intervene and tell the Medical Council what to do. The same applies to Comhairle na n-Ospidéal. Senator Henry has more experience of the comhairle than I. When people do not like what the comhairle tells them, in terms of where consultants should be appointed, they ask the Minister to intervene. There is a reluctance to accept that statutory bodies which have been established to do certain tasks must be allowed to do them.

The Medical Council was set up with great care and given clear functions with regard to the medical profession. Any Minister must be extremely careful not to undermine its statutory independence. I have had consultations with the board of the Medical Council on a number of issues and we have agreed to have ongoing consultations so that its professional development and training remit can be fulfilled while its impact on services in the short term is recognised. This problem deserves to be ironed out. Statutory health bodies have been established and given clear functions. We must acknowledge that.

Investment in health in the past three years amounts to £4.1 billion, although that figure means very little to patients or to people attending accident and emergency units. The hierarchical structure of hospitals has changed little in the past 100 years, despite much change in health and society generally. Hospitals retain the old hierarchical structure of consultant, registrar, house officer and intern. We must change and reconsider what we are doing. The medical manpower forum was not established by my predecessor to while away the time. Delays are regrettable but the forum will deal with issues which must be agreed by all sides and critical issues are outstanding. The medical manpower forum was established to investigate medical staffing in our hospitals and bring forward recommendations.

One of the reasonable expectations of a patient entering hospital is that he will be looked after by medical and nursing staff who possess the skills and experience necessary to undertake the task. The medical manpower forum was established to focus on addressing the imbalance in hospitals between career posts and training posts, the need to improve postgraduate medical training to keep more Irish medical graduates in the country and the need to provide the highest quality of medical care for those who require the services of hospitals.

At present there are approximately two junior doctors for every consultant employed. Non-consultant hospital doctors regard career prospects as poor and many emigrate. Young doctors tend to leave at the point where they have just acquired the skills and expertise and are ready to make a real contribution to Irish hospitals. Women doctors also leave the system and there is a need to examine the reasons why this is happening so that solutions can be found to facilitate the optimum use of their skills and develop training structures to accommodate their needs. I am not happy to preside over such a system and I intend to make major changes in the way hospitals are staffed. Other areas which require attention are the different needs of larger and smaller hospitals, combining other disciplines with medical staffing, general practitioners and nurses, and coping with the demographic changes which have occurred in Irish society.

The Medical Manpower Forum, in association with the various medical interests, will address longer-term contracts for non-consultant hospital doctors. I want to give greater certainty to young doctors as to where they will be working and what they will be required to do. A system of structured rotations that includes training in the larger teaching hospitals as well as smaller general hospitals will give young doctors a broad range of experience and make them fit to fill posts as consultants in the Irish health service. Other concerns include revised arrangements for medical training and the need to take the requirements of women into account. There is much to be done here and I am anxious to progress with agreed improvement and make greater provision in the system for the needs of women.

Institutional structural reform is needed to allocate clear responsibility for ensuring the quality of training in Irish hospitals. There is a need to place more fully trained doctors in our hospitals. This is especially true of night cover and at weekends.

The Medical Manpower Forum seeks to propose policies that maintain and improve patient care while providing a satisfactory working environment and career structure for all hospital doctors. While the forum is expected to advocate an increase in the number of doctors and consultants, major changes are recommended to the structure of training for NCHDs as follows: each hospital should have a training strategy and there should be development of training partnerships with UK and US hospitals, with accreditation of training placements abroad, with training structures and opportunities made available in modular form, both full-time and part-time, forming part of an overall professional development structure that also meets the needs of nurses and other grades of hospital staff. The report will address the need for improved medical education.

Other changes recommended include advocating the development of new training structures which allocate protected time to research, an important issue, the provision of career opportunities for Irish medical graduates with a research orientation, a five year national research strategy, the development of links with private funders and the exploration of roles for senior medical researchers. The Medical Manpower Forum has much to offer NCHDs and we want to publish its first report shortly.

Senator Henry raised the point about the meetings of the forum. Over the past few months, there has been a series of bilateral meetings with individual organisations that constitute the forum to try to make progress on some of the thorny issues that are still unresolved. We think there has to be change. Other interests will have different perspectives on those issues but we will have to continue to negotiate to arrive at a conclusion. We must also resolve the situation with the junior doctors which is currently with the LRC. This House is not currently the correct forum to resolve those issues. The matter is with the Lab our Relations Commission and both parties should work in that context to resolve the outstanding issues.

I take a deep personal interest in the non-consultant hospital doctors' issues. We have already agreed an interim agreement on overtime rates. I have taken a personal interest in the entire industrial relations framework in the health arena because I am conscious that we had 12 major disputes in the past four years. We must move on now to a new era. The LRC will engage in an audit of the health situation in terms of industrial relations. The national partnership group for health under the Programme for Prosperity and Fairness will be meeting to develop protocols and so on.

I am developing the concept of involving all the health partners in a strategic approach to health over the next ten years so that we could collectively develop a strategic plan for the next decade together. All the players should have a sense of ownership in that plan. It is the direction I want take away from the sort of "pot-shotting" going on between management, partners or the different players and to move on to a different plane and put industrial relations on to a new framework.

Some junior hospital doctors work long hours which had the effect of making many NCHDs more inclined to seek positions in other countries or, indeed, in other professions. For this reason, I welcome the new proposed EU Working Time Directive. Initially, NCHDs as doctors in training were, as the Senators know, one of a number of groups excluded from the original EU Working Time Directive adopted in 1993.

I am glad to note that agreement has now been reached on a formula which provides for a nine year transition period to apply the directive to junior doctors. I took the initiative to move from the 13 years down to nine years and I would like it noted that this is an indication of my goodwill towards resolving the situation in which junior doctors find themselves. We must work together to find the right logistics and mechanics to enable us to achieve that timeframe which will be a challenge in itself. We are committed to reducing doctors' working hours to an average of 48 per week as quickly as we can in accordance with European legislation. If we can do this quickly, I will be glad to do it. I am confident that, with the full co-operation of the profession, we can achieve that objective in the nine years ahead.

As part of our preparations for this eventuality we are conducting a major study of NCHD working hours on a joint basis with the Irish Medical Organisation. The study is being undertaken at eight hospitals by PA Management Consultants. The report of the study will be available by the end of this month.

As I have outlined, I had consultations with the Medical Council already, which has decided today that candidates who achieve an overall pass mark in the PLAB – Professional Linguistic Assessment Board – examination conducted by the General Medical Council in the United Kingdom will be exempted from the requirement to take the Irish equivalent assessment. Part 1 of the PLAB can often be taken in the applicant's country of origin. This should make it easier for some non-EU doctors to consider working here.

Some health boards have been actively trying to recruit junior hospital doctors from countries such as Germany where currently there is a surplus of non-consultant hospital doctors. I am also aware that health boards are attending medical employment fairs to encourage junior hospital doctors to work in Ireland. We have been proactively talking to health boards and telling them to enter the market, start recruiting potential junior doctors and meet their manpower shortages and requirements.

On nursing, at the end of 1998, a total of 26,695 wholetime equivalent nursing staff were employed which represents over 31,000 individuals due to the very significant numbers who have opted to work in job sharing or part-time arrangements. In addition, significant resources have been invested to facilitate general practitioners in employing practice nurses in their surgeries. There are now several hundred nurses working in this area.

While the number of qualified nursing staff in employment is now at an all time high, the transition from the traditional apprenticeship model of nurse education to the diploma based programme has impacted on the availability of nurses. This is because the service contribution of students trained under the traditional model has been replaced by a skill mix of registered nurses and non-nursing personnel. While this has enhanced the quality of nursing care through the creation of additional nursing posts in hospitals, it has had the effect of absorbing the pool of surplus nurses that existed when student nurses were part of the rostered workforce.

The House may recall that in 1993-4 when the first diploma based programme was being planned, there was increasing resistance from the nursing profession to maintaining a high student intake at a time when nurses on registration were finding it difficult to find employment. This issue was highlighted by An Bord Altranais in 1994 in a report which referred to a general contraction in nurse employment both at home and abroad. In 1990, the Department commissioned a study of nursing personnel which was presented to the Department in 1995. That took a long time to complete. That report recommended a gradual reduction in the number of student nurses up to the year 2000. We can see how dramatically the situation has changed. Ironically, there is now a general shortage of nurses not only in Ireland but in the United States, Britain and most other European countries.

Against this background, it is encouraging there has been a net inflow of nurses to Ireland in recent years. Data maintained by An Bord Altranais show that, in 1996, the inflow was 939 nurses while the outflow was 1,079 nurses. By 1998, the number coming in had increased to 1,400 while the number leaving had decreased to 850. The inflow figure for 1999 is 3,181 which represents a dramatic increase over 1998. This trend proves that Ireland continues to be competitive when it comes to recruiting nurses from abroad.

As the House will be aware, agreement has been reached between the relevant Departments, to refer to Senator Jackman's point, on a procedure for fast tracking immigration clearances and work permits for non-European Union nurses. The indications are that there is not a nationwide problem regarding the availability of nurses and the difficulties largely relate to the greater Dublin area. While some nurses have always moved from Dublin to other parts of the country, investment in hospitals and the development of regional specialities in recent years have increased demand for nurses outside the Dublin area.

Nurse recruitment is carried out on an ongoing basis in most hospitals and the level of vacancies fluctuates accordingly. At any given time, significant numbers of nurses would be in the process of being appointed by employers or moving from one employment to another.

Hospitals are taking a number of recruitment initiatives. We have been in touch with hospitals and again in touch with health boards telling them to go to the international fairs and start recruiting and make sure we can bring in as many nurses as we can. For example, Beaumont Hospital's most recent initiatives to attract nurses included large stand-alone advertisements in national and international papers and nursing magazines highlighting what the organisation can offer, participation in the recent national recruitment skills fair in the RDS and interviewing foreign nurses. The hospital continues its advertising programme in Northern Ireland, England and Canada as well as its in-house recruitment and retention initiatives.

The Mater Hospital anticipates that approximately 70 nurses from the Philippines will be employed in the near future. However, it will be necessary for them to attend a six week orientation course prior to commencing employment. The first such course commenced last week.

Tallaght Hospital is engaged in an international recruitment drive. It has made 92 job offers to date with the first recruits expected in early July. Its overseas recruitment will continue throughout this year. St. Vincent's Hospital, Elm Park, is involved in a number of initiatives, including contracting ex-members of staff and offering more flexible working hours. It also continues to work with nursing recruitment agencies to fill vacancies.

St. James's Hospital is also employing a range of initiatives to fill positions. As well as advertising in the national press, it interviews and appoints successful candidates who forward their CVs without any invitation. A nursing recruit ment agency is also being utilised to locate specialised nursing staff worldwide, particularly in South Africa, for the critical care and operating theatre areas. The hospital is promoting flexible working hours and creating a family-friendly environment. A proposal to develop an on-site crèche is being prepared. I visited the hospital recently to open a new cardiac facility and it was interesting that it had made great progress in terms of recruiting nurses. The lesson is that different initiatives are being taken by hospitals and agencies but some are more proactive than others and are, therefore, making greater progress in terms of manpower issues.

The major Dublin hospitals have also undertaken a recruitment and retention research project. An action plan for implementation of the report's recommendations is under consideration by chief executive officers and directors of nursing. A range of initiatives has also been taken, or is being progressed, at national level with a view to stabilising the situation and improving it, where possible. These initiatives include new arrangements which have been introduced to give better starting pay to nurses taking up employment by giving full recognition for previous experience at home and abroad. A significantly improved regime of allowances in respect of nurses working in specialised areas, such as operating theatres and intensive care units, has also been introduced.

Standardised overtime working arrangements have been introduced following agreement with the nursing unions. Some 11 hospitals throughout Ireland provided back to nursing courses in 1999 for those wishing to return to the workforce. A total of 304 places were available. The expansion of these courses is aimed at maximising the available nursing workforce. During 1999/2000 16 new post-registration programmes have been developed. This year there will be 660 places on such courses in specialised areas of clinical practice. Some 11 of the 16 new programmes will be located outside Dublin in response to an identified need.

An anti-bullying document prepared by the HSEA and agreed with the nursing unions was published in December 1999 and has been widely promoted within the service. The promotion structure within nursing, including the introduction of a clinical career pathway, is being significantly improved on foot of the recommendations of the Commission on Nursing. Up to 1,250 clinical nurse midwife specialist positions are to be introduced for nurses who have recognised expertise in particular areas. These posts attract clinical nurse manager 2 salary. Nurses are also benefiting from an agreement to upgrade 1,100 staff nurse posts to clinical nurse manager grade 1, which is being implemented.

A study of the nursing and midwifery resource by the nursing policy division of the Department of Health and Children commenced in 1998 with the primary purpose of forecasting future nursing and midwifery resource needs. Following this, a national study on turnover in nursing and midwifery has been commissioned by the Department through the Health Research Board and awarded to the Department of Nursing Studies, University College Cork. Employers have stepped up recruitment from abroad with significant success in Scandinavia and the Philippines, in addition to ongoing recruitment within Ireland.

Swift progress is being made on the implementation of the agenda for change mapped out by the Commission on Nursing. It is all systems go from the Department's perspective in this regard. It was interesting that when all the nursing union leaders spoke at their respective conferences they heaped considerable praise on the nursing division of my Department. They were satisfied with the bona fides of that division in terms of its drive and commitment to implement the commission's recommendations. They had problems with regional authorities in terms of implementation on the ground. We have spoken to health authorities in respect of the absolute importance of fulfilling the agreement that was reached as a consequence of the industrial dispute and we have maintained close dialogue with these authorities to make sure that outstanding payments are made to nurses as fast as is feasible. Many health boards have difficulties in terms of payroll systems, etc., in implementing this complex agreement but we are sparing no effort to implement the recommendations of the Commission on Nursing.

I will continue to oversee their implementation. I have met all the unions in the nursing profession on a number of occasions, including the PMA. We had a good discussion with that union recently and I am glad that collectively we deferred the industrial dispute which had been planned. Channels of communication were opened that could lead to a better industrial relations climate. That is my objective and it is something that I am keen to develop with the HSEA and the Department.

The Commission on Nursing recommended that the Department, health service providers and nursing organisations should examine the development of appropriate systems to determine nursing staffing levels. The need to address skill mix issues was also highlighted in the commission's report. Both of these recommendations are included in the priority action plan agreed with the Nursing Alliance as part of the settlement of the nurses' strike.

We are also keen to attract young people into the nursing profession. The number of training places increased by 153 between 1998 and 1999. This was the first increase in places since the diploma programme was introduced in 1994. Some 3,100 student nurses are in training. The 2000 intake will be 1,500, an increase of 300 on 1999. This increased figure was agreed with the Nursing Alliance as part of the settlement of the nurses' strike. A further 20 places are available on a new direct entry midwifery programme which is being introduced on a pilot basis. There was a record intake of psychiatric nurses last year. We have turned the corner in terms of attracting young people into psychiatric nursing and have opened new schools in this field. Two more will open in Ardee and Monaghan. We have developed good relationships with the institutes of technology in certain locations and they will serve as host schools.

In 1999, following a local and national recruitment campaign costing £400,000, which was funded by the Department, the number of applicants increased by more than 40% on 1998. This resulted in the largest number of direct entrants to nursing for several years. A total of 1,215 training places were filled in 1999, including record intakes of students to psychiatric and mental handicap nurse training. Further funding totalling £400,000 was made available to the various schools of nursing nationwide late last year to enable them undertake local marketing campaigns aimed at promoting nursing as a career. This year there were more than three applicants for every available training place. This is most encouraging bearing in mind that the total number of training places has been increased by 25% over last year to 1,500 and the reduction in the volume of applicants for public service positions generally.

The annual maintenance grant for nursing students, which is not subject to a means test, has been increased to £3,325 with effect from 1 April 2000. The grant is almost double the maximum grant for which other third level students may qualify. In addition, allowances for external clinical placements, books and uniforms have also been increased. These initiatives represent a significant effort on our part to improve the situation. In the longer term it is hoped that the substantial increase in the number of student places will provide enough registered nurses to fill all vacancies.

I refer to the important fees initiative which I announced recently at a cost of £15 million over a number of years. From 1 January 2001 nurses working in the public health service who want to undertake nursing and certain other undergraduate degree courses on a part-time basis will have their fees paid in full by their employing agencies. Fees will be paid in return for a commitment on the part of the nurses to continue to work in the public health service for up to two years after the completion of their courses. This fees initiative will continue until at least 2005, at an estimated additional annual cost of £3 million. It is intended both to marry people's needs by giving them opportunities and to monitor the supply side of nursing.

The initiative is designed for the benefit of nurses who do not already have a degree and includes fees for access courses and nursing degrees undertaken through distance education. It will apply to nurses employed in our public health service in either a permanent or temporary capacity. An important objective of the initiative is to provide an assurance to graduates of the three year nursing diploma programmes that they will have an opportunity to undertake a part-time degree course and have their fees paid.

This should act as a real incentive to newly qualified nurses to enter the workforce following registration and to remain there, thus alleviating the current shortage of nursing personnel. The thrust of this fees initiative is to encourage graduates from the nursing diploma programmes to enter the workforce immediately and for employers to retain them. I am glad to say this initiative has been warmly received by the nursing unions who regard it as the most equitable approach to the provision of financial support to nurses and midwives wishing to undertake post-registration education programmes, irrespective of their model of pre-registration training.

I wish to conclude by again referring to the issue of funding. The health budget this year is in excess of £4 billion and the increased investment in funding under this Government is unprecedented. A major opportunity is opening up to bring about fundamental and lasting improvement in services. It will take a sustained effort but the challenge is to deliver a service that has the confidence of the entire community, where standards are uniformly excellent and where it is acknowledged that decisions, including decisions about resource allocation, are made wisely and on the basis of objective evidence concerning needs.

Since taking office, the Government has made available an extra £1,500 million to health, which represents a 56% increase in the day to day resources going into the health service. This level of increased investment will be sustained and if I have anything to do with it, it will be improved over the years.

An indication of the priority attached to health by the Government can be seen in the fact that previous Governments made available just over £400 million in extra funding. That said, we recognise that in moving forward, not only do we have to spend additional moneys but we must get value for money and we must reform procedures within hospitals and the health service generally. Money alone will not solve this issue. Many good points were made in the House this evening on management issues and the reorganisation of what is happening in the health service, in particular, in hospitals. I am keenly aware of that.

Over the next seven years, a spending programme of approximately £2 billion will be undertaken within the provisions of the national development plan. There is no doubt that will have a dramatic effect on improving facilities. It will impact on the quality of services in hospitals, including accident and emergency departments. My Department is currently engaged in a review of bed capacity under the Programme for Prosperity and Fairness to assess bed needs in the health service over the next few years. I understand the change in figures that has taken place over the past ten years and where we stand in the OECD statistical table. We are examining that area in a critical fashion and hope to have feedback on that matter by the end of July when we will feed that information into the Estimates process.

The only difficulty we will have in spending the £2 billion is whether or not the system will be able to deliver the range of projects covered under the NDP. That is the big issue now. Whereas people are lobbying for various units, this presents a huge challenge to the health service because such moneys have not been invested in capital projects before. It involves getting design teams organised, presenting briefs and achieving all that work in the 2001-07 period. The timeframe in which to spend the money is very tight. I am also conscious of building inflation and other difficulties that are coming down the tracks, which will present real challenges. In addition, people are seeking more than the £2 billion that will be available.

The only question that one can realistically pose in terms of extra capital allocation, if I get it, is whether or not we would actually be able to spend it. Would the system be able to deliver the projects in the timeframe we have set? That is one of the major challenges facing us. My Department will have an overseeing role in spending the money and we will work with the health boards in providing extra resources to enable them to get these projects done on time.

This represents an historic opportunity if we can deal with the organisational issues. I acknowledge the points that Senators have made and I recognise that we have much work to do and more progress to make. However, if we can marry organisational change with the increased investment we will witness an improvement to the quality of health care. I thank Senators for having raised this issue and for allowing me to address the House.

Mr. Costello

I thank the Minister for his comprehensive presentation. I did not catch all of it but it sounded impressive with £2 billion being spent over the next five years. That works out at £400 million per annum, although the Minister did not indicate whether the expenditure would be front loaded. The motion is warranted, given the experience we have all had in recent months. It calls on Seanad Éireann to deplore "the lack of any sense of urgency on the part of the Government in addressing the medical and nursing staffing shortages in Irish hospitals". We have never seen such a level of unrest in the medical service, with nurses on strike and junior doctors marching in the streets. The position is extremely bad at present. I wish to concentrate on my own experience in a hospital casualty department.

An Cathaoirleach

If I might interrupt Senator Costello for a moment, I must inform the House that the Minister has to leave to travel to Belfast and he wishes to apologise to the House for not being able to remain for the duration of the debate.

Dr. Henry

I thank the Minister.

Mr. Costello

I am not sure if I wish to express too many thanks. I would like the Minister to be here for the entire debate because now that we have heard what he has to say, there will be no opportunity for him to come back to address the points we will make.

I wish to concentrate on my own experience in casualty. I was in casualty in the Mater Hospital in 1994 on the day that Ireland played Italy in the World Cup. The match was starting at 7 p.m. and I ended up in the hospital at 1 p.m., yet I barely got out in time to see the match, with two fractured arms. I was in pain for those six hours.

Last Friday, I was in the Mater Hospital again and the situation has not changed significantly in those six years. I wish to go through the procedure that I experienced. I went to a general practitioner at 6 o'clock on Friday evening, experiencing body pains and a tremendous headache that I had not experienced before. I had had the body pains about a week earlier but they had not diminished to any great extent and I felt it was time I saw a doctor. I am glad to see Dr. Fitzpatrick in the House and perhaps I should have attended him. My GP decided it would be best for me to go to casualty and he telephoned the Mater so that I would be seen to very quickly because I had to attend a number of functions that evening. In addition, as I had a severe headache the matter was considered as a priority.

I arrived at the hospital, was seen and was told by the friendly nurse that I would be dealt with well within the hour. There were just two people ahead of me. I waited until 10 p.m. and there were still two people ahead of me. I had to leave at that stage because of the functions I had to attend. I asked if I could go and come back at midnight and was told that I could go but that my position in the queue could not be guaranteed. My position in the queue had not changed in the three hours I had been there, even though I had been referred there by my GP and had been informed by the nurse on arrival that I was unlikely to be there more than an hour.

I arrived back at the hospital at 12.30 a.m. and nothing had happened. The two people ahead of me in the queue were still there and had not been seen even though they were priority cases. I was eventually seen shortly after 4 a.m. One of the people in the queue had been moved aside and was not regarded as being as serious a case as me. So, in fact, from 7 p.m. when I had arrived, one person in the queue was dealt with before me on the priority list by 4 a.m. in the morning, a period of nine hours.

I was told that it was not a particularly busy Friday night, but some emergency cases were coming in. A reasonable number of people had been there before I arrived. One person had been there from noon and still had not been dealt with. Another person with a bad eye injury, who had come from Newry and was on the way to Wicklow but stopped off needing treatment, had been there since 1 p.m. The person still had not been dealt with when I left at 4.30 a.m. They had been there for almost 16 hours, yet had not been dealt with. They had not even been given a painkiller. I had to intervene to try and obtain one for the person who had a ferociously enlarged eye, through which they could not see, following an attack on them in Newry.

A woman told me that her husband had been admitted and seen by a doctor. Two hours later she went to the cubicle to which he had been taken and discovered that the doctor had disappeared and his file had been left to one side. The nurse said to the woman that she wanted her to appreciate it was not a nurse who left her husband there but a doctor. Another person was there with a child who had a severe football injury. They were there before me and they were still there when I was finished.

This took place in the casualty department of the Mater Hospital last Friday night. It was almost impossible to get the attention of a doctor or a nurse; one could not make eye contact. A staff nurse was in charge but not in the sense of managing the situation. Nobody was responsible and there was no way that one could courteously ask a question and get a courteous response. People were bypassed and no information was given. People waited for hours on end without any indication of when they would be seen. They were not told their place in the queue or when they might be treated.

This is my experience, and it was the most horrendous experience I have ever had of any public service. If a politician or a retail outlet provided such a service to their customers, they would not be re-elected or it would go out of business. They could not function; it would not happen. This lack of service was inflicted on the most vulnerable people one can imagine. These people were frightened, injured and in pain. This relates to one casualty department but it is not much different from my experience of the same department six years ago.

The Minister said wonderful things are in progress. There is a need for a major overhaul of structures and how health services are provided to the public. Hospitals are not treating the public as paying customers. This might happen in relation to private health structures, but the situation with regard to public health care is disgraceful in terms of the interface between the public and hospitals in casualty departments. An inquiry into this matter is warranted. I do not understand how the public can continue to be treated in that most discourteous fashion day after day in terms of how long they must wait for services.

I welcome the motion tabled by the Independents. I am not sure that an amendment to the motion should be accepted because there are no improvements on the ground after three years and there is a question mark over future developments. The motion should be put and the Government should accept it in its entirety.

Dr. M. Hayes

I am sorry the Minister, Deputy Martin, is no longer present. I am a little schizophrenic because I spend a good deal of my working life drafting replies for Ministers to the types of points made by Senator Henry. I am ashamed to say that I have drafted items like the proposed amendment which elevates blandness to an art form. It is a pity there is a question of dividing the House on this matter because the motion is an expression of concern about a vital public service. This service is of great concern to us all and I am greatly heartened by the Minister's statement. I would prefer it if Senator Henry's motion was considered an expression of concern and that the Minister's statement was viewed as an acceptance of that concern and a response to it rather than a rebuttal.

In discussions about hospitals and health services, people appear to think that only nurses and doctors work in them. I wish to assert the role of other people who work in the health services and particularly those who are less fashionable, such as ancillary workers, porters and domestics. They are an important part of the caring organisation. If some of their jobs were enriched, it would enable them to take some of the load off nurses. This would release nurses for tasks for which they are more highly trained.

I am also glad the Minister does not want to answer questions on matters of detail. I accept the issues raised by Senator Costello. However, they have little to do with manpower and everything to do with management and attitude. There is a need for a health service in which the customer is king and is treated as such and in which differences are not made because of one's ability to pay. Why should it be less pleasurable to enter a public hospital than a private hospital? Why should a lower level of care be tolerated?

While the Minister is right to stress the responsibility of statutory authorities, a strategic overview also needs to be taken. An eye needs to be kept on whether these statutory authorities are discharging their responsibilities uniformly. Some issues overlap and cannot be addressed within the bounds of a health authority. However, there is a need for a proper debate about the type of health services that are possible, needed and can be afforded and how they can be delivered. More than anything, there is a need for leadership. The Minister, Deputy Martin, appears eminently qualified to give that leadership and I hope he takes the matter by the forelock and pulls it forward. He will find that he has to challenge large vested interests, particularly in the professions, if he is to turn the situation around.

The problems in Ireland are no different from those that have appeared elsewhere. I was in France recently and there was a strike by junior hospital doctors. The same problems also arise in Northern Ireland and Great Britain. The diffi culty is that lead-in times are so long and the whole issue is so complex that changes take an enormous amount of time. However, despite the explanations given by the Minister, it is not enough to leave it to a manpower forum. There is a tendency in all health services to reach for some form of consultative committee or a report. There are enough reports; implementation is needed.

We should be heading towards a consultant-led service. Senator Henry pointed out that the day of the single handed consultant is long gone. The day of the three person team is going rapidly if one is to get a one in five rota instead of a one in three rota. This could do interesting things in terms of addressing the problems of the misappropriately named junior hospital doctors. One of the problems in that regard is the number of consultants is not determined by the number entering the system at the bottom, but the number allowed out through the hole at the top. This must be widened.

If the number of consultants is multiplied by two, there is a need to consider how they are disposed and where they work. People will have to put up with some degree of centralisation. There is a need to start considering epidemiology. Not everything can be done perfectly everywhere and we should not try to achieve that. However, in the short term, there should be a focusing of resources on diseases and conditions which are killing or debilitating people. There is a lot to be said for tackling cancer, heart disease, drugs and geriatric problems in a way which brings tangible and rapid improvement.

It is increasingly possible to look across the Border to Northern Ireland and to bring it into the pool as well. That could help to solve some of the demographic and locational problems in both parts of the island. Northern Ireland is no better off in terms of waiting lists or employment problems. Nevertheless, there are possible synergies and I encourage the Minister to consider them. I am chairman of a hospital in Belfast and we have just taken on cataract work from the North Eastern Health Board which enables it to shorten its waiting lists and enables us to employ another ophthalmologist and, therefore, to shorten our waiting lists. There is a well developed network of professional connections in this field, North and South, and I encourage the Minister to consider that.

We need to go beyond manpower and to look at how medicine is and can be practised in this country. People should be encouraged to look at things radically. We should look at the possibilities of tele-medicine, for example, and of decentralising diagnosis while centralising treatment. Hospital management is a peculiarly difficult operation. However, as the Minister said, there is no point in pouring money into an operation unless it is capable of being well used in a strategic sense.

The health services are full of dedicated and concerned people. Their concerns not only require money but consideration. Many of them need to be loved a bit more than they are at present. Someone compared managing a hospital to managing a hotel. However, one bears little resemblance to the other because customers do not generally arrive at hotels in ambulances and in pieces in the middle of the night. There is one analogy which can be made. If staff are treated well, they will treat the customers well. It is important to have a content, happy and motivated staff in the health service. It is also important to ensure that the customer is king and the client is served.

We must turn the service around and make it more service oriented in the same way as the best service industries. The benefits are there to see if we do that, although it will take a long time. I hope we can agree on that sentiment, on what the Minister said and to support the concerns of Senator Henry and her colleagues without attempting to be complacent or bland about them.

Mr. O'Toole

I compliment Senator Henry on bringing this matter to the attention of the House because it is the type of issue we need to discuss. On many previous occasions we on the Independent benches have tried to raise such issues. Senator Henry has tried time after time to get more information on the annual report of the psychiatric services in hospitals. It is important to look at what we are doing here.

I listened to the Minister but he seemed to see the picture through rose tinted spectacles. Although he said many things with which I agree, he did not get to the fundamental point that there is a lack of a sense of urgency in addressing the problem. The Minister is right to say that politicians have a habit of giving something to a committee and, when they do not like the result, of asking the Minister to intervene. However, that does not take from the fact that there are problems which are not being addressed.

We, as public representatives, have an appalling record in our approach to the health issue. We, and parties in particular, have used it time after time as a political football. I could go through every one of the past four or five elections and give examples of big billboards which advertised what one party would do with the hospital queues and what had happened when the other party was in Government. The elections in 1989 and 1992 were largely about health issues. The way the health issue has been handled is unacceptable.

I also remember the outcry when the South Western Health Board decided to reduce the waiting lists for hip operations by getting some of them done in Belfast, as Senator Maurice Hayes mentioned. I do not understand why anyone would worry about that. One of the great problems in Irish society is the demand for a hospital in every village and a specialist in every town. However, that is not what this motion is about; it is about making a service available. I agree there are extraordinary synergies which could be and are being developed. There is no doubt that a hospital, such as Altnagelvin in Derry, is dealing with many people from the north Donegal hinterland. That is the type of operation which should continue.

The closure of Barrington's Hospital was considered to be the end of the medical service as we knew it in Limerick. However, it was a good decision because it was unnecessary to keep it open. The proper thing to do was to develop services in the region. I cannot remember who was in power at that time but it is irrelevant because whoever was not in power led the opposition to it and agitated people, which always leads to problems.

Mr. Costello

Deputy O'Dea did that.

Mr. O'Toole

I have a vivid memory of that great gentleman, Jim Kemmy, leading the charge. I recall talking at the time to the then Minister for Health, Barry Desmond, who was a member of the Senator's party, and he told me that not only were the Limerick people opposed to the closure of Barrington's Hospital but they wanted to open a fourth hospital in Limerick. He did not say that publicly at the time, but he did not have any difficulty in hindsight. I could recall other stories as well.

There are extraordinary demographic changes in Irish society. People are living longer and medical science is allowing them to live more comfortable and better lives. However, this creates more demands for medical services because as people get older they require more care. As knowledge and medical science have progressed, they have become more specialised and focused. Where a generalist, a semi-specialist or a specialist might have dealt with something in the past, it now requires a specialist of specialities to take it further in many cases. People know more about their conditions and, therefore, they demand an understanding of what is happening to them.

We must go back to the old economic argument. The first rule of economics is a simple one, namely, the first requirement for a developing economy is an educated and healthy society. Health and education require investment. I can listen to Ministers of all hues but it is the same advisers who are doing all the work, writing the speeches, giving advice and deciding on policy. The Government moves the issue on as elections bring new political masters in and out like Lanigan's ball but the reality is that the decisions are being taken there. This is the incontrovertible fact.

Despite all the statistics that have been given to us and all the factual evidence that more and more money is being invested in health and also in education, the reality is that in terms of the services per head of population and in terms of the spend as a percentage of gross domestic or national product, we are behind our European partners. As I said during the negotiations on the PPF on the areas of health and education, the objective should be to spend on average the same as the average of our European partners in terms of percentage of gross national or domestic product on our health and education services. That is when we will have arrived.

It is not a question of the simple measurement of whether we have put more money in this year than last year or five years ago. We are starting off from such a low base that these are not the appropriate measurements. The appropriate question is the level or percentage of gross domestic product that should be invested in our health services. That figure is the figure which will be the average for Europe. We are not doing that and there will be a sense of urgency until we do it.

This is the answer to the Department of Health and Children officials who say that if we give them this they will want more and they will never have enough. The way to deal with this matter is to have a long-term objective and to have a graded way of reaching it. It is for that reason that I strongly support—

Mr. Glynn

The amendment.

Mr. O'Toole

—the motion. Sorry to disappoint the Senator. People have been jumping sides all day. We will wake up tomorrow morning and nobody will know what party anybody is in. Thank God I am an Independent.

Mr. Glynn

The Senator will not go through that tomorrow morning.

An Cathaoirleach

The time is very limited at this stage.

Mr. O'Toole

It takes guts for those on the Government side to sneak in at the end and commend the Government on its efforts to address the problem. Let us see a result. If ever there was a time for performance related pay, this is it. There is a lack of urgency and there is a demand. The Government is not doing the business in terms of putting enough into this area but it should keep trying and let us see the results at the end.

Mr. Glynn

I promise Senator O'Toole I will not jump left or right but stand where I am. I welcome the Minister to the House. He is deeply committed to resolving whatever difficulties exist in the health services. While I am not saying that everything is Utopia, the amendment before us reflects the factual position pertaining to the performance of this Minister and this Government.

Senator Henry might feel aggrieved that she did not get this debate sooner but I can tell the Senator and the other Members of this House that I was calling for a college of nursing in Tullamore for 15 years. In fairness to the local media, they gave me credit when that eventually came. I accept it did not come to Mullingar but, taking up the point that the Minister made earlier, we were talking about a regional facility and that is the context we should be thinking about. I would also refer back to 1985 when the Midland Health Board took a decision pertaining to the rationalisation of hospital services and from that decision flowed quite a number of specialties which we would never have had under the old system, including rheumatology, ophthalmology, ENT, paediatrics, etc. It is important to address this matter in a regional context because that is what is relevant today.

Senator Henry expressed concern about the nursing shortages, especially in the psychiatric services. Although I am no longer in the profession, I still have an abiding interest in it. I am pleased to go further than the Minister went in respect of the exact statistics pertaining to the recruitment of psychiatric students, which would indicate to all and sundry that we really have turned the corner in the context of recruiting for this nursing discipline. In 1997 we had approximately 100 recruitments and 92 in 1998. The following year we had a record intake of 254 and in the year 2000 we have 300 places. In addition, I am pleased to say there is a practice of retraining nurses who have left the profession. That does not pertain to the psychiatric discipline alone but to all the other nursing disciplines. That is an important use of a resource because any professional person, or any person who has a skill, who is non-practising is a disregard for an important resource.

I referred earlier to the college of nursing in Tullamore. When the college was set up in September 1998, we had an intake of 20 students. In September 1999 we had 30 students and in September this year we will have 42 students. It is clear that in this context, while we are not clapping ourselves on the back, we certainly have turned the corner.

There has been, for very practical reasons, a difficulty in relation to the recruitment of nurses for the Dublin area. A number of factors impact on that difficulty, including the problem of parking and the cost of accommodation. There is a whole plethora of reasons nurses are difficult to recruit.

In terms of students wanting to pursue diploma courses, there is no doubt that has had an impact. The position that obtained in England, which I understand is now discontinued, was that they had the SRN and the SEN grades. When I visited a psychiatric hospital in Leicester I met the nursing officer, a well informed gentleman who was very courteous to me, but in the main his staff on the day was a dual qualified SEN and a number of other ancillary staff. If that gentleman had to go off the ward, there was no qualified person to replace him. We have criticised ourselves in many ways and we have been criticised here today, in many cases unfairly, but that is one problem we do not have to contend with and we should be grateful for that.

I have long felt that our general practitioners are in the main an underused resource. I find it objectionable that if a person gets a thorn in their finger or if they have a pain in their big toe, they go to the casualty department of the local general hospital and immediately become a waiting list statistic. In the main, our general practitioners provide an excellent service but greater use could be made of them. They perform a valuable role currently but that role could be expanded.

To return to the question of the psychiatric services, we debated a motion last year, again put forward by the Independent Senators, on inappropriate bed occupancy. The practice of lodging in psychiatric hospitals is an abuse. Such people are occupying acute beds, and that is not what psychiatric hospitals are for – they are for treating people who have psychiatric illness. Each bed therein is an acute bed and it should be used as such.

The shortage of doctors in Britain will also impact on recruitment of non-consultant doctors here. The long-established tradition of Irish junior doctors going to work in Britain proves the old Irish adage bíonn adharca fada ar eallach thar lear – far away cows have long horns. It is important for junior doctors to travel and to get experience but it will further impact on the situation here.

What has been said by the Minister will impact in a positive way. I welcome the £4 million bed replacement announcement by the Minister. If anything has contributed in a major way to back injuries among nurses it is inappropriate bed stocks. The allocation is aimed primarily at psychiatric and geriatric hospitals, but it will have a knock-on benefit for general hospitals as well.

Ms Leonard

I also support the amendment. From a nurse's point of view I particularly welcome the Government's commitment to the implementation of the full recommendations of the report of the Commission on Nursing.

We all recognise and acknowledge that there are shortages in the nursing and medical fields. I entered training as a nurse in 1987, when the country was in a deplorable state financially. I was fortunate to be able to enter the profession at that stage. From then until the mid-1990s nurses have been treated in a deplorable manner. That is not a partisan view but is the view of all sides. I particularly welcome the initiatives which the Minister discussed here tonight. However, I would like to put on the record the treatment that nurses received between 1986 and 1994-95.

First, it was very difficult to enter the profession. If one did not have an honour in biology and an honour in English – why one needed an honour in English to enter nursing I do not know – one was totally disregarded, regardless of individual qualities of patience, a flair for nursing and a bedside manner. In my hospital 21 students completed their course at that time, eight of us were given temporary employment which lasted approximately six months, after which we were on our own. Most nurses, and most of my friends at that time – 1991 – were forced to emigrate or to work in any care setting in nursing homes and so on just to gain experience as a nurse. Many travelled abroad. Nursing was always seen as a training that gave one a passport to the world. However, at that time the emigration was forced and not by choice. Nurses who train nowadays may travel abroad by choice.

In addition, at that time one could not get a job if one did not have experience, but one could not get experience because there were no jobs. In 1994-95 many hospitals offered employment to nurses on a temporary basis. They were employed on an 11 month contract, after which time they were automatically discharged from their duties, despite the fact that others were coming in to take over their role. That was because if they stayed on any longer they would have to be made permanent in the hospital.

I do not believe in apportioning blame. However, hospital employers at that time were responsible for the deplorable way in which nurses were treated. I firmly believe that the problems of the early 1990s are only manifesting themselves now because nurses left the country and chose not to return. If the opportunity arises to take up employment as a medical or pharmaceutical representative, in human resource management or many other areas, particularly health and safety which has come to the fore in the last number of years, nurses will take it.

Despite all the qualifications a nurse may have, it is a particularly physical job which requires dedication. It is no longer a vocation and I am delighted that we have passed the stage where nursing was seen as such. Nursing is a job which requires dedication and commitment. At the moment it requires ongoing education. Nurses must keep abreast of what is happening because changes are taking place in nursing care and treatments on a weekly basis. Unfortunately, we often lose sight of where we were. There are problems now. I would be the first to acknowledge that because I have many friends who are still working in the profession who are having difficulties. However, we must recognise the initiatives which have been introduced in the past few years, particularly as a result of the nursing commission's report.

The recommendations I particularly welcome are those relating to education and the way nurses are being encouraged back into education whereby their fees will be paid if they commit themselves to working in the public health service for a number of years. I worked in a hospital in the early 1990s at a time when if a nurse wanted to take a one-day course to improve herself – which would benefit the people she was looking after and the hospital she was working in – she had to do it on her day off. For the past 15 years, until 1997-98, every nurse had to do that. Money has never been the issue for nurses. Recognition has always been the issue – recognition of the job they do, the care they give and the profession they are involved in. However, at that time, no matter what a nurse wanted to do, she had to do it completely at her own expense and she had to organise for somebody else to work in her place if she could not get the day off. They are the facts of the matter.

The initiatives the Minister has outlined are particularly welcome from the point of view of nurses. I have no doubt that it will encourage people into the profession. Change will take time. Nursing has not been seen in the last couple of years as the ideal occupation because of unsocial hours, the day and night duties. Everything a person does not want exists in nursing. However, of all the jobs I have ever done, there is none that can give such job satisfaction. That is something we lose sight of when we get side-tracked on the issue of the amount of money an individual earns. If nurses feel they are treated well in the profession, and can avail of the opportunities the Minister, Deputy Martin, and his predecessor Deputy Cowen have set in train, it will attract more people into the nursing profession and retain nurses in it. More importantly, the care they are giving because they are satisfied in their job will benefit the patients in the long run and improve our health service.

I am sorry I do not have time to go into the medical aspect but that could take another eight minutes.

Dr. Henry

I wish Senator Leonard had more time because it is by personal testimonies like hers that we can see the value of having people with experience in these areas talking in here. I have often said to her that I worry about the fact that no kudos are ever given to the clinical skills of nurses in this debate. When I phone someone at 10 p.m. to inquire about a patient I want to be told more than their pulse and blood pressure measurements. If a nurse tells me they do not like the look of a patient then their comment can tell me an awful lot more about the condition of the patient. A comment from someone who has worked in this situation means an awful lot more than measurements. Senator Tom Fitzgerald and I argued about this issue yesterday but I will leave it at that.

I am profoundly disappointed in what the Minister has said. It is fine to talk about all the initiatives taking place in nursing. The Government has been in power for three years yet nurses had to get out on the streets before there was some action. Apparently the non-consultant hospital doctors will have to do the same.

The Minister began by saying that we are undertaking a fudge in this House. I rather resent his comment. He went on to say that statutory bodies such as the Medical Council, Comhairle na n-Ospidéal and all the health boards stand alone. That is a true statement. Later he said that he had phoned the health boards and told them to do something about the situation. He said he had told them to go abroad and look for people to employ. Why does he not tell them to find a way to retain the people we already have? If he did that we would not have to go abroad or look in Germany for people. We should fix things up so that we can retain the people we already have.

I was rather annoyed that the hierarchical situation within hospitals had to change. The only change that must be made is for the top of the pyramid to expand. This would allow for more consultants and junior hospital doctors or non-consultant doctors would be able to see a career path for themselves. Has the Department of Health and Children looked at the number of consultants taking early retirement? Has it looked at the length of time they will draw their pensions? I regret to tell you that it is not all that long.

Senator Glynn talked about involving GPs more. They are pinned to their collars most of the time. I agree that far too many people go to casualty departments. It is estimated that 80% of people who attend such places would be better off going to their general practitioner. That is not to say that GPs are doing nothing. They are extraordinarily busy and we are losing them through emigration as well.

My motion only concentrated on the hospital service. We have talked about changing medical staff but what about changing the management staff? The Minister did not mention management staff in his reply.

Ms Leonard

Hear, hear.

Mr. Glynn

I will not argue about that.

Dr. Henry

We have criticised the various posts down the country where non-EU doctors can go. The training bodies will not allow them to take up positions in these places because they believe there is not sufficient training available. We will have to fill those posts with Irish and EU graduates because someone must run those hospitals. I do not think the Minister really stated what he was going to do about this. I am still not clear if he has accepted that Ireland will not ask for another derogation on the Working Time Directive. Perhaps he will tell me that we will definitely not seek any more than nine years. This length of time is bad enough and I do not want to see any more slippage in this area.

The Government has been in existence for three years. What happened to the Tierney report? Why should we start again with the Medical Manpower Forum? The Tierney report looked very good to me. Dr. Tierney was a very nice man and he produced a report. We are continually churning things over.

Comhairle na n-Ospidéal is not independent. It must report everything to the Department and seek its approval. The Minister's officials will confirm that.

I know the Medical Council is a stand alone body. The Minister could introduce an interim solution for a few years by extending temporary registration from five to seven years. This would mean that the non-EU doctors we have captured and got here would have to stay on for another few years. Many training courses take six years while temporary registration lasts for five years. This is a bit of an anomaly.

Like Senator Leonard I could go on all night. Some time Senator Leonard and I will have a night to ourselves in here. Senator Tom Fitzgerald could tell us about his experiences as a patient and Senator Quinn could be present as well.

Amendment put.

Tá

Bohan, Eddie.Callanan, Peter.Chambers, Frank.Cox, Margaret.Cregan, JohnDardis, John.Finneran, Michael.Fitzgerald, Liam.Fitzgerald, Tom.Fitzpatrick, Dermot.Gibbons, Jim.Glennon, Jim.

Glynn, Camillus.Kett, Tony.Kiely, Daniel.Lanigan, Mick.Leonard, Ann.Lydon, Don.Mooney, Paschal.Moylan, Pat.O'Brien, Francis.Ó Fearghail, Seán.Ormonde, Ann.Quill, Máirín.

Níl

Burke, Paddy.Coghlan, Paul.Cosgrave, Liam T.Costello, Joe.Henry, Mary.Jackman, Mary.

McDonagh, Jarlath.Manning, Maurice.O'Dowd, Fergus.O'Toole, Joe.Quinn, Feargal.Taylor-Quinn, Madeleine.

Tellers: Tá, Senators T. Fitzgerald and Gibbons; Níl, Senators Henry and Quinn.

Amendment declared carried.

Motion, as amended, put and declared carried.

An Cathaoirleach

When it proposed to sit again?

Mr. Dardis

It is proposed to sit at 10.30 a.m. tomorrow.