Health Service Reform: Statements.

Minister for Health and Children (Ms Harney)

I propose not to use a script if that is in order.

The topic for discussion this afternoon is the health reform agenda. The words "health reform" are meaningless to most people. Essentially health reform concerns improving services to patients in all areas of the health system, including at hospital level, in the disability sector, in the mental health area and in acute hospitals. The journey the Government has begun of reforming the administrative and management system in the health service with the establishment of the HSE, the amalgamation of all the health boards and many other organisations — in all more than 50 organisations were submerged into the new organisation known as the Health Service Executive — is but a means to delivering better health care services for patients.

In the past decade we have increased the funding of health care by fourfold. This year's current expenditure on the provision of health care services will be just under €15 billion and we will spend more than €500 million on capital services. On capital investment in health, along with Norway, we are at the top of the league in the OECD, spending as we do in excess of €500 million this year. In 1997 expenditure on health was 15% below the OECD average. By 2003 we had gone to more than 17% above the OECD average and no country in the world has ever increased its expenditure on public health at the rate at which we have done in the past decade. As we invest that money people are entitled to ask whether we are getting the value for that investment, whether we are getting the outcomes for patients and whether we are getting the services. Clearly investment on its own, without reform and without changing the way we do business will not change the outcomes we all expect for patients.

There have been considerable positive aspects in recent years. Since the cancer strategy was introduced we have employed more than 100 additional cancer consultants and 300 more specialist nurses. Mortality from cancer has been reduced by 15%, considerably ahead of the targets that were set, which is very encouraging. Clearly where we provide a world-class service in terms of the expertise and the manner in which we organise the service, we do well. Children's cancer services used to be provided in two hospitals in Dublin. Even though it may have been delivered in other hospitals around the country, essentially it was planned in two hospitals in Dublin, at Tallaght and Crumlin. That service was centralised into the hospital at Crumlin a number of years ago. Even though it is planned in Crumlin, much of the chemotherapy etc. can be delivered locally in approximately 15 or 16 other places. Ireland is top in the European Union in outcomes in children's cancer. That is not the case with other cancers because of the fragmentation of the service.

Much of what we are doing in health care is trying to bring best international practice to the provision of services. This can be extraordinarily controversial. For example we know from evidence internationally and from experts in Ireland that a woman receiving breast cancer surgery in a unit performing fewer than 100 procedures per year does not have the same outcome as a woman whose surgery is performed in a unit carrying out 100 procedures or more per year. In many places surgeons can perform as few as four or five breast cancer procedures in a year. From all the evidence from both home and abroad we know that does not give good outcomes and does not provide the service women are entitled to expect.

A number of months ago I established a group led by Professor Niall O'Higgins to make recommendations on symptomatic breast cancer to set standards. Those standards are due to be presented to me shortly and will be implemented across the country. The cancer control strategy that the Government endorsed less than a year ago and which is now the policy of the HSE is about ensuring that wherever in the country cancer services are provided, they are all provided to the same national standard which leads to the outcome everybody is entitled to expect.

Much of the debate on the health services centres on hospitals. In reality we spend more than 60% of the day-to-day health budget on primary, community and continuing care. Just over 30% of the budget goes on hospital services. However, much of the focus and public debate is on hospital services. Clearly hospital services are incredibly important. There is a debate on the number of acute beds we need. We have 13,500 acute beds in the public hospital system. At present I believe we have approximately 1,900 to 2,000 beds in the private hospital system. That stock of beds is greater than the number of beds available in Sweden. Some 11% of our population is over 65, compared with 18% in the UK and 27% in Germany. When considering acute hospital beds we must do so in the context of the population. Clearly older people are more inclined to use the acute services because a greater number of people are ill than in countries with a younger population. Therefore the debate should not be just about the number of beds. Clearly we will have the number of beds we require and the HSE is carrying out an audit to establish future needs in this regard. In the past ten years we have invested in approximately 170 new beds each year. In the previous period it was 30 new beds per year.

The issue with beds is how they are used. For the top 20 procedures patients spend 50% more time in hospital in Ireland than they do in Australia. Even within Ireland in some hospitals patients having an appendectomy can spend 3.5 days and in others they spend 6.5 days. For a hip operation it can vary from one week to more than two weeks. Clearly we must ensure we have the appropriate stay in our acute hospitals. One of the most effective ways to ensure people do not spend longer than they need in hospital is to carry out ward rounds every day in order that patients are seen by a consultant every day because if they are not seen by a consultant they will not be discharged to go home.

We have too few consultants in our health care system. We have approximately 2,100 consultants and need double that number. We have more than 4,000 junior hospital doctors and need approximately half that number. While we need 6,000 doctors in our hospital system, we need half the number of junior hospital doctors and double the number of consultants. That is the reason I am keen to employ new consultants on the basis of a new contract of employment that meets the health care needs of the 21st century rather than a contract of employment introduced in different circumstances which most of those who have viewed it would agree does not meet the needs of our health care system. It has been described by Dale Tussing as the most attractive hospital consultants' contract anywhere in the world. I do not necessarily say that is my view. I am sure others would have a different view. The fact is it does not serve our needs.

What do we need from a new contract? We need doctors working as part of a team. We need a clinical director in charge of that team. We all accept the hospital manager is not the appropriate person to be in charge of the independent clinical decisions that are made by physicians or the rota and so on that doctors work. We need doctors available 24 hours per day, seven day per week if that is what is required. Clearly that will not be required in every specialty. We cannot have a position where junior doctors are covering because we do not have enough hospital consultants.

Recently I spoke to a respiratory physician who did a round on a Saturday in his accident and emergency department. He told me he was able to send home seven patients whom his junior doctor had decided to admit to the hospital because he had the confidence to make that decision. He knew they did not require to be hospitalised and was able to make a follow-up appointment with them for his outpatient clinic the following week. That is the kind of decision making one gets when a hospital consultant has the experience and the confidence to make those decisions. That happens in other health care systems as much as it happens in the Irish health care system.

I am optimistic about the talks process which began yesterday. I was happy to read this morning that all sides said the atmosphere was cordial and businesslike. We are now at the stage of discussing what the nature of that new contract of employment should be. It is ironic that it has taken so long to get to this point. One would think the Minister for Health and Children was trying to reduce rather than increase the salary of the doctors. If the reform does not work, there will probably come a day when a Minister for Health and Children will have to negotiate a salary reduction rather than a salary increase. If this is how difficult it is to get a new salary negotiated that will enhance the payments and change the work practices of consultants, I shudder to think what the experience will be of the Minister who will arrive with an opposite agenda.

Obviously the health care system is very dependent on nurses. Some 35% of those who work in health are nurses. There are 12.2 nurses working in the system per 1,000 of population. In France the number is 7.5 nurses by 1,000 of population. In the EU it is 8.5 nurses per 1,000 of population. We have more nurses working in our health care system than in any health care system in the world. As the House is aware the nurses have served notice of industrial action commencing this Friday.

Nurses' pay is part of public pay. The Government's public pay policy is negotiated through the social partnership agreement. Recently the Government made an arrangement with trade unions representing hundreds of thousands of workers who have endorsed that agreement. Effectively, it delivers a 10% pay increase over the next 27 months. Separate from the national pay agreements there is a benchmarking process which benchmarks public sector pay against private sector norms. Nurses have a number of issues. We are seeking to encourage them to use the benchmarking process to have these matters adjudicated on. The eight claims have gone to the Labour Court which has recommended that some be considered in the context of benchmarking. I have already put on record that in the area of mental health, those reporting to nurses earn approximately €3,000 per year more. Some 1,000 nurses are affected and clearly that is an anomaly we are open to having adjudicated on and resolved in the benchmarking process.

The issue of a 35 hour week is different matter. I said in the other House yesterday, and I repeat it here, that if it is the case that nurses will do in 35 hours what is currently done in 39 hours, the Government is open to discussing that issue. If it is the case that to reduce the working week from 39 hours to 35 hours we will have to employ an extra 4,000 nurses when we already have more nurses in our health care system than any country in the world, clearly we cannot do that. That is why I have said on a number of occasions recently that we should have a process or a forum where these issues could be discussed with all stakeholders in the health care system.

We need to do with health, in terms of reform of work practice, what we did with the economy in the mid-1980s. At that time the social partners and Government got together, had a shared analysis of the problem and had the courage to come forward with a programme of change that has delivered much of the economic success we enjoy today. There should be a similar approach with all the stakeholders together discussing how they can change work practices so that people can work together as part of teams, and how diagnostics can be used on a longer day basis than under the current arrangement. Effectively, after hours diagnostics can only be used on an emergency basis because of the manner in which people are remunerated and it is extraordinarily expensive. We need to change working arrangements to deliver services for patients when they need them.

Negotiating these changes with individual groups of workers is not as satisfactory as seeking to do the change with all the worker representatives together because people must work in a team. Having a changed circumstance with one group of employees will not work if we do not have another group of employees on side for the process as well.

Recently we provided for nurses to prescribe. I want to empower nurses in our health care system. They are an under-used resource in terms of their experience and expertise. Nurses should be able to order diagnostics. That a nurse in an accident and emergency department cannot order an X-ray for a patient and must wait until the doctor comes to order it is crazy. If the nurse could order it, when the doctor comes to see the patient, he or she would know from the diagnostic results what was wrong with the patient. Under our system we must wait for the doctor to order the diagnostics. These are crazy practices that have built up in our health system for many years that do not exist in other countries.

We must embrace change and empower nurses. I believe the nurses' organisations are up for that change but it must be done in the context of wider reforms reflecting other groups of workers. Certainly the Government will sign up to the idea, first mooted by the Irish Congress of Trade Unions, to be fair, of a forum or a process and I hope all stakeholders in the health care system, including consultants, will do so because it could be an innovative way of delivering the kind of change that reflects the needs of patients, and of genuinely improving the health care system.

The focus in the reform is on moving more services into the community and primary care. Last year we chose to support 90 primary care teams. Such teams include general practitioners, specialist nurses, public health nurses, physiotherapists, occupational therapists, dietitians and so on. These teams, working together, can provide an enormous service to the public. For example, all over the world it has been established that if chronic illness, such as diabetes, is managed, the cost of medication is reduced, as is the need for hospitalisation in many cases. The management of chronic illness must be done at primary care level. We are providing resources to the Health Service Executive to initiate chronic illness management at primary and community care level.

A major issue for society and one that puts enormous pressure on the public acute hospital system is the issue of care of the elderly. We have more than 22,000 people in residential care over the age of 65. International evidence suggests that approximately 4.5% of people over the age of 65 require residential care because they are not in a position to be cared for at home or in the community. We are at that figure. However, one third of those in residential care in Ireland today need not be there if home supports or community supports were in place. The policy is to put in place home supports so that older people will only go into residential care as a last resort. The preferred option of older people, their families and all the representative bodies that represent older people is to provide support at family and community level.

By the end of this year, 5,000 older people will be supported at home through home care packages. These packages are customised around the needs of the individual and average approximately €450 per week. Some are more expensive, some less so, depending on the particular needs. Whether at the €450 level or a lower level, they are substantially less expensive from a financial point of view than residential care and are the preferred option. International evidence suggests that if people can remain at home, they live higher quality lives and, on average, live two years longer than if they reside in residential care. That is the international evidence. We do not have data in Ireland.

Supporting people at home is not just about a home help or meals on wheels, important as they are. It is also about having services at community level. For example, physiotherapy is very important for older people, while chiropody is a very basic service. We still have huge shortages in some of these areas at community level, which is why, in recent years, we have considerably increased the number of therapists we are producing from our education system. This must continue. The new school of podiatry will open shortly in Ireland where we can train our own chiropodists. At the moment, they must be trained either in Northern Ireland or overseas.

Education and training are essential in the health care system. We are producing 325 medical graduates at present. The Government decided some time ago to accept the recommendation of the Buttimer and Fottrell reports to more than double the number of medical graduates. That increase began this year with the provision of, I believe, 60 places at undergraduate level in 2006. This year, an extra 40 places at undergraduate level will be provided and for the first time, graduate entry into medical school will begin. When that process is completed in a couple of years, we will be graduating over 725 doctors from Ireland and the EU. This should be sufficient to meet the needs of our health care system. Certainly, the intention is that we will have enough graduates from our own stock. We will always want to supplement that with the people coming from overseas to work in our health care system, but we clearly need to educate more doctors in our medical schools here. This process has now begun.

Clearly, in many areas, there are negotiations underway with various organisations, including general practitioners in respect of the reform of primary care and, in particular, the GMS. Those negotiations are ongoing and I hope they will be successful. A key part of them is the management of chronic illness at community level.

Equally, we must negotiate with pharmacists. The HSE and my Department had a very successful round of negotiations with producers of medication, namely, the pharmaceutical industry and the medical device sector. When this new contract is fully operational we will save approximately €100 million per year. The HSE then began to negotiate with the wholesalers, of whom there are three in the Irish market. Shortly after these negotiations began the wholesalers produced legal advice sent to them by a pharmacist. This advice suggested that they could not negotiate with the HSE because the outcome of their negotiations would affect the prices paid to the retail sector, namely, the pharmacists, and would therefore be illegal under Irish and European competition law. This was a surprise to us. We were not aware of it.

The HSE obtained its own advice, which confirmed that what the pharmacists said was true, and the Attorney General has so advised. Under EU law it is not open to the State to negotiate prices with pharmacists or any other group. It can negotiate a contract and the nature of what is in that contract, but a different process must be found to settle price. I hope that we will be able to find a mediation or independent process chaired by somebody that is acceptable to both sides to be able to discuss the nature of the contract we wish to have with community pharmacists. I have spoken to the HSE and hope we can put this in place in the coming weeks because it is important. I wish to put on record, because it is misunderstood, that it is not a question of not negotiating with any union. That is not the issue. The issue is that under European law, the State cannot set a price with any group of citizens. It can only negotiate price with its own employees. This is why a pharmacist asked me recently why I was negotiating with the consultants. They are our own employees and are in a different category to people who are self-employed and in their own business. I believe a resolution can be found and we want to work on the basis of being positive and making progress, not on the basis of putting our heads in the sand and saying we will not talk to anybody. That is not my approach nor is it the approach of the Government or HSE.

I will not mention hospital acquired infections because I was here last week to discuss that matter. I say this because I fear Senator Browne will accuse me of not talking about hospital acquired infections.

Mr. Browne

I would never accuse the Minister of anything.

Ms Harney

We had a long debate on the matter and there is a strategy in place, in particular to recruit infection control nurses, surveillance scientists and antibiotic pharmacists. I have said many times that hygiene is a significant issue in our hospitals. It has a role to play in respect of infection. Hand hygiene is the most important form of hygiene in this regard, but hygiene in general is important. The two hygiene audits that have been carried out have thrown up some very interesting results. First, they have shown that it was not a question of the hospitals that outsourced performing worse than hospitals that had their cleaning service in house. Equally, the audits showed that it was not a question of old hospitals performing worse than new ones or that hospitals with microbiologists performed better than those without them. What it did show was that it did not matter whether the hospital had insourced or outsourced services or a combination of both or whether the hospital was old or new. Hospitals that were well managed performed extraordinarily well. The good thing about the second audit was that there was a huge improvement across the hospitals, which is very encouraging. It proves that one can manage what one measures.

Clearly, this feeds into wider issues. We know the biggest issue affecting MRSA is the over-prescribing of antibiotics. Senator Henry gave an excellent speech here last week on many of these issues. Among the issues being dealt with by the HSE is a programme of education for general practitioners which must include patients as well. The countries I have looked at which do very well in this area, for example, the Netherlands, place huge emphasis on informing and educating general practitioners and patients. We all tend to become a little obsessed with the need for antibiotics if we start sneezing. The number of people I know who have antibiotics in their hand bags is incredible. To be honest, before I got this job, I would have thought that having antibiotics is a good thing because one gets over the cold quickly and that is the end of it. If we do not need them, we should not take them because we become resistant.

In respect of swabbing patients when they go into hospital, one could have MRSA in one's nose but not on one's hands or vice versa. Dr. Neligan, who is not a fan of mine and writes about me at least every second week and sometimes every week, recently addressed a Fine Gael meeting in the midlands. I will probably encourage him to write about me again. A friend or two of mine attended the meeting, during which he told the audience that half of them were carrying MRSA and I believe they were very shocked. They were not carrying MRSA because they were members of Fine Gael, but the reality is that we all carry it. When people are sick, they are more vulnerable and when one is in an environment where is a lot of sickness, one is clearly more vulnerable. In respect of isolation, the hospital of the future, which it will take quite a long time to reach, will probably be one with single rooms. The new children’s hospital we are building will have single rooms for these kind of reasons.

The decision on the children's hospital has been made and endorsed by the Government. There is no perfect site. One thing we do need is a national children's hospital for very sick children with cancers or who require heart surgery. As Linda Dillon, a woman from Crumlin who tragically lost her daughter, Alice, to cancer last year, said to me in my office and subsequently on "Morning Ireland" recently: "Get on with it. Let us not have any more reviews, delays, analysis. We have been waiting a long time for get what our children need, which is a world-class hospital". We are going to get on with it. The consultants are currently scoping out what will be in the hospital, but I hope it will be a hospital with single rooms so that as we move with new hospital developments, we cater for the issues that arise with serious illness and infection. I have had discussions with the HSE and my officials in this respect.

It is a pleasure to be here. I apologise to my officials for having to write this wonderful script. If anybody wants it, they can have it. There is a considerable amount of regulation. The Medical Practitioners Bill is being moved in the other House on Friday. Its purpose is to regulate the medical profession. This Bill is long overdue because it is 30 years since we had the last Bill. The Cabinet cleared the Pharmacy Bill yesterday. Believe it or not, we are reforming an Act from 1875. I understand that 30 years ago, a predecessor of mine informed an annual dinner that it would be done in the following six months. This has been a minefield and is a great tribute to the officials who have worked very hard on it.

The Health Bill 2006 will establish the Health Information and Quality Authority, a new State body responsible for authoritative information, setting standards and inspecting against those standards. There is a huge amount underway on the legislative side, as well as on change at HSE level.

My aim and that of the Government, and I believe, everybody in this House, is to have a world-class health system in Ireland and to have people visit this country in the future to see how we did it in the same way they visit today to see how we created our economic success. This is the ambition we have set for ourselves and there is no doubt it is achievable. It is not achievable overnight and will not be achieved next year or the year after. It will take quite some time to get there, but get there, we will.

Ms White

Our life expectancy is below the OECD average.

Ms O’Rourke

What about euthanasia?

Ms Harney

I do not agree with euthanasia.

Mr. Minihan

Senator Browne should have come.

Ms Harney

He would have been very welcome.

An Cathaoirleach

Order, please.

Mr. Browne

In regard to primary care teams, I was disappointed to see the recent resignation of a key person in the HSE. I understand it was due to frustration with some doctors who are not playing ball on the issue. The private sector is moving into this area. I understand they are developing primary care centres. This approach makes sense in so far as all the required services are available in one place, for example, chiropodists, physiotherapists etc. I regret the lack of feedback from doctors on this issue, even though I have been in contact with them on numerous occasions. As far as I can gather they do not tend to make known their views to anybody. The focus should be on the patient at all times. Doctors must remember this. Today and last week in the Oireachtas Joint Committee on Health and Children the Minister acknowledged the need to increase the number of medical graduates and the number of people opting to study medicine at postgraduate level.

People are living longer and the new generation of doctors will not make house calls to the same extent or work the same hours as before. We must prepare for that now. The Minister for Health and Children is correct in referring to a doubling of medical graduates but this is not sufficient. The figure should be trebled. Many doctors are keen to work from 9 a.m. to 5 p.m., Monday to Friday. I do not envy any doctor on call who receives a telephone call at midnight from a person with chest pain and who must decide if it is a heart attack or indigestion. We must recognise that doctors are not prepared to work the long hours worked by previous generations.

We must examine preventative health care. Many people suggest the Department should be called the Department of disease because we tend to be reactive rather than pro-active. Has the Minister negotiated with the Minister for Education and Science to ensure every secondary school has a physical education hall to allow students to exercise and get fit? We all have a responsibility to care for our health. Can heavy smokers be surprised if they have cancer after smoking for 40 years? As legislators we have an onus to inform the public but the public has a responsibility to lead healthy lives.

We must provide community facilities such as swimming pools. The problem is that it takes so long. The Government had to find €1 billion to repay the illegal nursing home charges. It is a pity that sum of money was not put towards community facilities. The Government could find that money when it was forced to do so but if one seeks money for a community hall during an Adjournment debate the reply is that there is no money available. Government thinking must be shifted to encourage the health and well-being of the citizens.

Mr. Glynn

I look forward to the contributions of my colleagues to this timely debate in which everyone has a relevant contribution to make. As Members of the Houses of the Oireachtas we must change the health services. In the past few years the demands on the health services have changed dramatically. The population is getting older and living longer. There is a greater inclination to avail of elective health procedures. Some 30 years ago, when a person went to hospital half of the community would cry at the terrible event. Nowadays, people can drive, take a taxi or cycle to the hospital for procedures.

There is demand for additional health services and we must examine how these are delivered. Are we afraid to change established practices? Are we deriving optimum benefit from services? Apart from our longer living and ageing population, the population has increased significantly through immigration. Many people have come to the country from eastern Europe to contribute to the economy and they are very welcome.

What are the reasons for the changes we seek to make? Some years ago the health services were administered by the county councils. The Health Act 1970 and the establishment of health boards caused a hue and cry. Some suggested the health services would be far better under the county councils. Whatever we may say about the health boards, many of the regional specialties would not be there without regional health boards. Some people may agree or disagree with this but it does not alter the facts.

Nothing remains the same. The health boards had a number of deficiencies. I bemoan the democratic deficit, about which I have spoken to the Minister. Representational fora exist but should meet more often. It is important that locally elected representatives can be updated by the powers that be in the HSE. Locally elected members are the conduit between the ordinary person on the street and the health service delivery organisation vis-à-vis the HSE. The Minister should examine whether these fora could meet more often and be given more teeth. Many members feel these fora have no powers and are not performing the function expected.

Under the health board system varying degrees of qualification were required for medical cards, for example. Different levels of nursing home subvention were available. I am delighted with the home care packages. A member of my family is in the early stages of Alzheimer's disease and lives in a three storey house in another country. It is a beautiful house but is unsuitable for someone with this condition. It was advised that the patient would be better off remaining in familiar surroundings. Placing the patient in new surroundings would add to the patient's confusion. It is important that old people be cared for in their homes. We must laud the home help service. Every effort must be made to extend this marvellous service and increase the hours. This is better for the health of the person and generates a few extra euro in the community's economy, especially in rural areas.

We must examine new models of care. Some years ago my brother-in-law and I visited his mother, who was in her 90s. She was in a two storey nursing home in London with in-house carers. The apartments were self-contained, with independent cooking facilities, a sitting room and a kitchen. There was also a community hall. Specially selected people fulfilled the role of watchdogs and it worked very well. It would be worth viewing this model and taking it on board.

Infrastructure is imperative for the delivery of services. As I have said previously, here and at the Oireachtas Joint Committee on Health and Children, we must find a way to fast track capital projects. This involves serious money and the Minister is doing her best but sometimes project teams add extras and facilities which takes forever.

I spent some years in the area of nursing and am delighted at the extended role given to nurses. I have long argued that junior doctors performed functions that could easily have been performed by nurses who in turn did jobs that could have been done by people with a short spell of training. This was a waste of a valuable resource.

I commend Mr. Carey, one of the Minister's officials who is here today, on his proactive approach to nurse training and his role in the establishment of the College of Nursing in the midland region. We are not, however, winning enough recruits for nurse training to care for those who are mentally handicapped or sensorily disabled. I will not get involved in industrial relations but I strongly support the nurses' cause. I have spoken to them and believe they have a strong case. This is in hand and industrial relations negotiations are difficult enough without people like me in a public forum complicating the issue. Some people with a qualification in nursing the mentally handicapped took a care assistant position because that is better paid. That is regrettable and must be addressed. Although there is an individual in the midlands who has revolutionised orthodontics some difficulties remain, of which the Minister is aware.

I am pleased the Minister will increase the number of consultants and reduce the number of junior doctors because consultants are important. I worked with a certain kind of consultant for many years and am aware that consultants play a pivotal role in the delivery of health services. I wish the Minister and the Health Service Executive well in the negotiations on the consultants' contracts because this is a difficult area. The Oireachtas Joint Committee on Health and Children has discussed the fact that when recruitment of a consultant is approved the money is available but the appointment takes as long as a wet Sunday. There must be some way to fast track this process.

A couple of years ago a delegation from the committee went on a study trip to see the primary health care system in France. There is a great differentiation between general practitioners' fees there and here. Running a practice is expensive but is it possible to examine and compare practices in the two countries because here fees are sometimes high. I have been asked several times to raise this issue.

We debated MRSA last week but it is worth repeating the point that it involves operational matters. It is not for the officials of the Department of Health and Children or the Minister to make sure that hospitals are clean. People are appointed to positions of responsibility to do this work. A famous doctor from St. Loman's, who twice stood for election in Dublin, used to repeat ad nauseam that no antibiotic should be prescribed without a culture and sensitivity test. I endorse Senator Henry’s point that some people who visit a general practitioner feel that the consultation was a waste of time if they do not get a prescription. That is nonsense. I spent some years in Britain where advertisements in the national media told people to take their doctors’ advice because that was often the best treatment. There was no reference to a prescription. People should think about that point.

The appointment of mental health teams should be expedited. There are some in place but it is necessary to go further with this work. I am aware that there have been improvements and that the Minister has devolved significant additional resources to the mental health service but this has been something of a Cinderella service. The Minister has corrected that situation but that should continue.

The Minister must try to tackle the scourge of diabetes which is a silent epidemic and will have a major impact on all aspects of the health service. I thank the Minister for listening and know that she will take cognisance of what I have said.

Dr. Henry

I am delighted to welcome the Minister to the House because she has a difficult role and I support many of her initiatives. I am particularly impressed by the initiative to get home support for older people which is incredibly important. Most people want to stay in their homes as long as possible. While it is expensive to have customised services for them, it is worth doing and is much less expensive than admitting them to nursing homes. I am concerned, however, that the programme may mean that the person must become an employer to deal with such help. The Minister can examine that position.

The management of chronic illness should also be transferred, as often as possible, to the primary services but frequently general practitioners want the advice of a consultant before they continue with the care of a person with a chronic illness. It can be a long time before a person can get access to a consultant appointment in order to be reassured that he or she is handling the person in the right way, or to get extra advice. For example, many diabetics wait long months, or sometimes years, to see endocrinologists. This does not encourage general practitioners to take a person back on to their books and mind the person alone because they are afraid that if they are not sure of what they are doing they will get repeat appointments every six months in the diabetics clinic and the person will be out on a limb again. It is important we try to establish services for general practitioners in order that they may rest assured their patients will be seen by hospital consultants rapidly and not after a year or more. This will ensure they receive the advice they need.

Many diabetics require additional supports. After arterial disease and neurological disease, one of the most common complications caused by diabetes is the development of foot ulcers. Access to podiatrists is almost impossible. There has been an ongoing fracas between the Department of Health and Children and the podiatrists since pussy was a kitten. As a result, patients with lesions that could be dealt with by podiatrists must be admitted to hospital, when their foot ulcers become sufficiently bad, and must endure a minimum stay of six weeks in an acute bed. Some of these individuals have had feet amputated because their ulcers were left untreated for so long. I am informed that it is proposed to appoint one podiatrist for every county. I do not know if that is true but surely we should appoint one podiatrist for every few thousand people. Money invested in this regard would be well spent.

The Minister referred to respiratory disease. As she is aware, I have a special interest in the respiratory unit at Peamount Hospital. It is important that one should not examine just bed occupancy when looking at conditions such as respiratory disease. Patient turnover must be also considered. A friend of mine who worked as a respiratory physician stated he used to try not to let his patients get into bed because if they could be kept sitting in chairs — I do not mean overnight or on a trolley — they frequently regained confidence in themselves. It is extraordinarily depressing and frightening to feel that one cannot breathe. However, the patients to whom I refer regained their confidence and were discharged by evening. Bed occupancy should not be seen as the only parameter and consideration should be given to patient turnover within units.

The Minister also referred to the different lengths of stay experienced by patients suffering from the same conditions in different hospitals. It can become traditional to retain patients for certain periods. This is an aspect which must be examined. However, we must also take into account the socio-economic conditions to which patients are exposed. If patients come from areas where such conditions are not so good, they may be retained in hospital for an additional two or three days in order to ensure they are back on their feet. Other patients who enjoy better living conditions at home may well be discharged earlier.

The position regarding nurses threatening industrial action is most unfortunate. We must take into account that there is a shortage of nurses and that the market is in a position to dictate. I am not convinced that nurses frequently carry out jobs that could be done by others.

Ms White

Hear, hear.

Dr. Henry

Making empty beds is one thing but making them with patients in them is quite another. It is not just that one must deal with the patient and make the bed, it is the fact that one might discover something that is of great importance while doing so. We are in a difficult position vis-à-vis nurses. It was very difficult for them to go on strike on the first occasion and I recall senior nurses weeping on my shoulder at the thought of doing so. It will not be difficult on this occasion.

Nurses will be able to prescribe in the future, which is perfectly acceptable, and the Minister referred to them ordering diagnostics. We already discussed the rationale — brought forward by the Minister — for having more consultants, namely, that people would be in better decision-making positions and would, we hope, have more confidence in respect of discharging people and ordering diagnostics. If junior doctors are not confident and tend to refer too many people for X-rays — I am aware of a survey which indicates that a junior doctor is seven times more likely to order an X-ray in respect of a case than a consultant — we must accept that a similar position will obtain with nurses and that this will give rise to an additional expense.

I am greatly concerned by the fact that there has been a major increase in the amount of money being spent in the health services and that one does not often obtain any idea regarding what something will cost. I wish to refer to the National Treatment Purchase Fund, in respect of which I spoke on previous occasions. This fund operates under a veil of secrecy, which is wrong. One can discover what the VHI, BUPA and VIVAS will pay in respect of procedures. However, one cannot discover what the National Treatment Purchase Fund will pay. The fund's annual report for 2005, the most recent issued, indicates that €64 million, a considerable amount of money, was spent and that 18,000 cases were treated. The administration costs relating to the fund are low, which means approximately €3,500 is being spent per case.

The only really expensive procedures among the top ten listed in the report are joint replacements and cardiac surgery. If we allow €10,000 per procedure — which the VHI would consider generous — in respect of joint replacements or cardiac procedures involving 2,000 patients, the total spent would come to €20 million. When this figure is subtracted from the overall amount of expenditure — that is, €64 million — €44 million is left. Among the other procedures listed in the top ten are those involving procedure scopes, tonsillectomies, varicose veins, skin lesions, hernias and grommets, none of which is expensive. The most common procedure carried out in 2005 related to cataracts and a total of 2,256 patients were involved. To have a procedure carried out on a single eye cost €3,000 in the most expensive of private clinics, while €6,000 would ensure a patient could have both eyes operated on. If we add up the figures in this regard, we find that a further €10 million has been spent. This means that €30 million of the overall budget has been accounted for and that the other €34 million was used for procedures involving skin lesions, hernias and tonsillectomies.

The VHI will pay far less than €1,000 — this includes the fee for the services of an anaesthetist — in respect of tonsillectomies, regardless of whether they are carried out on adults or children. Allowing for expenditure of €1,000 per case, this means we paid €1.5 million for the 1,351 tonsillectomies carried out under the National Treatment Purchase Fund. Where is the money going and why can we not be informed with regard to the type of commercial deals the Government is making?

I was obliged to undergo an MRI scan — Members will be delighted to discover it was perfectly clear — at the Blackrock Clinic at a cost of €259 to the VHI. I telephoned the VHI because I thought there had been a mistake only to be informed that this was the cost under the deal it had negotiated. In my opinion, it was a pretty good deal. Are taxpayers being obliged to pay way over the odds for procedures carried out under the National Treatment Purchase Fund? It is not right that we are being denied access to some form of ballpark figures in respect of individual procedures and that an overall sum is being provided. Procedures relating to skin lesions, grommets and varicose veins cannot cost more than a few hundred euro. The cost of hernia operations must have increased dramatically, particularly when one considers that only 253 were carried out under the National Treatment Purchase Fund. I cannot understand why such common procedures cost so much. I really resent what is happening in this regard.

In addition to what I have just outlined, I understand that GPs are going to receive access to diagnostic services in private facilities. That is great but they should also receive access to such services at public facilities. If a GP refers a patient to a public hospital for an X-ray, there is no cost. GPs should have access to diagnostic facilities at public hospitals. Why is it not possible to extend the use of diagnostic equipment into the evening? Most patients requiring diagnostic procedures are ambulatory and would be well able to attend at a hospital after work. I cannot understand why patients are referred to private facilities but I presume the Department has done a very good deal in this regard. The cost of X-rays at these facilities varies from €54 to €112. At which end of the scale will the Department of Health and Children pay? This is very important and there is no reason that we should not be informed of such things. I resent it very much. The practice in the Department of Health and Children at present appears to be strongly towards the privatisation of the treatment of patients.

I refer the Minister to an editorial in the Canadian Medical Association Journal 2004 by Steffi Woolhandler and David Himmelstein from the department of medicine, Cambridge Hospital, Harvard Medical School, Cambridge, Massachusetts. One cannot get a better address. They discuss the privatisation of health care in the United States and what it has cost. They state that "investor-owned firms have come to dominate kidney dialysis". Where did we hear that previously? It was in Ireland, where patients now go to private facilities. They also dominate nursing home care. That is also the case in Ireland. As I told the Seanad a few nights ago, when I was in the casualty department of St. Vincent's Hospital there were several patients there who looked as if they had been brought there by private facilities because it was felt that they were near the end of their lives. They were, and they should have been left at home in bed. I checked on this later and discovered I was correct. The editorial also refers to inpatient psychiatric and rehabilitation facilities.

We could not choose a more expensive way. Health care in the United States costs 15% of GDP, and 8% of that is private. In Japan and Sweden, two countries which the highest longevity rates in the world, private health care accounts for 1.6% of GDP. I wonder if we are getting value for money in some instances. Why can we not get the figures? I am sure Senator Quinn would not adopt this type of attitude towards his suppliers, whereby they would send him supplies and ask for a blank cheque in return. Why should we have to do it? We simply want to be told what the prices are for hip operations, coronary bypasses, tonsillectomies and so forth. If it is commercially sensitive information, let the suppliers argue between themselves. They will know what the average is. Many of the private hospitals at present are enormously dependent on the National Treatment Purchase Fund for their survival. The Minister is aware of that.

I am glad we are increasing the number of doctors qualifying from our medical schools. It took 30 years to increase the numbers, but it is most important. However, there is a problem with intern places for people to complete their qualifications. We must supply them with intern places. There is already a serious shortage. When we were told they could no longer take up intern posts in England, I went over to argue with the Medical Council about it. Unfortunately, I discovered that we had banned English students from filling intern places here about 20 years ago. That finished my argument on that score. It is an important issue.

I am pleased more consultants will be appointed and I wish the Minister well in her negotiations on the consultants' contract. Given that 70% of consultants are public only at present, I am sure something can be worked out with the other 30%. I wish the co-located hospitals could be step-down facilities rather than acute hospitals side by side with acute hospitals. I express that wish as a patient, not as a doctor. All our high care equipment and expertise in acute areas, such as intensive care, should be located in a single area. The private investors could make far more from running a step-down facility. If I could find out who they are I would send them a note to that effect. They might then take it up with the Department. It would be better for them, better for us and better for the patient. Everybody must think ahead; we will want the best treatment possible from the health service. I wish the Minister well with the changes she is trying to make.

Mr. Minihan

I listened to the Minister, Deputy Harney, and her upbeat comments on the reform agenda being driven through the health service. It is refreshing that despite the onslaught of criticism and ongoing gamesmanship, we have a Minister who is so committed to driving that agenda in the interest of patients. The key issue is the interests of patients. On the one hand there are the Government, political parties, policy makers and officials, while on the other there are the consultants, doctors, nurses and the many health care professionals associated with the health service, down to the administrators in hospitals. All have different and competing interests. In the middle are the people it is all about, the patients.

Nobody can deny that reform is necessary. We can argue and debate about how that reform should take place and what it should comprise but we must all agree that it must be patient driven and in the interest of the patient. Health is an emotive subject. It is traumatic for any family or patient who must experience our health service. However, we should not lose sight of the fact that an independent survey found that 90% of patients who had experienced the health system were more than satisfied with the care they received. A total of 10% were dissatisfied. There will always be dissatisfaction.

The key issue is speedy access to the service. Patients want to be seen, treated and discharged faster. The reform agenda is about ensuring that people are seen faster, their treatment is speedily provided to the best standard and with the best care, and that they are discharged. It is about ensuring we no longer have continuous delays in the occupancy of acute beds and that people are discharged to step-down facilities. I dislike the term "step-down" but it appears to be the buzz phrase in use. People should be moved out of acute beds and into facilities where they can receive the necessary care to recuperate.

The reform agenda will only be fully embraced when the competing parties set aside self interest, empire building and promotion of their speciality or interest and work together. That applies not only to medical professionals but also to political parties, officials, bureaucrats and the like. We all must put self interest aside and try to work towards improving facilities for patients. As we move nearer to an election, the self interest becomes more vocal. There is the self interest of constituencies, with people wanting hospitals at every crossroads and more cancer facilities. However, we must ask if that is in the interest of all patients. I believe we have set out a reform agenda that is focused on delivering services for patients and we must continue in that direction.

The horror stories are, of course, traumatic and capture public attention. However, we probably have not done a good job, or the media are not interested, in presenting the success stories. There have been success stories. It is no harm, for example, to briefly consider accident and emergency services. There are still horror stories but waiting times in accident and emergency departments have dramatically improved in all 35 hospitals with those departments.

New accident and emergency facilities are being provided. A new management focus, driven by the HSE, is in place to improve the health services. Hospitals and accident and emergency facilities are being monitored. The hygiene audits have improved cleanliness in hospitals. Waiting times for operations and major surgery have decreased from years to months. At times it is difficult to listen to the criticisms of the health services when there have been positive improvements. I accept there is room for more. The National Treatment Purchase Fund, which was received pessimistically when first mooted, has brought about tremendous results. I have criticisms of certain aspects of it, such as orthopaedic services where there are difficulties with figures for referrals and outputs. This is not due to availability but because of professional self-interests not pushing the treatment fund to work properly. It is only when self-interest is put aside can progress be made.

The Government's announcement on the package of services for older people, including the fair deal package which will commence in 2008, is welcome. Society and the sense of family have changed dramatically. The traditional arrangement of three generations living together has changed, resulting in a greater requirement for care of the elderly. Care for the elderly must be provided in a safe and secure environment. Some reports on nursing homes have highlighted unacceptable conditions. Standards and inspectorates are being put in place and a proper approach to this new demand on our health care system must be put in place.

Unfortunately, many people in the political establishment and the Department of Health and Children do not view pharmacists as an integral part of the health care system but as retailers. The number of customers who seek medical advice in pharmacies, without any prescription or sale of product, and who receive professional advice from a highly qualified medical professional is seldom acknowledged. How is that costed? How does one pay for that advice?

On the argument of drug costs and the 90% paid for by the State, it must be remembered that pharmacists have no mark-up on this. The State pays the pharmacist for the cost of the drug at cost price and a dispensing fee. There is misperception about the role of pharmacists and they are viewed too much as retailers. If there was a greater use of pharmacists' professional knowledge, a far greater service could be made by them to the overall health plan. Advice on conditions such as diabetes and testing are some examples.

Health care reform is moving in the right direction. It is only by keeping it focussed that we will achieve the results that are in the interests of patients. As the general election approaches, I hope the public debate and the debate in the Oireachtas does not derail a reform that is necessary and long overdue in the health service.

Mr. Ryan

I do not propose to launch into my usual type of diatribe about the quality of the health service.

Ms Feeney

Is that a promise?

Mr. Ryan

No. It will most assuredly not be kept if Senator Feeney keeps interrupting me.

It is extremely important in dealing with reform of the health service to ensure the action taken is designed effectively to make it better. The word "reform" is one that is used too loosely. We must ask ourselves what type of service we want to provide. I am not sure everybody on the other side of the House would agree with my definition in this regard. What we should seek to provide is universal, guaranteed, free at point of use access to the services necessary to sustain and restore well-being. Where such sustenance and restoration is not possible, we must provide care and comfort, either at home or in hospital, that is universal, guaranteed, and free at point of use.

That is my definition of a good health service, devised while wearing my engineer's hat and arising from my enormous obsession with having ideas clear in my head. It is the curse of an engineer that one is not allowed to fudge. One must say either this or that; there is no room for "maybe". That is why engineers and economists do not mix well and engineers and social scientists mix even worse. Being married to a doctor, I will not say how doctors and engineers mix.

I make no apologies in referring to the observation of the leader of the Labour Party that health care is not a market commodity but a community service. This is not to get away from issues such as value for money and so on. However, the market is a poor measure of value for money in the health service. Neither is it a guarantee of discipline, nor a particularly useful instrument. It was considered a glorious triumph when, in the interests of competition, the Competition Authority forced VHI to stop negotiating with consultants as a group.

The ideology of the Competition Authority is that competition controls prices and that people will be drawn towards the best price. The difficulty, however, is that a person suffering from an illness such as cancer will examine the prices charged by consultants and may well choose the cheapest rather than the best. Which consultant is the best? VHI is not available as a mediator because that is no longer allowed. In the absence of any other information, who will patients consider the best — the cheapest or the most expensive?

This turns on its head the entire ideology of competition. A person suffering from a life threatening illness will want to choose the best treatment. The only index available to patients in making that decision is cost. Many will conclude that a consultant who charges half the rate of a competitor is doing so because he or she is not as good and cannot attract patients. That may not be true but it is the perception that will arise.

There will be an orgy of investigations by the Competition Authority as it tries to prove collusion among health service providers in keeping prices high. The first chapter of a first year economics text book will tell us that consumers seek to maximise their utility. The Competition Authority seems to believe this is true in all cases and that patients will balance their health against a price. That is not the case, however, because people do not see their health as a commodity, like buying oil for the winter. That is why the market model is suspect. Similar activity is now taking place in regard to pharmacists.

I am aware that many negotiations such as this are ineffectively carried out. Given its poorly supervised monopoly, VHI was less than rigorous in its negotiations with both doctors' organisations and hospitals in agreeing what was value for money for a particular procedure or service. I agree with Senator Henry that it is a great pity the National Treatment Purchase Fund considers itself entitled to withhold the type of information that commercial entities like VHI, Vivas and BUPA are obliged to make public. I cannot accept there is any rationale for this other than a protectionist mentality on the part of the National Treatment Purchase Fund. The irony of a pro-competition Minister defending that secrecy and the absence of the rigours of the marketplace is astonishing. Perhaps a better service is being provided because more is being paid. There is no reason we should not know whether this is the case.

Discussion of the health service is infected by claims about the advantages of the alleged rigours of the marketplace. One need only read the eulogies on competition written by the eminent economic correspondent, Mr. Marc Coleman, of one of the newspapers that claims to be the newspaper of record. Perhaps there is a competitive model of a health service that works. I am not aware of such, however. The best health services in northern Europe, including those in Germany, France and Sweden, are funded by government to the tune of between 7% and 10% of total spending. According to all the commentators, however, that is unaffordable for this State. We are repeatedly told there must be an insertion of the disciplines of the marketplace.

Those disciplines are in place across the Atlantic. Two comparisons are sufficient to point to the failings of this model in the case of the United States. Infant mortality rates in that country are higher than in any state in northern Europe. This is one index of the quality of universal health care. The other is life expectancy. Life expectancy in Sweden is far higher than it is in the United States. This may be because the price of alcohol is so enormous in Sweden that its inhabitants cannot drink themselves into an early grave as we in this country are trying to do. There is no doubt, however, that on these two indices of performance, the Swedish, French and German health services, and even our own, are superior to that of the United States.

Moreover, the costs of that underachieving health service are such that I cannot understand why people in senior positions in Irish public life nod in that direction. Some 16% of GDP in the United States is spent on health care. This means that instead of us spending €12.7 billion per year on health care, we would have to spend €25 million to match the percentage of GDP spent by the United States. Has anybody faced up to the reality that where one takes a marketplace approach to health services, one is dealing with a commodity for which there is a limitless demand and for which people will pay a limitless price. It is therefore entirely unsuitable for market rigours. An attempt to introduce such rigours will merely distort it and make people rich without any significant improvement in the service itself.

This is where the issue of private hospitals on public land comes into question. It introduces into the context of public health provision issues to do with the way the market works. I do not refer to the silly old hard-line lefty stuff to the effect that private health providers are only in it for profit. It is possible to run good quality services that are profitable. Profit and good quality service are not inimical but given the nature of the commodity, as some people regard it, there is limitless demand because people want ever better services for which they are prepared to pay limitless amounts. Principles of supply and demand and elasticity do not work in health care so we should be wary of going down that road.

If the market model does not work, what are we to do? I do not dispute that things have improved in some areas and everybody acknowledges that inside the hospital system, despite MRSA, the quality of medical care is as good as one could ask for. I know affluent people abroad who are able to pay for high quality private care where they live but return to Ireland to give birth in Irish maternity hospitals because of the quality of care. Who delivers that high quality service? Coming from the left, as I like to think I do, I say it is the doctors and nurses who deliver that service, among them the much-maligned consultants.

I will declare that my wife is a hospital consultant. She works very hard, entirely in the public sector, and the only time she ever worked in private practice was when the public sector declined to give her a job. The minute she landed a public sector job she gave up private practice because she had no interest in it, as is the case with the majority of her colleagues in psychiatry in Cork, although I cannot speak for every region. Consultants, who receive much criticism, are the central deliverers of the quality health care about which this country boasts, as are the nurses who are threatening to strike. The debate ought not to be about beating consultants over the head or silencing them. The most effective and vocal lobbyists for the quality of public health care are hospital consultants, yet it is proposed that they be silenced by a clause in their contracts.

I work in a public body, Cork Institute of Technology. Short of defamation and libel I can say what I like about what is wrong with the service and I can make public its deficiencies when and where I like. I can be warned of the consequences for student demand if I say foolish things, and the Department of Education and Science might be upset at what I say but I cannot be silenced. Why would anyone want to silence hospital consultants unless they thought there was something to hide? The suspicion is now widely held that one of the strategies of the Health Service Executive is to make its problems internal, invisible and silent, which is a dreadful prospect. The health service will only be reformed by open, transparent and accountable decision making. If we take the opposite path, we will make it worse, although it might look better.

Is the allegation true that there has been a directive to move people out of accident and emergency units and into corridors, so that they are no longer regarded as being on trolleys in accident and emergency units? Why do we have to reinvent the wheel in connection with MRSA? Other countries have sorted out the problem and I will shortly say why that is the case.

Ms White

The Senator should tell the House.

Mr. Ryan

I explained why it was the case during the debate last week on MRSA. The fundamental problem with the health service is that the quality of its management is abysmal. It is entirely recruited from inside the service and does not have the necessary injection of external expertise to manage the system. It has the largest budget in the country but is managed by people not qualified or experienced in dealing with budgets of that scale. That is not an excuse for turning it into a privatised service, which is what the Government is in danger of doing.

The only way to make management better is to make it open, transparent and accountable. No decision should be taken in the health service which is not accompanied by the name of who took it, so that a person who did not agree with it would know whom to talk to about it. That happens in every private organisation and I know the pharmaceutical industry quite well. It is not possible to move a bucket across a room without a document stating that, for example, Brendan Ryan moved it. That is the way to maintain clear lines of accountability. One can go into a hospital to find a ward closed in the morning but no one to say who was responsible. That person must not be able to hide behind public relations people but must face up to the consequences of the decision. In that way we will guarantee that anybody who is not up to the job will leave and take early retirement. It is not as simple as that because all sorts of interests, such as trade unions, have a say in such matters but that is the required fundamental reform.

I do not understand why a rich Government did not expand the proportion of the population eligible for medical cards to 40% because that is an obvious way of taking some pressure off the public hospital system. The only reason I can imagine is one of ideology. Why are we carrying out another study into the number of acute beds in the country when we know from the OECD that our figure is among the lowest in the world?

Ms Feeney

I will share time with Senator Daly. I welcome the Minister of State at the Department of Health and Children, Deputy Seán Power, and his hard-working officials. I know one of his officials personally because I served with him on An Bord Altranais and I assume he is one of the officials referred to by Senator Ryan as coming up through the system. I do not know any more committed or hard-working official than Mr. Bernard Carey. I have watched him spearhead the nursing agenda through many different stages, increasing the number of places in schools of nursing at a time when no one else contemplated it. There is nothing wrong with the present staff at the Department of Health and Children and long may it last. I wish Mr. Carey well in his new role.

All is not well in health and we on the Government side would be fools to claim it was. However, it is not all bad either and it is a question of whether the glass is half full or half empty. From my vantage point it is half full. All the bad stories we hear every day about health pull at our heart strings and no one is more likely to have her heart torn apart listening to Joe Duffy or Pat Kenny discuss the issue than I. I have children and siblings and know what it feels like when one of them is ill. However, for every bad story we hear, two good stories go unheard.

One such story involved a brother of mine who returned from a long-haul flight with a sore leg. He went to a walk-in general practitioner after a few days and was sent to an accident and emergency unit in St. Michael's Hospital, Dún Laoghaire, as a public patient. The treatment he received was second to none. He was kept in for two weeks as a day patient and now attends a warfarin clinic. As late as this morning a consultant rang him to tell him not to take warfarin because his blood reading meant he did not require any more medication. He was to come into the hospital instead. No one will ever hear that story but that man is singing the praises of the nurses and doctors he met there. The VHI was not involved, everything was done through the public system and he was very well looked after. That is not to take away from the hundreds out there who have a bad experience in hospital.

Leaving aside the political point scoring and the parochialism, the National Children's Hospital is a hospital for sick children throughout the country. It is not a Dublin hospital, it is not a Tallaght hospital or Mater hospital, it is a national children's hospital. The debate is scaring away the top Irishmen and women who have been trained outside the country and who want to come back. When they hear the parochial debate they say to themselves that they are better of in Britain, America or Canada, where they can do what they are asked to do in their job description without politics or religion muddying the waters.

The health budget has increased four-fold since 1997.

Seanad Éireann debate - Wednesday, 21 Feb 2007