Health Services: Motion.

I move:

That Seanad Éireann:

—noting the emerging crisis in the delivery of our maternity services all over the country;

—noting the recent unnecessary death of a person in Monaghan due to the downgrading of the accident and emergency service in Monaghan;

—noting the 33 hour wait by an ill woman on a trolley in Limerick Regional Hospital recently;

—noting the determination of the Minister for Health and Children to implement the disastrous recommendations of the Hanly report;

calls on the Government to drop the Hanly report and to upgrade the accident and emergency service currently available in general hospitals all around the country in order to ensure that every patient in need of a service gets the service they need when they need it, and to further ensure that the crisis in the maternity service is not allowed to deteriorate further.

I am happy to move this motion on behalf of the Labour Party group. The reason for tabling it — we appear to debate health a great deal in this House — is that the issue cannot be ignored. The state of our health services is one of the major preoccupations and concerns of the public. That is not the main reason one would table a motion, although it is a good one. It is because our role as an Opposition group, particularly in Private Members' time, is to seek to make the Government accountable for its actions and also to engender public debate about Government policy, Government decisions and to raise in a public arena matters of major concern.

Last week when I considered what we should discuss in Private Members' time it appeared that issues around health were at the top of the agenda, particularly the delivery of maternity services, the crisis in acute services in the Monaghan area, due directly to Government policy in regard to Monaghan General Hospital, the 33 hour wait by an ill woman on a trolley in Limerick Regional Hospital, which was highlighted in the media last week, and the determination by the Minister for Health and Children to implement the disastrous Hanly report, which is the area on which I wish to concentrate. My colleague, Senator Tuffy, who will second the motion, will speak on the issue of maternity services, which is appropriate considering that she is the most recent mother in the House.

I shall speak about the position in Monaghan and the situation in Limerick, with which I am quite familiar, given that I live near Limerick. The Minister of State at the Department of Health and Children, Deputy Tim O'Malley, whom I welcome to the House, may be aware, as I am from staff in Nenagh General Hospital and people I have met, that people from Limerick and its environs are using the accident and emergency service in Nenagh because they cannot get into Limerick Regional Hospital. If they go to Limerick to access the accident and emergency service they have to wait hours and sometimes two days. I know of people who were sent to Limerick Regional Hospital from Nenagh hospital with fractures and were there for almost two days. I spoke to a lady recently who spent almost an entire weekend in the hospital's accident and emergency unit despite it being a so-called designated hospital under the Hanly recommendations. People from the Limerick area are travelling to Nenagh hospital to use its accident and emergency service because of the horrendous delays in Limerick Regional Hospital.

A debate took place in the other House last week on the position in the north east. I have read that debate. I specifically wish to raise one comment made by the Tánaiste and Minster for Health and Children, Deputy Harney. In her remarks the Tánaiste made it clear she is determined to implement the Hanly reforms. That was the first time she made it clear she would do so and it is one of the reasons the motion is before the House. The Minister of State, Deputy Tim O'Malley, contributed to the debate. The Tánaiste stated: "The board proposes to recruit five additional non-consultant hospital doctors to facilitate the early restoration of 24 hour, seven-day medical cover to Monaghan General Hospital, at an estimated additional revenue cost of €500,000 a year." She went on to say that revenue funding for ten additional beds has been approved.

The language used by the Tánaiste is the same language that is used in regard to Nenagh hospital — the notion of 24 hour, seven-day medical cover by non-consultant hospital doctors. Non-consultant hospital doctors have also been recruited for Nenagh hospital. This is a clever play on words and it raises the question as to when an accident and emergency service is not an accident and emergency service. It is not an accident and emergency service when surgical services are removed. It is notable that in Monaghan General Hospital surgical services are being removed, therefore reducing Monaghan to what the other hospitals in the Hanly recommendations should provide, namely, 24 hour, seven-day medical cover.

The provision of medical cover effectively amounts to a minor injuries clinic. Without the backup of consultants on site and surgical services it cannot be said to be an accident and emergency service. We can see from the Monaghan area what are the implications. The family of Mr. Benny McCullagh know them. He was a man who lived very close to Monaghan General Hospital and who died because the hospital could not treat him as it did not have the acute service required. That is the consequence that will follow the implementation of the Hanly report. I have no doubt that what is happening in Monaghan is a test case in this regard. If it can be implemented in Monaghan and in the mid-west, Hanly II will be rolled out and the reform will be in place. I also do not doubt the total determination of the Minister to do that. I ask her to come into the House and state that in clear terms. If she does not attend the House this week I ask the Minister of State to state clearly that it is the Government's intention to implement the Hanly reforms because it believes that is what is best for the patient. There is a body of opinion that believes that.

However, the fundamental basis on which Hanly is positioned is totally flawed. In that regard I refer not only to the report itself but to an analysis of it prepared by Ms Catherine McNamara, a health economist, on behalf of the hospital services action group. Ms McNamara is not the only person to have pointed this out. In this widely available document, which was published some months ago, she points out that the evidence for the basic proposition in the Hanly report, namely that higher volume hospitals produce better outcomes, is flawed. The statistics and evidence to which the report refers are misinterpreted.

The Hanly report states that larger volume hospitals produce better patient outcomes. It refers to the York report in that regard, yet the latter report came to the exact opposite conclusion. The members of the National Task Force on Medical Staffing did not read the York report or, if they did, they chose to interpret it in a different way. Therefore, criticisms of the Hanly report are not the wild rantings of culchies from the regions, whether it be Monaghan or north Tipperary, as one would have it from certain urban commentators, particularly those from Dublin. They are not the mad rantings of country people who allegedly want a hospital at every crossroads. The fact is that the very foundation of the Hanly report is totally different from what the task force says it is and therefore the policy is flawed. However, the Government, by way of its single-minded, "must be right" approach, is determined to wreck the health service of communities throughout the country with its disastrous policies. An example is the downgrading of Nenagh accident and emergency unit, which would result in thousands more using an already overcrowded facility in Limerick.

If one asks why the Government wants to do this, one will start to see clues. Obviously there is another agenda, which in turn is one of a series of agendas. An article inThe Irish Times from Saturday, 13 November 2004 offers a clue to the nature of the real agenda: “The Tánaiste and Minister for Health, Ms Harney, will signal next week [presumably this week] that she wants public hospitals to enter into agreements with the private sector to develop additional medical facilities on their campuses.” Of course this is happening already. The Minister will know that there were recent tenders for the building of a private hospital close to the existing public facility in Limerick. This indicates that the real agenda is to build private facilities and to have a system in which one buys one’s health care. This is the bottom line.

We see evidence of this approach in many areas, particularly in the tax breaks for capital funding for facilities for the care of the elderly. Such facilities are not capable of taking and do not want to take elderly people with medical conditions who cannot leave hospitals because they have nowhere to go. Such people are, according to a horrendous phrase, the "bed blockers". Nursing homes can only take relatively healthy old people. Hospitals have to take the medical patients because the nursing homes cannot afford highly qualified nurses and medical personnel to care for them.

It is clear that the PD agenda of the Government, which is accepted by Fianna Fáil, is to have private facilities in public hospital premises. This, on its own, is not necessarily bad, except that underlying the agenda is the principle that we should be buying our health care. The national treatment purchase fund is another example of this. I fundamentally object to the idea that one should have to purchase health care in a private market. Under this British system this would be called Thatcherism.

If one cannot afford to buy health care, where will one get it? The public system is being run down and the idea is to force people to use the private system. There is considerable evidence of this, which, unfortunately, I do not have time to set out this evening. I hope we will have a comprehensive debate on the Hanly report in particular. I call on the Minister to think again. It is not too late to reverse this disastrous health policy and to realise that the circumstances in Monaghan will replicate themselves around the country. Is that what the Government intends to achieve?

I believed the Minister for Health and Children would be present today. She is in my constituency and I wanted to have the opportunity to wish her well in her new position. I had hoped to ask her about Peamount Hospital in my area. I do not know if the Minister of State will be able to update me on it. I want to know the Department's opinion on the plans for restructuring the hospital and on the need to provide more respite care resources.

Apart from its implications for Peamount Hospital in my constituency, the Hanly report does not constitute a significant local issue. I read an economic analysis of the Hanly report by a Dr. McNamara and having considered the report's implications for Peamount Hospital, including the proposals to reduce or remove its TB care services, I can see why it is flawed. I hope the new Minister for Health and Children and the Minister of State will consider this. It is good that a report such as the Hanly report has been published, but one does not just accept such reports lock, stock and barrel. One should consider the Hanly report critically before implementing it and accept that there will be different views thereon.

As Senator O'Meara has stated, there is a tendency to portray those who criticise the Hanly report as if they were backward and living in rural communities that are against progress. As Maeve-Ann Wren stated in her book, in reference to the election of Deputy Connolly——

It is not in order to refer to those outside the House.

People are voting for candidates like Deputy Connolly because they want more accessible health care services and because they are unhappy with the present health system.

As Senator O'Meara stated, I will refer specifically to the maternity health services. I had a baby recently and this has really made me conscious of issues concerning babies, children and families. Two days ago, the Minister of State, Deputy Tim O'Malley, awarded Limerick Maternity Hospital a UNICEF and World Health Organisation award, which is part of a programme initiated by the two organisations to promote breastfeeding. I did some research and noticed in a newspaper a reference to the implementation of a ten-point plan in this regard. The World Health Organisation and UNICEF introduced this concept circa 1989 and a number of hospitals in Ireland are trying to implement it. The World Health Organisation and UNICEF assess the implementation of the plan and interview mothers who have been to hospitals to understand their experiences of those hospitals' practices and procedures. Limerick Maternity Hospital must be commended on being the first Irish hospital to receive this award and for faring so well in the assessment procedures.

Breastfeeding should be promoted but should not be pushed on people. The statistics indicate that it helps to reduce the incidence of diabetes and so on. Promoting breastfeeding will reduce diseases in the future and help the health system. I had a good experience in the Coombe maternity hospital, but there is room for improvement in many areas. Hospitals need more resources and the Government needs to be proactive in providing backup for hospitals to provide services. The hospitals are very busy, even though statistically there are fewer births than in previous decades. Given the closure of hospitals and cutbacks in budgets, hospitals are finding it difficult to deliver a service, particularly in supporting new mothers who wish to breastfeed. If they do not wish to do so, they should be helped as much as possible. I hope the Government will do as much as possible to promote this initiative. An official in the Department of Health and Children co-ordinates this policy but perhaps the Government will consider putting in place legislation to deal with the issue. The Limerick maternity unit tried to ensure that a formula would not be advertised by health professionals. This is done on a voluntary basis but perhaps legislation needs to be put in place.

Children require good maternity services in order to get a good start in life. All the supports necessary should be provided for mothers. I do not have the figures for 2004, but the masters of two maternity hospitals in Dublin, the Coombe and Holles Street, indicated that their budget was cut in 2003, which is unsatisfactory. In 2003, the Coombe Hospital had the highest number of births since 1972, when it was encountering Government cutbacks. I hope this policy will not be continued by the Minister of State, Deputy O'Malley, and the new Minister for Health and Children.

The national treatment purchase fund is a Progressive Democrats policy. While it is currently achieving some success, it is not a good long-term policy. It will do nothing to create extra beds, yet is using up valuable resources. If we are to solve the problems in the health service, much more needs to be done in the long term than buying services from the private sector.

I move amendment No. 1:

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

"commends the Government on its continuing substantial investment in the health services; notes the progress already made in implementing the health strategyQuality and Fairness — A health system for you; and endorses the commitment of the Tánaiste and Minister for Health and Children to achieving health reforms that will benefit all members of the community.”

I cannot accept Senator O'Meara's comment that there has been a scaling down of investment in the public health service, which is not true. The statistics indicate the opposite is the case. For example, the funds invested have allowed the Government to hire 8,200 new nurses, 438 new consultants, 661 new occupational therapists, 456 extra physiotherapists and 200 extra speech and language therapists.

I am a long-standing member of the Midland Health Board and a number of consultant posts have been approved and brought on stream in the past six or seven years. In 2000, a consultant physician, a consultant in the area of oncology, a consultant in the area of accident and emergency, a consultant haematologist, a consultant orthopaedic surgeon and a consultant radiologist were appointed to the Midland Regional Hospital in Tullamore. New posts approved by the board include a consultant in emergency medicine, a consultant anaesthetist — date to be confirmed, a consultant nephrologist, two consultant anaesthetists and a consultant surgeon. A total of nine consultants have been appointed in Mullingar since 1997. Documentation from the Midland Regional Hospital in Mullingar lists a consultant radiologist appointed as per the service plan 2004. In the past few years, Portlaoise has received three new consultants and consultants have been appointed in the areas of accident and emergency. This does not indicate that the Government has reduced investment in the area.

The funds invested have gone a long way towards the largest hospital modernisation programme in our history. They have contributed to a dramatic increase in care places for people with disabilities and contributed to improving cancer survival rates and exceeding ambitious targets three years ahead of schedule. In 2003, almost 200,000 more cases were dealt with in our hospitals than were dealt with before we started our programme. This is clear evidence that what the Senator said is not true. In 2003, more than 1 million people were treated in the health system — real people, receiving real treatment for serious conditions. We also know there is a long way to go in many areas.

Everyone recognises that funding alone will not and cannot deliver the health system people deserve. We have now published the most comprehensive reform programme in the history of the health service. Each element of the system, from primary care to acute services, has been analysed. A challenging agenda for delivering world class care has been set out. We are supporting a reform programme, which will make fundamental changes to health care in Ireland. Health reform is not just about changing structures, it is about accountability, planning, financial management and control systems. When we talk about financial management and control systems, we must ensure that when we put money into a system it will deliver and achieve results. I do not think anyone can criticise the incumbent Minister or previous Minister for ensuring that we get value for money. Crucially, it is about ensuring that funding goes to where it is most needed, namely, direct patient care.

Everyone knows that reform is not an option, it is absolutely essential. The existing structures and work practices within the health service are 35 years old. As I said previously, we should not be afraid to push out the boat because the health boards have served us well.

Why did the Government abolish them?

The Deputy's party was in favour of it. It did not vote to keep them.

The Senator without interruption.

The Senator is part of a headless organisation running around and delivering nothing.

In terms of representation — I do not mind who smiles on the opposite benches — it is important to reintroduce the democratic balance into the new structures.

When will the Government do so?

We will do it. When the Senator's party was in power it did nothing.

It is not included in the legislation.

The Senator's party did absolutely nothing.

We did not abolish the health boards.

The existing structures come from an era when most modern medical technology did not exist and when dramatically fewer health professionals were employed. It is fair to say that over the last number of years significant achievements have been made in the delivery of the health service.

There has been criticism of the Hanly report. If one were to take seriously everything that has been said by Senators on the opposite side, we would have a hospital in every town.

The Senator should cop himself on.

Those of us who live in the real world know that is not feasible.

The Senator should treat the House with respect.

It is true. I am a strong supporter of the health system.

Does the Senator support the Hanly report?

There was reference to the national treatment purchase fund.

How much is it costing?

It is all about delivery of services.

The Government is doing a very bad job of it at the moment.

It is about taking care of people. Senator Bannon may rant and rave but when the Fine Gael Minister for Health was in office phase 2A was ready to open for a year and he provided not one penny to open it. If I were the Senator, whatever about being seen, I would not be heard.

I booked tickets to see the comedian John Kenny in Carlow next week but he will find it hard to compete with that.

The Senator should keep to the motion.

My question is whether the Hanly report is dead or alive or is it politically still in the accident and emergency unit? Every week Senator Leyden goes on and on saying it is gone. The former Minister, Deputy Michael Smith, has publicly broken ranks by stating he is against it. We had the ludicrous scenario of the former Minister for Health and Children going around parts of the country such as Nenagh and Ennis a few weeks before the local elections telling people not to mind the Hanly report because nothing is going to happen.

What is the status of the Hanly report? The Fianna Fáil amendment does not mention it, nor does it indicate that Fianna Fáil is in favour of it. The absence of Fianna Fáil Members from the Chamber does not augur well for it. They are obviously terrified to speak on this issue because they know the Hanly report is a disaster.

Most people would have no difficulty in travelling a distance for elective surgery. Most people in Carlow would have no difficulty travelling to Dublin, Waterford or Kilkenny for elective surgery. However, they have grave difficulty with the withdrawal of their accident and emergency and acute services. Anyone who has had to use those services recently will not want to see them abolished. That is a fundamental flaw in the Hanly report.

Coupled with that is the fact that we do not have people employed in the ambulance service who can administer the level of medical care that is needed. Other countries have a very highly-skilled, professionally-trained ambulance staff. We do not have that here. Our staff are trained only to carry out a very limited number of medical procedures. That is a fundamental flaw. The Minister cannot say that if the accident and emergency service is withdrawn from Kilkenny, it can provide a better ambulance service. I know of one recent example of a person in Carlow who started to choke when a piece of rasher got stuck in her throat and she had to drive all the way to Kilkenny. One can imagine how terrified she was. Imagine how she would have felt if she had had to go to Waterford, which is twice the distance. Let it be clear that people have no difficulty travelling for elective surgery, but they have great difficulty with the withdrawal of accident and emergency and acute services. That is the fundamental flaw in the Hanly report.

The impression has been given that Mary Harney was born only six weeks ago and had no part to play in Government. She has been in Government since 1997. In Cabinet there is meant to be collective responsibility, although we did not see it today when Senator Morrissey and the Minister for Transport, Deputy Cullen, were tearing each other asunder on radio. She was there and she approved the budgets. She cannot, therefore, blame the previous Ministers for Health and Children, Deputies Cowen and Martin. She bears responsibility. It is nauseating to see her carrying on lately as if she has had nothing to do with health over the past seven years. She had and the public are not so foolish as to believe otherwise.

Last Monday week, having been appointed spokesperson on health, I went with Deputy Twomey to St. Luke's Hospital in Kilkenny where there was no one on trolleys in the corridors. That has nothing to do with Deputies Harney or Tim O'Malley.

Deputy Harney is the Tánaiste and Minister for Health and Children.

It has nothing to do with the Minister for Health and Children but rather with the staff at St. Luke's who manage their resources excellently. There is a paediatric unit which children can attend with their parents. There is a day ward. However, there is no toilet in the ward and people must go down a corridor to access a toilet. I hope the Minister will take that on board and do something about it. There is also a minor injuries assessment area and a small dedicated accident and emergency unit.

The hospital also works very well with local general practitioners in an effort to eliminate the practice of people coming into accident and emergency units except as a last resort. It is thanks to the dedicated staff at St. Luke's that we have an ideal example of what the Minister should encourage the Dublin hospitals to do. The Hanly report seems to be having a go at hospitals outside Dublin. If Mr. Hanly were being truthful, he would focus his attention on the Dublin hospitals because that is where the difficulties are, not in Nenagh, Ennis, St. Luke's and other hospitals outside the Dublin area.

Recently, the Minister spoke about getting €1 billion extra in funding. The reality is — and I challenge the Minister to clarify this — that three quarters if not more of that funding will go on staff wages and administrative costs. Of the €1 billion we will be lucky to see approximately €200 million in extra resources for the health service.

The health strategy published a few years ago referred to diagnostic health centres. There were to be three in the country. Carlow was in line to get one, given that it is the only county in the country without a general hospital. There were plans afoot for a private hospital in Carlow which was to have the diagnostic health centre attached to it. That idea seems to have evaporated.

It is worth noting that my colleague from Monaghan, Deputy Crawford, tabled a question recently to the Minister for Health and Children which showed that the outgoing Minister for Health and Children had spent €30 million on nearly 150 reports, very few of which were implemented. I challenge the Minister, and Senator Glynn as Seanad spokesman on health, to organise a debate in the House in which we could have a progress report on each of those reports. I am sure we could do it in two minutes because they were published, put on a shelf and are now gathering dust.

The abolition of the health boards seems to be the greatest farce of all time. The number of health boards has gone from 11 to four. The CEOs are still in place. The CEO of the South Eastern Health Board will be staying on for a further six months. Why are we reducing the number of health boards from 11 to four if the same administrative structures remain in place? What is the purpose of doing so? I have asked for the Minister to come to the House and explain whether there will be staff redeployment or staff losses within the health board. Staff working in the health boards are rightly concerned about their livelihoods. The public are also concerned that the plan to reform and slim down the health boards appears to be a myth and that there will be a more bureaucratic service, which they do not want.

It is very worrying to hear the masters of the maternity hospitals say they are thinking of putting a cap on the number of patients during the summer months in the interest of patient safety. They announced that there are only nine delivery wards in the hospital and that one day there were 19 women in labour at the same time. In Limerick the staff levels are too low. There is one consultant for every 750 births when the Institute of Obstetrics and Gynaecology recommends a patient-consultant ratio of 500:1. This has been going on since 1998, a year after the PD-Fianna Fáil Government took office. The Government has ignored the situation at its peril and it will come back to haunt it in the coming months.

I welcome the Minister of State, Deputy Tim O'Malley, and am glad of the opportunity to discuss the health service. I wish to speak about my constituency of Dublin Central, which includes the Mater and Temple Street Children's Hospitals. Some €16 million was invested last March in the project to relocate Temple Street Children's Hospital to the Mater Hospital complex, the most significant health service investment in the country. Some commentators cannot decide where the problems are but flit about without settling on any specifics. I have witnessed the effort and professionalism of the staff in Temple Street Children's Hospital. They are committed to providing a first-class service to the children of Dublin and elsewhere.

The Mater Hospital complex has been allocated an investment of €600 million, which will provide for a new accident and emergency department, operating theatres, day units, outpatient facilities and on-call rooms. Earlier this year, a new heart and lung transplant unit was opened. These are concrete developments. I dispute Senator Browne's contention regarding a concentration on Dublin and I shall list some of the indisputable facts. There have been developments in cardiology and radiotherapy at University College Hospital Galway; a new oncology unit is in operation in Limerick Regional Hospital; Cork University Hospital has a new radiotherapy centre and a chest pain clinic; and there is a new medical assessment unit and additional beds in St. Luke's Hospital, Kilkenny.

Are any of these facilities properly staffed and operational?

Senator Bannon should allow Senator Brady to continue.

Some €59 million has been invested in Mayo General Hospital over the past five years, while more than €150 million has been invested in Tullamore Hospital.

These are significant investments in what constitutes a regionalisation of health services. One can talk all day about the problems that exist. As public representatives, we hear daily about constituents' difficulties with accident and emergency services and waiting lists every day. However, of the more than 1 million patients who were treated in our hospitals in 2003, some 83% found it a positive experience. We must give credit where it is due. Everybody agrees that immediate reform is needed and this is the objective the Government is implementing. We all hear the scare stories and everybody has a family member who has experienced the hospital service. Senator O'Meara spoke about services for the elderly. Significant resources are being invested in this sector to fund facilities such as housing, heating, home visits and so on. Senator Glynn mentioned the number of new physiotherapists. We can offer criticisms until the cows come home but that will not improve conditions for those people who are depending on health services.

When will the Government improve those services?

It is a question of taking responsibility. Everybody accepts there are gaps in the services. We all acknowledge there is a problem with the provision of accident and emergency services.

These problems were caused by incompetent Ministers and incompetent Government policy.

At least the Government is taking responsibility by doing something about the problems. We are investing on a daily basis to effect improvements in services. We can debate the nature of the problems all night but somebody must take responsibility for tackling them.

Nobody is taking responsibility. That is the issue.

I will adjourn the debate if Senator Bannon continues to interrupt Senator Brady. Senator Bannon will have his chance to speak on the issue later.

There is a commitment to double the number of consultants but there must be an acceptance among the consultants that change is essential. I recently encountered the case of a mother whose young child had been attending a consultant for six or eight months, at a cost of €120 per visit. This parent was told that it would be two years before an operation could be performed on the child. After utilising the national treatment purchase fund, the child will be admitted to a private hospital in Mullingar next week.

It was necessary for this child to be treated in a private hospital.

These are the issues we must consider. We must arrive at a position whereby the improvements we are paying for, through the significant investment that is being undertaken, are taking place.

I congratulate the Minister of State, Deputy Tim O' Malley, and the new Minister for Health and Children, Deputy Harney. It will not be long before we see significant improvements in the entire area.

Hear, hear.

I agree with the part of the Government amendment that states there has been substantial investment in the health service. The only issue which bothers many of us involved in the sector is the question of where this money has gone because there are terrible deficiencies in the sector.

Senator Browne mentioned that Dr. Declan Keane, the master of Holles Street Hospital, has warned there would have to be a limit on the number of deliveries that can take place there next summer. I compliment Dr. Keane on informing young people of this nine months ahead of time because it casts an entirely new light on family planning. A woman hoping to conceive must ensure there will be a bed available for her in nine months time. It is interesting that the former master, Mr. Peter Boylan, advised patients not to contact the hospital or any doctors about this situation but to discuss it with their local Deputy. This is a serious political issue. There is a terrible shortage of beds in the maternity service, not only in Holles Street Hospital. There is an increased population, including an increased population of young people, and we are pleased to observed that, following a drop to 50,000 from 70,000 some years ago, the birth rate is again rising.

The major crisis relates not only to the lack of accommodation within the hospitals for the safe delivery of babies but to the serious lack of midwives. Ireland is well below the United Kingdom recommendations on staffing in this regard. It is difficult to ascertain the number of midwives necessary to ensure good care for women, antepartum, during labour and postpartum, but we cannot seriously say that we have already achieved such levels. The expert group on midwifery education at graduate level is due to report shortly. The worry is that, if the group recommends we should train a given number of graduates here, there will be insufficient graduates to train until 2009 or 2010.

There is a serious discrepancy in the number of graduates available to be recruited and the number that will be required. This problem is exacerbated by the change to a four-year degree programme from a three-year course for nursing, which means there will be no qualifying people next year. There will be a dearth of recruits to midwifery for several years after that. A pilot scheme was conducted in Trinity College which proved popular, with almost the entire class graduating. That scheme ended in 2003, however, and there has been no attempt to operate it again.

It is astonishing to see the emphasis put on overseas recruitment because we know that we cannot recruit midwives abroad. This is interesting in the context of the debate which took place in the House this afternoon about trying to ensure that our registration arrangements are acceptable on an international basis. Many midwives who qualify outside the EU are regarded as obstetrical nurses and are not in a position to be employed here. We must be careful about these issues and cherish those people who qualify in this country. We are not doing this.

I am sure Senator Brady is aware that the other day, 76 mature students graduated from the Mater Hospital but only 30 of them were offered permanent posts at a time when the master of the hospital has a dire shortage of nurses. When one hears of beds being closed in a hospital it is usually because there is a shortage of nurses. When one hears of operations being postponed, it is frequently because there are no intensive care nurses or operating theatre staff available. We have a serious situation regarding nurses. We are not cherishing them enough and are offering them only temporary posts. Is that being done to save on PRSI payments or such like? It is a serious issue and one we need to immediately address.

We also have a crisis in our accident and emergency departments. I was interested to hear the Tánaiste's solution when she addressed accident and emergency nurses at a recent meeting. It is to set up treatment units run by nurses. There is nothing the matter with that, but where will we find the nurses? If we cannot find them to staff the hospitals in the established posts, how will we get them to staff the new units proposed to be, set up? At the same time we are concentrating on primary care and, as the Minister of State described earlier, many of the co-ops that have been set up are doing extraordinarily well.

However, the Mater Hospital is in a crisis regarding its accident and emergency department. It is dreadful. I have seen people in the outpatient department being treated on trolleys and doctors treating people who were still in ambulances in the car park. The CEO of the Mater Hospital said that general practitioners in the area should try to do more to prevent so many people attending the accident and emergency unit, with which I agree.

Why is the Ballymun health centre still unopened two years after it was built, long after it should have been commissioned and opened? There is a problem with the provision of heating and electricity in the old Ballymun health centre such that it is dangerous to use. The centre is allowed to employ more staff but it has nowhere to put them. Whatever sort of turf war is going on there should be resolved immediately. This is not the only case where this type of thing is happening. Good facilities have been built in many institutions throughout the country but they have not been opened due to the fact that they are not being commissioned or the hospital in question is not allowed to employ the necessary staff.

Some Members may remember when I used to debate with former Senator Cassidy the position regarding the wing in Mullingar General Hospital, which had not been opened. As far as I am aware, that remains the position today.

That is not the position.

It is open.

Is it open?

It is about three times the size it was.

I have been told about places being open previously, but when I checked they were not open. I will check this one.

It has advanced.

That is better because I heard of a radiotherapy unit that was supposed to be open, but on checking I found it was not.

Dr. Henry to continue without interruption.

Senator Henry posed a question, which I felt obliged to answer.

It would be rude not to have answered.

We should take careful note of two developments. We pay agency fees to recruit nurses abroad and we are not looked on kindly in the developing world for taking their best trained and most intelligent people. We should put a stop to that.

There is also another development we need to carefully monitor. The other day a friend of mine, who was on a panel to recruit an orthopaedic surgeon in a town not far from Dublin, told me that not one Irish national had applied for the post. The Minister of State will remember the emphasis people who were working abroad put on the fact that they want to return to work in Ireland. This is not the first time I have observed that no Irish nationals applied for some jobs. It is because people are not being given the tools to work with or the facilities they need when they return to Ireland. Professor Aidan Halligan will not be the only one to say he will not come back here.

I welcome the Minister of State, Deputy Tim O'Malley, to the House and wish him well in his role in the Department of Health and Children. I also wish the Tánaiste every success. I fully support the amendment.

Much reference has been made to reports. The Hanly report addresses the key issues of how to provide safe, high quality acute hospital services, 24 hours a day, seven day a week and to do so as the working hours of our junior doctors are reduced in line with EU law. In response to that, the approach is to provide appropriate services and procedures in local hospitals, including those claimed by some to be under threat. The proposals will mean a better service for patients.

The Hanly report also recommends investment in local hospitals to provide more services for patients, including elective medical and surgical procedures, outpatient services, pre and post-natal maternity services and better access to diagnostic facilities. The report also recommends a full range of acute hospital services should be available within each region so that patients should not have to travel outside their region other than for specialised supra-regional or national services.

At the core of the report is the retention of local access to acute hospital care. It recommends the decentralisation of a large proportion of the elective care and other services currently delivered in large acute hospitals to smaller, local hospitals. Properly resourced local hospitals can do much more and eliminate the need for people to travel outside their region for most procedures.

Contrary to some reports, the Hanly report does not propose the closure of any hospital. Nor does it propose that any accident and emergency departments or maternity units should close. Instead, the report makes specific recommendations for reorganising hospitals in two health board areas——

To downgrade them.

——the east coast and the mid-west — and sets out a series of principles for the future organisation of hospital services nationally.

To downgrade them.

Senator Brennan to continue without interruption.

Like many Members on the Opposition benches, I would like to see an improved health service. I was a member of a local authority for a number of years and many resolutions for this area were discussed. I also share the concerns of the former secretary of LAMA. LAMA made a number of important submissions to the former Minister for Health and Children, Deputy Martin, which represent a vital and constructive input by the local authority sector on proposed changes to Ireland's health board structures.

The former general secretary of LAMA, Senator Bannon, stated that it was pointed out to the Minister that while LAMA recognises the need for rationalisation, it was also imperative that the public receive the best provisions available. I agree those remarks by Senator Bannon at the time. They are as true today as they were two years ago. It is imperative that we get good value for money. It is in all our interests to ensure that the best health service possible is provided throughout the country. I wish the Minister every success in implementing the proposed changes.

The necessity to return to the House over and over again to talk about health care is getting a little monotonous. It is time we all agreed on what is wrong and agreed on a remedy.

It is time to acknowledge what is right.

I do not know if acknowledging what is right has much to do with anything.

The Government will do an excellent job at telling us what is right. Until some issue blows up in the newspapers it will tell us everything is right.

The Senator is not listening.

I was taught in my days as a student in UCD that the job of management was clear: it was about planning, organising, staffing and controlling. It is the Government's job to manage the health service. Its members tell us, although I do not agree with them, that they have not controlled expenditure because they now admit, as the former Minister for Finance told us over and over again, that all the money went down a black hole. I do not share that view, but that is the Government's view, that it failed to control expenditure. It wasted money. That is what its members said. I could give them a reason for that. It is because they spent the money before they had a strategy. They had a lot of the money before they put together a strategy on how to spend it. That is not a great idea, but I do not believe they wasted the money.

There has been a significant increase in staff in the health services. That is one of the jobs of management. It called for more staff, but it was mostly management staff. Who are they listening to when every middle ranking manager suddenly discovers that he or she needs an assistant manager and then the assistant manager also needs a secretarial assistant? If one wants to find out why someone decided something one must meet the secretary to the assistant manager who tells one whether or not the assistant manager is available who, in turn, will talk to the secretary to the manager who will then tell one when the manager will be available. That is the experience of health care professionals. When they discover that a ward, which was open last week is now closed, their first question is, "Who decided that?" No one in a health board can say who made the decision.

The same will be true of the health service agency when it gets going, headless as it is at present. That is the job of management. No decision should be taken in the health service unless an identifiable person with management authority is clearly responsible for it. If they do not want to accept responsibility they should not be in the job and it is the job of the Government to deal with people who will not accept responsibility. Decisions are passed around from one to the other with no certainty as to who is responsible.

Centralising into a super-agency will change nothing because the personnel who will manage the health services, as distinct from the people who deliver it, will be the same people who are in charge now, except that they will be accountable to nobody. There will no longer be any local involvement. Extra staff do not help because failure to control means that staff are not where they should be.

The least said about organising and planning the better. How could anyone claim credit for planning who agreed the capital expenditure of €500 million to build new facilities and forgot that they would need to be staffed and equipped? Suddenly, there was a budgetary crisis because all these wonderful facilities were lying empty. That was management's failure.

We must not get away from the fundamental fact behind a distortion of which people hid for a long time. We are not spending enough money on our health services. The OECD figures show that we manage to include certain services in health expenditure and, to a great extent, spend money twice. When the Government talks about care of people with disabilities, it cites the chunk of the health budget which goes on such services. When it talks about health services it puts that chunk back into the health services. The truth is that, comparing like with like, we are close to the bottom of the OECD table and we are probably at the bottom of the table of comparatively rich countries. In deference to Senator Mansergh, I will not identify our position on the world table of richest countries. According to the famous report inThe Economist we are the fourth richest, but other people see it differently.

We are among the lowest. The two indices of managing and funding the health service are both disastrous. There is no point in citing statistics about the extra numbers of this, that or the other. The measure is what the public get, and what they get is a mess. The fundamental cause of the mess is the lack of clear lines of accountability and responsibility and identifiable individuals who are responsible for budgets when those budgets are adequate.

What level of genius was required to figure that if the country is experiencing an economic boom and draws in vast numbers of former emigrants or new residents, the birth rate would rise? What level of planning and insight was needed for this conclusion? The problem is not confined to the Department of Health and Children. The Department of Education and Science is still on the trajectory of a declining birth rate in planning primary schools. We are subject to the tyranny of averages. In some parts of Ireland we have big schools which are empty, while in other parts of the country, villages with four times the population are served by schools which were designed and planned for the days when people were fleeing from those places in vast numbers.

The same issue arises with maternity services. I used to think we were doing extremely well in the area of infant mortality until I checked the figures this evening. In 1990, our infant mortality rate was 16th from the top of 29 OECD countries. In 2002, we were at the same level. Our infant mortality rates have progressed not a whit in 12 years of prosperity. We are still towards the bottom of the table. Our performance is not bad. By comparison with developing countries it is very good but it is not something about which to boast. To restrict funding to maternity services when infant mortality statistics do not show a spectacular success is close to scandalous.

If we are to have a health service of the quality our people deserve we need a fundamental change in the quality of management at every level in the health services because management has failed abysmally. Our doctors and nurses are among the best trained in the world but our management is letting them down. Good managers must be provided with spectacularly increased targeted resources to deal with the problems. Otherwise, we will end up with the same miasma of waste and incompetence which has held back the development of our health services.

I am grateful for this opportunity to reply to the issues raised during the debate on this Private Members' motion. Senator O'Meara spoke briefly about patients from Limerick going to Nenagh hospital. The distance from Limerick to Nenagh is only approximately 20 miles.

It is 32 miles.

The road must have extended in the past few days. It was always approximately 23 miles from Limerick to Nenagh. Much of the Limerick area, such as Maroo, Castleconnel and Ahane, are approximately 12 or 15 miles from Nenagh.

And Newport.

Far from being an adverse reflection, it is a compliment to Nenagh hospital and its efficiency.


People now have a choice.

The Minister of State wants to remove that choice.

They can either go to Nenagh hospital or to the regional hospital in Limerick.

Senator O'Meara asked if the Government is implementing the Hanly report. The answer is that it is.

I thank the Minister of State for that information. I ask Senator Leyden to take note.

I note that Senator O'Meara opposed the suggestion of a private hospital in Limerick.

I did not.

She questioned the validity of having a private hospital in Limerick.

I questioned it.

Limerick is the only city in Ireland without a private hospital.

It has the highest incidence of people who have voted with their feet and paid for VHI and BUPA. The people of Limerick should have a choice. I note the Senator's remarks. Many people in Nenagh and north Tipperary will note them also.

Senator Tuffy questioned the validity of the treatment purchase fund. She should ask any of the 20,000 public patients who have had treatment paid for by the fund rather than raise it as an issue with which to beat the Government. Those 20,000 people are very happy with the service they have received. As a result of the success of the fund the Government is considering extending the system to take more patients from outpatient waiting lists. I hope that proposal will be acted upon to the benefit of patients.

Senator Browne said the Minister for Health and Children had blamed her predecessors, Deputies Cowen and Martin, for deficiencies in the health service. I ask him to come here and tell the House when the Tánaiste made those remarks. I am not aware of them and I never heard her make those comments.

I wish to put on the record of the House exactly what the Government is doing, the amount of money that is being spent and the success of the Government in this area. This year we will allocate over €10 billion to health care, an increase of almost €1 billion over 2003. This investment has ensured the employment of extra health professionals providing quality services to patients.

In the past eight years, an extra 8,000 extra nurses have been employed in the health services. That is an average of 1,000 nurses per annum. Listening to some commentators one would swear that no new members of the nursing profession had been employed in that period, or that there was a deficit of nurses. An additional 500 consultants have also been employed along with an extra 1,800 other medical and dental personnel. We have also employed an additional 660 occupational therapists, 450 more physiotherapists and some 200 extra speech and language therapists.

Some speakers castigated the Government and said much of the money was being spent on paying people but, obviously, if people are employed they must be paid. I have no problem in paying good wages to the many excellent personnel we have in the health services.

These figures illustrate the extent of the Government's commitment to allocating extra resources where they will have most benefit — to staff providing services to patients and clients. The increased funding in the hospital sector is reflected in measurable increases in services. The number of patients discharged from hospital having been treated as either inpatients or day cases in 2003 was more than 1 million, an increase of over a quarter in the number of patients treated compared to the number in 1997.

Many people do not yet realise that day activity is now a significant component of hospital-based care. There has been a substantial increase of over 80%, from approximately 243,000 cases to 447,000, between 1997 and 2003. That represents a major change in practice, which has provided a successful outcome. That is the way modern surgery is going to go with many more day cases being treated.

In 2003, there were some 1.2 million attendances at emergency departments and some 2.2 million attendances at acute hospital outpatient departments. It is important to view the current debate about hospital services in the context of these figures. We have invested in services, provided thousands of extra health professionals and are seeing the benefit to patients in terms of increased services over the past seven years. There is no doubt that more remains to be done but it is important to acknowledge also what we have achieved.

The Labour Party motion refers in particular to maternity services. It is important to set out a number of facts to set in context the debate on the availability of maternity care. In recent years, staffing levels have risen substantially in the three Dublin maternity hospitals. Medical staffing has increased by 25%, nursing staff has increased by 15% and health and social care professional staff has risen by 36% since 1998.

The Government has acted to address concerns about capacity and infrastructure in a number of maternity hospitals. During the summer, the previous Minister for Health and Children, Deputy Martin, approved proposals at the National Maternity Hospital, Holles Street, designed to increase capacity in delivery rooms, theatres and neonatal intensive care units, as well as providing improved postnatal facilities for mothers and babies. He also approved the appointment of staff to oversee and manage the project, and the process of selection of a design team is under way.

The Department of Health and Children has been working closely with the Coombe Women's Hospital and the ERHA to progress the future development of the hospital infrastructure in response to increasing demand for services. We have approved the appointment of a design team at the hospital to allow planning to commence on a new capital development, which will include an extension to the neonatal intensive care unit, upgrading the existing ICU, a new caesarean section theatre, a day assessment unit, an ultrasound suite, a parent craft-admissions unit, an upgrade of mechanical and electrical services, and ward upgrading. The estimated capital cost of these works is almost €20 million.

At the Rotunda Hospital, a development which included the amalgamation of the paediatric and neonatal intensive care units, as well as the upgrading of postnatal beds on the third floor, was commissioned in 2003, at a capital cost of approximately €10 million.

The Eastern Regional Health Authority has also been working with the three Dublin maternity hospitals to consider ways to address the increase in births — up by 8% between 1998 and 2003 — and to introduce initiatives that would alleviate some of the current pressures. These initiatives include the further development of community-based midwifery lead services, such as the Domino and early transfer home programmes.

The Government has acted to develop maternity services in other parts of the country and to address specific pressure points. For example, the Mid-Western Health Board has recently been given financial clearance for a seventh consultant obstetrician-gynaecologist. A capital development is under way to provide an additional delivery suite, theatre and an extension to the admissions-reception area. These improvements are expected to be ready in early 2005.

Work has also commenced on the development of new midwife-led units at Our Lady of Lourdes Hospital, Drogheda, and at Cavan General Hospital at a combined estimated capital cost of €1.5 million. This service will offer women greater choice and control within the maternity services. It is anticipated that these units will be fully commissioned early next year.

The Government has provided additional revenue funding of €1.2 million to commission the new maternity unit at Letterkenny General Hospital in early 2005, together with equipping costs in the region of €0.8 million. The new unit will provide enhanced facilities and additional midwife staffing, as well as some increase in capacity.

Construction work is continuing on a new amalgamated maternity unit at Cork University Hospital. Construction is expected to be completed by the middle of 2005. This new maternity hospital represents an investment of €75 million and will replace the existing facilities at St. Finbarr's Hospital, Erinville Hospital and the Bons Secours Hospital, Cork. The unit is designed to cater for approximately 7,000 births annually.

The product of these investment initiatives in maternity services will be reflected not just in terms of expenditure, activity and employment numbers but also in the continual drive towards improving the quality of services provided. The Government is committed to the further development of maternity services in line with available resources.

Accident and emergency services have been the subject of considerable concern in recent times. I, too, am concerned about the present situation and the difficulties being experienced by patients in accident and emergency departments. Patients should be treated with dignity and respect. It is important to put the provision of acute hospital services in context. Over the past two or three decades there have been numerous important advances in surgical technology and in anaesthesia. These advances have improved greatly the range, safety and effectiveness of the procedures that can be offered by modern health systems. Modern medicine has allowed us to live longer and have a better quality of life. As a consequence, however, there have been dramatic increases in the demand for treatment.

Delivery of the emergency service at hospital level is interdependent on the inpatient elective service, day and outpatient care. The effective delivery of emergency services cannot be dealt with in isolation from the delivery of all hospital based services. A key conclusion of the Comhairle na nOspidéal report on accident and emergency services, published in 2002, was that a hospital-wide response was needed to meet the requirements of the emergency service. Improved processing of patients through the emergency department, via minor injuries units or medical assessment units, is but one aspect of the hospital-wide response needed.

Earlier today, Comhairle na nOspidéal formally presented its report on acute medical units to the Tánaiste. This report recommends how acute medical units should be developed and operated to improve the experience of acute medical patients through the hospital system.

In tackling the problems in accident and emergency departments it is also necessary to look beyond the acute hospitals and to examine the impact of primary care, non-acute care and community care on the accident and emergency service. We need to take a whole systems approach, which addresses the needs of people on a timely basis in the most appropriate setting. The Government has already introduced a number of initiatives aimed at improving the delivery of acute services and alleviating the pressures on accident and emergency departments.

Improved and expanded accident and emergency departments are being provided. Recently, new accident and emergency departments have been provided at Cork University Hospital, James Connolly Memorial Hospital, Naas General Hospital, South Tipperary General Hospital in Clonmel and Roscommon General Hospital. The accident and emergency department at the Mater Hospital has also been refurbished and a new accident and emergency department is under construction at St. James's Hospital.

Following a submission from the Eastern Regional Health Authority in June 2004, the Department of Health and Children approved proposals for short and medium-term actions to be taken to address the problems associated with emergency departments in the Dublin academic teaching hospitals. The cost of these new initiatives is €2.4 million in a full year and includes the appointment of a consultant in emergency medicine and specialist nurses, the establishment of rapid assessment teams and a clinical decisions unit, and the provision of multi-disciplinary teams to assess patients.

Additional emergency medicine consultant posts have been approved. Some 51 emergency medicine consultants are now employed in acute hospitals, which represents a 260% increase since 1997. The availability of senior medical staff in emergency medicine departments should facilitate rapid clinical decision-making, and the enhanced management, diagnosis and treatment of patients.

Pressures on the hospital system, particularly in the eastern region, arise in part from difficulties associated with patients who no longer require acute treatment but are still dependent. Funding of €16.8 million has been made available to the ERHA, which will result in some 600 patients being discharged to a more appropriate setting. Planning for the discharge of patients by acute hospitals and the liaison with the community services has been prioritised on an ongoing basis by the Eastern Regional Health Authority. Initiatives such as Homefirst, Slán Abhaile and home subvention are all contributing to providing alternative care packages allowing older people to be discharged. A total of €5 million is also being provided to the Southern Health Board under the delayed discharges initiative in 2003-04 to facilitate the discharge of patients from the acute hospital system.

Increasing acute bed capacity will also have an impact on the delivery of emergency services. The Government is committed to increasing acute hospital bed capacity as indicated in the health strategy. Since 2002, funding has been provided to hospitals to open an additional 900 beds. Some 600 of these beds are already open and the rest will come on stream in later this year and in 2005.

Notwithstanding the initiatives that have been introduced to date, the continuing difficulties and delays in accident and emergency departments are not acceptable. The Tánaiste has stated that the delivery of accident and emergency services will be an area for particular attention during her term as Minister for Health and Children. She has spoken of the need to identify the particular pressure points within the health system that affect the efficient delivery of emergency services. As Senators already know, the Government delivers. I am very confident that the Tánaiste will deliver what she has promised by way of a package of measures and initiatives to address problems in accident and emergency departments. She has promised that this will be done in the context of the 2005 Estimates, which are due for publication tomorrow.

Any improvement in accident and emergency services, and in acute hospital services, must be strongly supported by increased emphasis on pre-hospital emergency care. The Government has been working to develop this area. Critical developments include a major upgrading in training and standards, the equipping of emergency ambulances with defibrillators and the training of ambulance personnel in their use, the introduction of two-person crewing and improvements in communication equipment and control operations.

Currently, ambulance personnel are limited in the range of medications they can administer at the scene of an illness or accident. To address this issue, the former Minister for Health and Children, Deputy Martin, announced policy approval for the development of the advanced paramedic training programme. Legislative changes are being progressed as a priority to provide a statutory basis for the administration by newly-trained paramedics of additional medications, such as cardiac medications, to patients. The new measures will mean that patients, wherever they live, will have equitable and rapid access to a wider range of emergency services. It is intended that this expanded service will start to roll out in 2005, following the completion of training of ambulance personnel.

The ambulance service has an important role to play in the delivery of an integrated hospital service throughout the country. To this end, the Government will continue to focus on the development of the service and to ensure that the issue of ready access to treatment remains at the centre or our health policy.

Considerable debate has taken place on how we should organise our hospital services. We face important challenges in developing a service that meets patients' needs quickly and effectively. While inevitably people will hold different views on how we can bring this about, we must acknowledge a number of critical realities if we are to agree on how best to move forward. These realities include the need to reduce the working hours of non-consultant hospital doctors and the importance of ensuring that patients receive the right type of treatment, in the right place, by a senior clinical decision-maker capable of making decisions without delay.

In the debate about the future organisation of acute hospital services, it is important to remember that we are obliged to implement the European working time directive, which involves a considerable — and welcome — reduction in the working hours of non-consultant hospital doctors. We are already involved in a process aimed at reducing average working time to 58 hours per week. This is part of a longer term process to achieve a 48-hour working week for junior hospital doctors by August 2009, less than five years away.

It is not acceptable for doctors to have to work 70 or 80 hours per week, or even more in some instances. Excessive working hours are not good for doctors or patients. We need to find alternative ways of providing services in our acute hospitals so that doctors can work reasonable hours and patients can be sure of a top quality service at all times. While this means considering carefully how we configure our acute services, it does not mean closing hospitals or downgrading them. Many hospitals have substantial scope for increasing the services provided, including those claimed by some as being in danger of losing services or closing. As far as the Government is concerned, we need to harness the potential of every acute hospital to provide the best possible service to the local community.

We must decentralise as many as possible of the elective treatments currently provided in the larger acute hospitals to smaller local hospitals. At present, the larger hospitals tend to provide a very high proportion of all day-surgery and medical procedures. If properly structured and developed, the smaller local hospitals could take on significantly more of these treatments. This would greatly reduce the need for people to travel outside their own region for most procedures. Far from reducing the importance of smaller hospitals, the Government is committed to expanding considerably the services that can safely be provided within local communities. This will be to the benefit of all patients and will ensure that they receive as many services as possible closer to home.

A second reality to be faced in the future organisation of hospital services is the need to provide much greater access to senior clinical decision-makers so that patients can receive speedy and effective treatment. We remain excessively dependent on doctors still in training and we have an insufficient number of consultants. This means that patients who could be diagnosed and treated quickly by experienced clinicians must, in some instance, wait for unacceptably long periods until their condition can be identified and dealt with.

The Government is committed to developing a consultant-provided service, rather than one which is predominantly consultant-led. We need consultants to work closely together in teams, so that senior clinical decision-makers have a substantial and direct involvement in diagnosis, delivering care and overall management of patients. Achieving this will require change. It will involve more consultants and fewer non-consultant hospital doctors, and will require reform of existing work practices.

We can and will make progress in developing our acute hospital services in a way that is in the best interests of patients. Whatever position we take on the future of acute hospitals, it is clear that the present situation is not satisfactory. We cannot continue with more of the same. Change is necessary, and we can achieve it in a positive way that benefits everyone. However structured, acute hospitals need to work closely together in recognised groupings, or networks, so that we can maximise the services that can be provided by each hospital. Every hospital, whether big or small, has a vital role to play. We need to stop talking about hospitals supposedly in danger or under threat and concentrate on how we can harness the contribution of every hospital in delivering quality services for patients.

The initiatives I have outlined for the House represent tangible evidence of the commitment of the Government to the provision of high-quality, cost-effective, timely and responsive hospital services for all. The Government is committed to supporting and developing critical services, including key areas such as maternity and accident and emergency services. Let us move away from scare tactics and unfounded claims of downgrading and loss of services. Instead, let us have a debate about how best to work together to develop a quality health service for the future.

I welcome a former distinguished Member of the House, Deputy Seán Ryan, to the Visitors Gallery.

I thank the Labour Party Members for proposing this motion, particularly the call for the Government to drop the Hanly report and upgrade the accident and emergency services currently available in general hospitals around the country. The health service exists to serve the needs of the sick and injured and that must determine any changes, particularly those that might disadvantage patients.

Many people oppose the report but there are positive aspects to it — at all times I highlight the positive and oppose the negative in this House. The proposal to concentrate accident and emergency services in centralised locations, however, is mistaken and would cause serious problems to people needing urgent care. When the Hanly report was first introduced in this House, a constituency colleague who was a former Minister in this Government was chairman of the Western Health Board. He had to courage to stand up and say that the report should be binned. I am disappointed that Senator Leyden's colleagues have not listened to him but he was right on this occasion. We disagree on many matters but I pay tribute to his vision of where this report should be. Perhaps he has signed the Fine Gael petition on medical services in Roscommon, he signs many things.

It is the job of the Opposition to question and dissect all proposals in the report. We recognise the value of multi-disciplinary teams but the reduction of the number of hospitals delivering accident and emergency services from 40 to 12 is not safe or acceptable. The plan is an experiment and experiments in health service delivery cause suffering and death if they go wrong.

The Hanly report spells disaster for Roscommon. It is anti-rural — we cannot replace a hospital with an ambulance service but we are supposed to be thankful for this. If a person in Roscommon has a heart attack, he or she must be driven to Galway because the hospital in Roscommon will be closed. Anyone who has travelled the road from Roscommon to Galway knows that it is not a super-highway. There is a golden hour following a heart attack but by the time a person reaches Galway and gets through the traffic there, that hour is gone. Patients could die on the road because even a first rate ambulance service cannot operate on a second rate road structure.

Consultants at Limerick Regional Maternity Hospital have warned that they may be forced to turn pregnant women away because staff levels are too low to ensure safe deliveries. That does not reflect a state of the art health service. According to the hospital there is one consultant for every 750 births when the institute of gynaecology recommends a patient to consultant ratio of 500:1. This is a crisis waiting to happen. The last Minister spent his time producing reports. He was the Minister for fudge, always kicking issues to touch. The new Minister should act on the reports and not kick them to touch.

The death of a 72 year old Monaghan man from a heart attack as an ambulance took him to Cavan General Hospital led to renewed calls for Monaghan hospital being put back in action as soon as possible. The Hanly report does not address the fundamental problems of bed shortages in major hospitals or the failure to provide suitable step down facilities that results in people spending too much time in hospital and not in the community where they should be.

I wish the Minister well in her job because much relies on the success of the health service. The Hanly report goes about it in the wrong way. It is anti-rural.

I welcome the Tánaiste and Minister for Health and Children to the House and take my hat off to the Minister of State, Deputy Tim O'Malley, who was in the House from 3 p.m. I had a script when I came into the House at the start of the debate but I threw it away when I heard Senator Browne. He said that no one on the Government benches would discuss the Hanly report. He said we were terrified to speak and wondered about the status of the report.

Why is it not mentioned in the amendment?

The Senator had his time and did much cribbing, saying things that were not true so I will have my say now without interruption.

Does Senator Feeney fully support the Hanly report?

No one on this side of the House is afraid to discuss Hanly. I am delighted to come in here and talk about it again, it is good news.

Does Senator Feeney fully support the Hanly report?

We have only been back in the House two months and already we have discussed some aspect of health four times on Private Members' business.

Does Senator Feeney fully support the Hanly report?

It is no wonder Fine Gael is in Opposition, it is in a rut.

It is a simple question to which there is a yes or no answer.

Members of both Opposition parties, the Labour Party and Fine Gael, are like a dog with a bone. Will they get up off their tails and move on and do something to give themselves a chance to get back into power?

I am waiting for an answer.

At this rate, Fine Gael is going nowhere.

Not judging by the European and local elections.

I have said all that I wanted to say on several occasions about the Hanly report. There was an article inThe Irish Times on 3 August 2004 on a report compiled by Dr. Peter Barrett of the Independent Reconfiguration Panel in Britain, which reviews contested plans for change in the British health service. He came to Ireland and had a look at the Hanly report and said he did not see anything in it to suggest hospital closures. He stated: “I saw a lot of suggestions that might modernise and change, but nothing about closure.” How much more is needed?

We never said that. There is nothing in Hanly about closure. It is about downgrading and loss of service.

The Senator most certainly did talk about closure. Dr. Barrett went on to say that there was nothing in Hanly to prevent flexibility, local consultation, development of local services and the keeping of services locally, as long as it was appropriate and safe to do so. Again, is that not best for patient care? He further said that the perceptions reflected people's anxiety about change. The Opposition is anxious about change. Nobody likes change, but it must be embraced. Do not run away from it.

I am sorry if I sound like a long-playing record but these are matters that have been pointed out from this side of the House time and time again.

The Senator is rusty—--.

Allow Senator Feeney to speak, without interruption.

There is nothing rusty about Dr. Barrett. Senator Bannon should read his report. The development of primary care and the ambulance service will, Dr. Barrett says, go hand in hand.

The needle is getting stuck.

I heard somebody referring to the ambulance service. Is that not another reason to listen to more people such as Dr. Peter Barrett and let us have less of the terrifying tactics from the Opposition? The only good thing I heard Senator Browne say was his reference to Dr. Gary Courtney, a man I know well. I have visited St. Luke's and many hospitals during my five-year term on the Medical Council. I wish to God I could take every Senator out of this House and send them to some of the hospitals I have been in around the country. One would not bring a dog to some of them, they are so bad. However, when the Government tries to do something, the Opposition shouts and roars and beats the same old drum, saying in effect, "Let us hold on to this".

On a point of information, I was using St. Luke's as an example.

Is the Senator making a point of order?

Senator Feeney will be heard, without interruption.

Unless the Senator has a point of order, he should not interrupt. Dr. Courtney's blueprint is working well. I take my hat off to this consultant. It is also working in other areas. Senator Feighan said no one wanted to know about Hanly outside Dublin. I object to that. I come from the north west and we welcome Hanly. We are embracing Hanly in the north west and do not have a problem with it.

Finally, I just want to raise a point made by Senator Ryan. He talked about infant mortality and said it was more or less the same today as it was 14 years ago, with little change. He had done some research in the Library. I question the research and the figures because no later than four to five years ago, UNICEF issued a report that claimed Ireland was one of the safest destinations in which to have a baby. I would like to ask Senator Ryan where he got those figures. I would love to have a good debate in this House, where we do not thrash out the same matters time and again. I wish Members of the Opposition, when they shout and roar about Hanly, would offer some alternatives worth listening to. Hanly is here as the result of an EU directive.

No, it is not.

It is very much a part of that. I represented the public interest on Hanly and I am proud because it is the blueprint to the future of medicine.

I welcome the Tánaiste and Minister for Health and Children and wish her well in her new job. However, I would prefer to see her in Mullingar this evening opening phase 2B of Longford-Westmeath General Hospital, a project that has been in the pipeline for 11 years. The shell is built and nothing more constructive has since occurred I strongly support the motion in the light of the Minister's determination to implement the disastrous and life-threatening recommendations of the Hanly report. How many lives have to be lost before the current Government admits to the report's inadequacy and, more important, takes action to drop it? Whatever the fate of this report, questions must be asked and answered as to how a critically-ill man was recently taken away from, rather than brought towards, necessary emergency treatment. This man, Mr. Benny McCullagh, lived 500 yd. from Monaghan hospital and suffered a heart attack at his home. An ambulance arrived quickly and he was treated by the paramedics, but then farce took over. Instead of being promptly brought a few yards to Monaghan hospital the ambulance took him 30 miles to Cavan hospital. The ambulance driver was not to blame. His instructions forbade him taking the cardiac arrest patient to Monaghan. Whether Mr. McCullagh would have lived had he been taken to Monaghan hospital is not for us to judge, but he deserved every chance he could possibly get. This is what he and other patients are not getting.

Quality and safety are mentioned over 100 times in Hanly, but if this is an example of how they are to be enforced, I tremble for the needy and vulnerable. In June 2002 the Government promised to implement a full range of measures to improve accident and emergency services, by significantly reducing waiting times and having senior doctors available at all times. However, the Hanly report intends to remove 24-hour accident and emergency services from the majority of hospitals around the country. Our accident and emergency departments are currently bursting at the seams. The Irish Nurses Organisation issues statements, almost on a weekly basis, to highlight the fact that its members cannot cope with the demands. This is happening in every former health board region. One has only to look in the newspapers or talk to any hospital nurse or doctor who will say they cannot cope with the levels of demand.

The Senator should come down to Roscommon.


The House will hear Senator Bannon, without interruption.

The Senator can talk. He binned Hanly long ago. Centralisation is the main recommendation of the Hanly report. There is no evidence that centralisation of acute care in general results in better outcomes for patients, rather it has disadvantages for the elderly and the disadvantaged.

They could not even keep their hospital open in Longford.

Canada and the United Kingdom have centralised services over the past decade, with no benefits whatsoever for patients. Canada ended up with a health care crisis. This was very evident, it was in the media and the Minister knows all about it. The result was partly due to the centralisation of services and the reduction of a 30,000 bed capacity. Centralisation removes local access and is socially disadvantageous for the young and, indeed, the elderly.

Following Fine Gael revelations which showed that approximately €460 million worth of hospital facilities were lying idle because the Government had failed to provide the necessary funding, the former Minister for Health and Children, Deputy Martin, miraculously came up with something like €85 million to open some of them. However, a great many were never opened, despite the promises made in the run-up to the local and European elections, and they still remain closed.

They have no staff.

Among these are Longford-Westmeath General Hospital, a hospital in Mullingar. A promised 12-bed observation ward has never been fully opened——


Allow Senator Bannon to continue, without interruption.

——because of staff shortages.

The Senator's Government left it standing for a year.

Senator Glynn, at great expense to the Midland Health Board, brought Members down, to show them what was available. However, they never had the guts to bring down the Minister to open that facility.

Fine Gael was there and could not open it after a year.

The future of Mullingar hospital was supposedly assured under phase 2B of the midlands regional health plan. Confirmation that the development would go ahead was issued despite recommendations in the Hanly report. This is done left, right and centre. There is a hospital action group in Mullingar like those which exist throughout the country but not one member of Fianna Fáil or the Progressive Democrats had the guts to turn up at any of its meetings to tell the truth to the people of Longford and Westmeath.

If there is nothing broken, why fix it? The money is ring-fenced.

There has been evasion all along on the issue.

The game is over. There is no point in showing up when the job is done.

It will be another year down the road if phase 2A is opened.

Senator Bannon, without interruption.

That Mullingar hospital faces the stark threat of downgrading is not good enough for the people of the midlands, especially those in Longford and Westmeath.

What about Longford hospital? Do not mind Mullingar.

The people want the hospital to be upgraded and the facilities outlined in phase 2B to be implemented.

To be or not to be.

We will settle for nothing less.

Of course, the people will get it.

The real issue is people's lives. The downgrading of Mullingar hospital would result in the removal of maternity, accident and emergency and other services which would be dangerous and morally wrong. The Minister and Senator Glynn should note that we will fight this tooth and nail. I will refer to County Longford.

What about Longford hospital? Senator Bannon and Barry Desmond closed it. I know them well.

The casualty unit at St. Joseph's Hospital in County Longford does not provide 24-hour cover despite several demands.

Senator Bannon will end up in hospital if he does not slow down.

A modern casualty unit requires a full complement of services. We want to see proper facilities put in place and operated on a 24-hour basis.

Who closed Longford hospital? It is the third secret of Fatima.

The Government has had many representations from my colleagues on Longford County Council and from me on the opening of a 24-hour casualty service in the county.

Senator Bannon can open phase 2A when he is in power.

Patients in areas like Longford who suffer heart attacks and other life-threatening problems at night are at considerably greater risk than people who live near hospitals with the relevant facilities and 24-hour services. I was put off the health board for fighting tooth and nail for such facilities.

They got sick of the Senator.

Senators Glynn and Moylan organised the campaign to have me removed because I embarrassed the Government too often on this issue.

If the Senator believed in it, he would have stayed on the county council, but he did not.

Senator Bannon embarrassed only his own party.

The Minister for Health and Children recently stated that the Hanly report was not about centralising services but about removing the need for people to travel outside their regions. I wonder what Mr. McCullagh's family and friends would make of that. I would welcome a positive response from the Minister because people are fed up with the bull which has been fed to them by Fianna Fáil and the Progressive Democrats.

I will probably be stoned by both sides. I have no doubt of the sincerity of any Member in his or her desire to improve the health service. We should accept that sincerity exists on all sides as we all want the same thing. I support the aim of the motion to improve health services because people are very sincere, but one can be sincerely wrong too.

It is a pity to refer to the "unnecessary death of a patient" when we do not know whether it was or not.

One has to face the realities of this world.

Senator Maurice Hayes, without interruption.

To do so adds to the grief of families. As the Senator informed us, an ambulance arrived within four minutes which compares very well with international standards. I wish people would not speak about downgrading hospitals as if to look after the elderly and those with chronic conditions were somehow less honourable and praiseworthy than to carry out spectacular surgery of one sort or another.

I offer these reflections to the Minister as I have been in the business for a long time. I carried out a review of the Northern Ireland hospital system and produced a report which was very similar to Mr. Hanly's. The words used may have been different, but the thrust was there. It is unfair and unreasonable to encourage people to believe one can provide full accident and emergency cover at every hospital around the clock. I wish people would stop talking about hospitals and consider hospital and health systems in which so much more can be done at the primary care level to keep people out of hospitals. A great deal can also be done to get people out of hospitals and into more suitable care.

At issue is the concentration of a small number of surgical specialties and cancer treatments. International experience does not support Senator Bannon's argument, especially in the context of cancer treatment. According to international experience, concentration improves outcomes and survivability.

The Senator should look at what happened in Canada and the United Kingdom.

Senator Maurice Hayes, without interruption.

Senator Bannon could not find Canada on a map.

The Minister of State, Deputy Tim O'Malley, made an interesting reference to Limerick where a co-operative practice found that only 8% of people presenting had to subsequently attend an accident and emergency unit. Oddly, I found the converse to be the case in a survey of two or three hospitals in Northern Ireland where 92% of people attending accident and emergency units would not have had to be there if proper minor-injury units had been provided. If I were the Minister, I would put my money in that area as is being done in the United Kingdom where walk-in centres are proposed. Such centres will be staffed by nurses and general practitioners, removing a significant population from accident and emergency units.

Even if one wanted to provide 24-hour accident and emergency services and high-level surgery in every hospital, one could not do it. It is not only a matter of money, one cannot get the people. If one could recruit the requisite number of staff, there is not sufficient workload to maintain their skills. An attempt must be made to organise the system in such a way as to concentrate some services while decentralising others, as permitted by modern diagnostic techniques. I encourage the Minister not to let the Hanly report go.

I welcome the Minister for Health and Children to the House and thank her colleague, the Minister of State, Deputy Tim O'Malley, for finally providing us with clarity on the important matter of the Government's decision on the Hanly report. The Minister of State was very clear that the Hanly report represents Government policy and will be implemented. Now we know and need no longer listen to remarks such as those made in this House two weeks ago to the effect that I could stop flogging a dead horse and cease to talk about the Hanly report because it was a dead duck. The horse is not dead and the duck is very much alive and part of Government policy.

Where is the binman now?

One has only to read the Hanly report to know what this implies.

I thank all Senators for their contributions and like Senator Maurice Hayes acknowledge that all Members are sincere in their beliefs on how the health system should operate. I hope people accept that about me. I believe fundamentally that the Hanly policy is disastrous. I disagree with Senator Maurice Hayes who says one cannot have an accident and emergency unit in every hospital. If accident and emergency services are removed from 26 hospitals as planned in the implementation of the Hanly report, many hundreds of thousands of people will have to travel long distances to avail of them. People's health will be put at risk.

While there are people who say I am scaremongering when I say that, I ask Members to believe I am not doing so. I have read a great deal of literature and examined a great deal of research. I am especially concerned that the fundamental premise on which the Hanly report is based is not borne out by the statistics contained within it. The statistics do not show that larger hospitals produce better outcomes. They show the opposite. The cornerstone of the Hanly report says something entirely different. Despite that, the Government is determined to implement it. That is the reason I do not believe what Senator Feeney said. I do not believe the Hanly report is all about implementing the EU working time directive because there are many ways to implement it. One does not have to deprive whole areas of the country and put the health of many at risk to solve the problem of the EU working time directive, which we had long enough to consider.

There are alternatives to the Hanly proposals which the hospital services action group will roll out in the coming months and at which I will invite the Tánaiste to look. They are well-worked out proposals based on some issues discussed in the Hanly report on team-building and so on. The fundamental cornerstone is that local access to acute hospital services is essential to maintain a health service that people need.

The Minister referred to the distance between Nenagh and Limerick and getting to Limerick as if it was just a hop and skip. As it happens the distance is not great. However, the distance from Upper Church and from Thurles to Limerick is much longer and the road is bad. I agree that is not the worst part of the country in terms of roads infrastructure and access to hospitals but the west is in a much more difficult position. Some people say the Hanly report has nothing to do with Dublin but something has been neglected in this debate.

Loughlinstown Hospital.

That is correct and also Blanchardstown hospital. If Navan Hospital is downgraded more people will come from the hinterland of Dublin to use, for example, St. Vincent's Hospital. Given that Portlaoise and Nenagh hospitals have been downgraded there is no accident and emergency service between Limerick and Dublin. There is no accident and emergency service on the N7 on one of the major arteries of the country. There will be no maternity service between Galway and Dublin because Ballinasloe hospital will be downgraded.

That is ridiculous.

It is not ridiculous. The Senator should read the report.

I have read it.

It is true. Senator Leyden does not want to believe it is true but it is.

The Senator was not in the House all evening.

We had clarity here this evening. We have been told——

The Senator should read the motion.

I ask the Senator to read the amendment.

I ask the Senator to conclude.

I will conclude on the issue of maternity services with a quote from Dr. Peter Boylan, a consultant obstetrician at Holles Street Hospital, on the fact that the hospital can get booked up for women needing the hospital. He said the Department of Health and Children was aware of the pressure in the hospital for at least ten years. He told "Morning Ireland": "The persistent answer we get is: you are fine, you don't need more people, you don't need more nurses, you don't need more doctors, the hospital is fine, go away and stop annoying us."

I would like to see that in writing.

Unfortunately, that is the reality for a consultant obstetrician in one of the hospitals delivering the majority of babies in Ireland. There is a crisis. Let us get real and let us stop talking and start acting.

That is after seven years.

Senator Feeney is caught in a trap.

Amendment put.
The Seanad divided: Tá, 28; Níl, 16.

  • Bohan, Eddie.
  • Brady, Cyprian.
  • Brennan, Michael.
  • Callanan, Peter.
  • Daly, Brendan.
  • Dooley, Timmy.
  • Feeney, Geraldine.
  • Fitzgerald, Liam.
  • Glynn, Camillus.
  • Hanafin, John.
  • Hayes, Maurice.
  • Kenneally, Brendan.
  • Kett, Tony.
  • Kitt, Michael P.
  • Leyden, Terry.
  • Lydon, Donal J.
  • MacSharry, Marc.
  • Mansergh, Martin.
  • Minihan, John.
  • Morrissey, Tom.
  • Moylan, Pat.
  • Ó Murchú, Labhrás.
  • O’Brien, Francis.
  • O’Rourke, Mary.
  • Phelan, Kieran.
  • Walsh, Jim.
  • Walsh, Kate.
  • White, Mary M.


  • Bannon, James.
  • Browne, Fergal.
  • Burke, Paddy.
  • Burke, Ulick.
  • Coghlan, Paul.
  • Cummins, Maurice.
  • Feighan, Frank.
  • Hayes, Brian.
  • Henry, Mary.
  • McHugh, Joe.
  • O’Meara, Kathleen.
  • Phelan, John.
  • Ross, Shane.
  • Ryan, Brendan.
  • Terry, Sheila.
  • Tuffy, Joanna.
Tellers: Tá, Senators Minihan and Moylan; Níl, Senators O’Meara and Tuffy.
Amendment declared carried.
Motion, as amended, put and declared carried.