Provision of Health Services by the HSE: Statements

It is a great pleasure to be here to discuss the health services. I propose to make some opening comments to set the context of what we are doing with our health services and then, by way of reply, to deal with the issues raised by Senators. One measurement used in any country to establish the quality of health services is life expectancy. When we joined the EU, life expectancy in Ireland was two years below the EU average. Today, it is one year higher. We have added four years to life expectancy during the past 12 years. A child born in Ireland today will live longer than a child born in the UK, Denmark, Germany and many other countries, something of which we must be proud.

Patient safety and quality guides me in the reform of the health services. We live in an era in which standards, monitoring and enforcement are at the heart of everything we do in health care. This dictates how and where things happen. If we are to be concerned with good outcomes for patients, we must be up to the consequences of patient safety and evidence based medicine.

At the heart of the cancer control plan was the fact that all the evidence from Ireland and outside suggested that when breast cancer patients were treated in a centre dealing with 150 new cases per year, their outcomes improved by between 20% and 25%. What does this mean? It means one in four or five women who would have died will survive breast cancer. I am pleased to say we have transitioned our breast cancer services from 32 hospitals some three years ago to eight centres now along with the satellite centre in Donegal. I am pleased to acknowledge the recent data published by the cancer registry showing that between 1996 and 2006 the survival rates for breast cancer in Ireland went from 70% to in excess of 80%. What does this mean? It means ten women who would have died in the mid 1990s are now surviving breast cancer. The improvement is even greater for prostate cancer. It has increased by 23 percentage points. Some 23 men who would have died in the mid 1990s are now surviving prostate cancer.

What else are we doing in cancer care? We are establishing rapid access clinics for lung and prostate cancer at the eight centres. Most of these are open and the remainder will open later this year. This will ensure that men with symptoms that could cause prostate cancer can rapidly be accessed and this is equally the case for lung cancer. We are also rolling out our screening programmes. Last year, 122,000 women were screened as part of BreastCheck. This has now been rolled out to every county in the country. Last year, 280,000 women between 25 and 60 years were screened for cervical cancer.

Recently, we began the introduction of the vaccine. Some 80% of women who go for screening will be prevented from having cervical cancer. The belt and braces approach will add a further 20% to the numbers receiving the vaccine and, hopefully, 25 years from now, will prevent young girls from getting cervical cancer. The first screening programme to involve men will begin on 1 January 2012 when we introduce the colorectal screening programme. Unlike other screening programmes, it will involve a good deal of self screening and the kit will be sent to people in their homes. A person will carry out his or her own test and send it back. Approximately 6% of those tested will require follow up measures such as a colonoscopy and approximately 12 hospitals in the country will provide colonoscopy suites. Between now and then we need a significant public awareness campaign but it must be informed by research and that research is under way. The reason for the research is because it is the first time people will have been involved in self screening and it will be the first time we have a screening programme involving men. Although the participation rate for BreastCheck is more than 70%, one of the highest in the world, we anticipate the rate for the new programme will be 50% which, by world standards, would be good. However, we need public awareness campaigns to be informed by good research and this is under way. Also, we need to train nurses to carry out colonoscopies and to ensure the infrastructure is in place throughout the country for the follow through. This is the reason it takes a period of between 18 to 24 months from the time one agrees to carry out a screening programme to its introduction.

I refer to infection control. I am pleased to say that in the past two years the rate of MRSA has declined by 39%. We have set remarkably ambitious targets for the reduction of health acquired infections, including MRSA. Targets include a reduction of 30% for MRSA and a reduction of 20% overall for health acquired infections as well as a 27% reduction in antibiotic consumption. Why has this taken place? The reduction has taken place because a focus has been applied to it and because we are measuring. It is not possible to manage anything or reach targets unless one measures what one has. In recent years for the first time we have been carrying out infection and hygiene audits within our public hospitals. They are proving to be remarkably successful because there is now a focus within the acute hospital environment on the need for infection control. Hand washing is the most basic and effective tool for minimising the spread of infection in an acute hospital. There has been a very significant increase in the number of health care professionals and visitors who participate in hand washing.

Earlier, I remarked that the focus is all on patient safety, patient outcomes and evidence based medicine. We have 57 hospitals in the country and 37 accident and emergency units. For a population for 4.3 million this means that the various services provided will change. There is no question of downgrading hospitals. At issue is upgrading patient care. This means we must enter a period of constant change. Ireland is no different to any other country in this regard. For example, our cancer control plan is being emulated in other countries. Several people have come to Ireland and met me and I have met people at international conferences interested in the manner in which we have introduced a very successful evidence based cancer control plan. Equally, we must learn from other countries the most effective and safest way to provide services for patients especially when it comes to acute hospital services. For more serious and acute illnesses, that service must be provided in larger hospitals where there are a larger number of expert staff working together in multidisciplinary teams with the patient at the centre of their care. It does not mean there is no role for smaller hospitals. Smaller hospitals can do more in respect of diagnostics, elective work and community based facilities. The future for health care is not a hospital future. Throughout the world, health care systems are minimising services provided in a hospital environment. The hospitalisation model is neither desirable nor affordable. More than 90% of our health needs can be provided in primary, community and continuing care, the reason there is such a focus on these areas.

I refer to care of the elderly. The Fair Deal is providing equity of access and treatment as far as funding is concerned for every older person and their families. No longer are siblings or children responsible for paying the long-term care needs of their family members. No longer will people have to mortgage their house to pay for their parents' long-term care. Everyone is treated on the same basis whether they are in a public or private nursing home. Of the 27,000 people in long-term care in Ireland, approximately 10,000 are in public nursing homes and 17,000 in private nursing homes. Heretofore, some 90% of the care cost in public nursing homes was paid for by the State. In respect of private nursing homes, approximately 40% of the care costs was paid on average and some 60% had to be paid by the individuals and their families. This placed an undue financial burden and a burden of trauma and concern on individuals and their families. Many of us are aware of a litany of family experiences whereby loans had to be taken out to fund the care. That was not desirable, fair or equitable and I am pleased it has been brought to an end. This year, more than €1 billion will be spent on long-term care of older people. As far as older people are concerned, the policy is for care in the community. Some 95% of older people can be cared for in their own homes and communities. From a starting point of zero some five years ago, there are now 11,000 people per year with home care packages and 53,000 people with home help. In fairness, home help has been in place for a considerable length of time. However, home care packages are a new part of the support mechanism at community level to support older people at home. Community services that traditionally would have been provided in acute hospitals are now being provided at home and older people in particular are the beneficiaries.

In addition to patient safety and evidence based medicine guiding what we do and where we do it, we have seen the emergence of great clinical leadership here. Dr. Barry White heads up the HSE quality control and clinical affairs division, a new division in our public health system. He has appointed a number of key leading clinicians to head up different care programmes. They are leaders in their fields who have considerable peer support and credibility among colleagues. Their remit is within the resources they have because we do not have additional money. The public health services were reduced by €1 billion this year. I refer to the resources being spent on these care areas.

They must come up with new and innovative ways to ensure their parents are cared for. I have seen fantastic clinical leadership such as that shown by Professor Keane.

Last week I published the new cardiovascular strategy which for the first time includes stroke patients. Each year in Ireland 2,500 people die from a stroke, 10,000 people have a stroke, there are 10,000 cardiovascular deaths, while 30,000 people live with the residual disability. For certain stroke patients, the effects of a stroke can be reversed if they are thrombolysed within four and half hours. A lead clinician has been appointed to roll out thrombolysis services throughout the country. Instead of thrombolysis services being provided in just a small number hospitals, they will be provided in every network.

Equally, in the case of acute coronary syndrome, if somebody is subject to stenting, or PCI, within 120 minutes, one can reverse the effects of a heart attack. Currently, stenting is done in four or five hospitals, but we will be moving to a situation where it will be done in ten hospitals. The lead clinician is Professor Kieran Daly from the coronary care unit in University College Hospital, Galway. He is a leader in his field both in Ireland and overseas. The leader in the case of stroke patients is Professor Peter Kelly from the Mater Hospital in Dublin, while the leader in the case of patients suffering from heart failure is Professor Ken O'Donnell. I mention them because, like many other senior clinicians, they are prepared to put their heads above the parapet and show genuine leadership in rolling out programmes within the budgetary constraints within which we are operating to provide care for patients. They are optimistic they can do this and very often it is about working in a different way. For example, if stroke patients are cared for appropriately as soon as possible, it reduces the length of time they will have to stay in hospital and greatly improves the outcome in terms of disability. Two years ago we had one stroke unit but now we have 12. However, we need a number of others. This greatly enhances the outcome for patients and reduces the burden and the cost on the hospital and the public health system.

The accident and emergency unit is seen as the shop front in terms of hospital activity. Four years ago few patients were seen within six hours, the target we had set. Today I happy to say 87% of patients are seen and sent home or otherwise within six hours. The vast majority of the remaining 13% are seen within 12 hours, but the target is six hours. We are determined to reach that target. There are six hospitals, in particular, which have not been in a position to reach it. They include among them the large acute hospitals in Dublin which require medical assessment units which are being put in place. I expect the improvements we have seen in Waterford, Letterkenny, Sligo, Portiuncula, the Midlands, Mullingar and many other hospitals to been seen in Beaumont, the Mater and Tallaght hospitals.

The new chief executive officer in Tallaght hospital, Professor Conlon, is making great improvements in the operation of the hospital and I expect to see similar improvements elsewhere. A new chief executive officer, Dr. David O'Keeffe, has been appointed in University College Hospital, Galway and I expect his clinical leadership, experience and managerial skills to bring great improvements. Even though we have made huge improvements, we still have some of the journey to travel. In our criticism of the deficiencies, we must be fair about the positive outcomes achieved.

Mental health services were referred to this morning on the Order of Business, to some of which I listened. For many years these services were the Cinderella of the health service. However, in 2007 we published A Vision for Change which is the future of mental health services and into which everybody has bought. It is about providing for community based services. I come from the Ballinasloe area of County Galway, as does Senator Mullen. When I was a very young girl, I remember visiting Ballinasloe and hearing about St. Brigid's. If memory serves me right, there were close to 3,000 patients there when I was a child. The story was that if one went into it, one had little chance of ever coming out. That is the dark past as far as dealing with mental illness is concerned.

I am happy to say the vast majority of mental health patients are now in a community setting being cared for at home or in day services, but we still have facilities which are not fit for purpose such as those mentioned by the Mental Health Commission in its 2009 report — St. Brendan's, St. Senan's and St. Ita's hospitals. I was asked earlier by the media what one had to say to the patients still in these facilities. The first thing is that it is not acceptable and that it will end. The new unit in Blanchardstown has been completed. Some 100 additional psychiatric nurses are being appointed and 30 of them will be appointed to that unit, to which the patients from St. Brendan's Hospital will move shortly. A new acute unit is being built in Beaumont Hospital for patients from St. Ita's Hospital, while new facilities are being put in place in Wexford for the patients of St. Senan's Hospital.

I say to the patients and their families that in the past this would not have been commented upon. Today we have an independent commission, a statutory body, the sole focus of which is on the interests of patients. It is the voice of patients and carries out inspections without fear or favour. Whether they are for mental health patients or elderly patients — there has been controversy about some of the inspections which have taken place of places in which elderly patients are cared for — if buildings or services are not fit for purpose, it must be brought to an end as soon as possible.

The Minister of State, Deputy Moloney, has put in a huge effort. However, there are still industrial relations issues which must be addressed. We require psychiatric nurses to move from the hospital setting into the community but this still has not been agreed. The Croke Park agreement has huge potential as far as public health services are concerned and I hope we will achieve redeployment. Nobody will lose his or her job. We are asking people to work in a different place in a different way. If we all put patients first, we can meet the challenges in the mental health services.

As Senator Prendergast is in the House, people in Clonmel, in particular, were not happy about moving into community facilities. However, I understand much good work has been done since our meeting with Oireachtas representatives in order that we can proceed with the €10 million project to improve community services in Clonmel and remove patients from the awful acute facilities that have been the hallmark of mental health services in the area.

I recently announced new proposals on behalf of the Government in regard to private health insurance. Half of the population have private health insurance policies. Notwithstanding the recession, the rate of decline has been less than 2% — I believe the actual figure is 1.6%. This indicates that there is strong support for the private health insurance market in Ireland. One can argue about why that is the case, but in a society in which people like me and most people in this room can afford to make a contribution towards their health costs, they should do so. The reality is that we have one company which has a disproportionate share of those over 65 years. VHI has 90% of the over 80s, 80% of the over 70s and 70% plus of the over 65s. Last year it lost €170 million on the over 65s. I am equally aware that it has a 60% share of the health insurance market and that many of its competitors believe that is disproportionate. Asking its competitors to transfer money through the tax relief at source system from its younger members to it is a huge bone of contention. It is the Government's strong view, based on the advice available to it, that as long as we remain the owner of a company and the regulator of the market, that is unacceptable.

There are no good health reasons the Government needs to own VHI which must be authorised on the same basis as the other companies which must put aside 40% of their premium income for their reserves to meet the solvency requirements of the regulator, but VHI does not have to do this. That is grossly unfair from the point of view of promoting competition in the market. VHI needs capital if it is to be authorised. The Government is willing to bring forward that capital on the good investor principle on the basis that when we sell VHI, the money will be returned. It would not make sense to sell VHI before it was capitalised because its value would decrease hugely. Most important, without a sustainable business model, VHI would not be attractive from a State or private interest perspective. To make it attractive, we must ensure older people are supported by younger people. That solidarity is the hallmark of our private health insurance market — that we pay more than health insurance should cost when we are young in order that older people do not have their premiums hiked up by virtue of their age or medical condition. This is known as risk equalisation. If we want community rating of policies, whereby we all pay the same for the same policy and do not discriminate or show bias based on age or medical condition, that requires younger people, under a risk equalisation model, to support older people. Our model of risk equalisation introduced in 1996 was struck down by the Supreme Court in July 2008. We must reflect on this. It is an extremely complex issue, but in the meantime we are using the taxation system to transfer money from younger to older people.

By 1 January 2013, the intention is to have a new risk equalisation model based not only on age and gender but also on health status. In the meantime, we must use the scheme we have as a transitional measure to make sure we continue to support older people, who are an increasing cost for health insurers.

In addition, insurers are required to comply with minimum benefits legislation. In other words, there are minimum benefits that they must cover but they are outdated now in light of our current experience and policy. For example, the legislation does not require insurers to cover primary care or preventive care. I will amend minimum benefits insurance later this year to require a heavy emphasis on primary care and preventive care. It should not be that one's insurance only covers episodes in hospital or diagnostics provided in a hospital environment. That is not desirable from a cost point of view or from a patient experience and outcome point of view. That will also be addressed. This will fit in with the new eligibility legislation we are preparing regarding what we are entitled to in the public service.

Evidence-based patient safety is at the heart of everything we do. Clearly, we must continue to encourage the clinical leadership that has emerged. We must also get more from less, as we will have less money next year than we have this year. We have taken €1 billion out of our public health service this year. It is a challenge but when we are challenged in Ireland and when we are ambitious, it is amazing what we can do.

It is an opportunity.

I have seen fantastic examples of more being done for less. Senator Quinn is well experienced in this from a business perspective. When people apply their minds to how they can do things differently and in a more innovative way, it is amazing what can happen. For example, with less money this year Beaumont Hospital has treated more patients than last year. It has fewer inpatient beds and less money but more people are being treated because they are being admitted on a day case basis without the requirement for 24-7 cover. The ambition is that every patient will undergo surgery on a same day basis, given 80% of those who require surgery can come in the morning, have their surgery and go home. That is best practice internationally. We are a long way off but we are moving in that direction. Anyone who needs diagnostics should not, unless it is essential, have to be admitted to access that service.

I look forward to the contributions of Members and to responding to the issues raised. Our health services have improved enormously. There are 6,000 people alive today who would have been dead ten years ago because of the cardiovascular interventions we now have. I instanced the improvements in cancer outcomes and they will improve further with the new services we have in place and the multidisciplinary care. Ireland is fortunate for its size to have clinicians of a world standing for a number of reasons. We can attract and financially reward clinicians as well as they are rewarded almost anywhere in the world. We have attracted high-powered, talented and experienced clinicians, including nurses, to provide world class services to our patients.

There are deficiencies, some of which resulted from the fragmented nature of the service we provided. If one spreads one's resource too thinly in terms of expertise, one does not achieve value in terms of outcomes. We have learned that from the cancer service and we must learn it in other areas. Instead of people becoming obsessed with institutions, we need to become obsessed with services. Patients ask me where they can get the best service when they are sick or where they can get the best service for their child.

Last week I met members of Helping Hands. This is a wonderful organisation based in the west of Ireland and its members move into the home when a child has cancer and the parents must travel to Crumlin hospital in Dublin where all cancer treatment for children is centralised. That is why we have one of the best outcomes in the world for childhood cancers. They move in and look after the rest of the family. They take the other children to school, provide food and so on. It is a fantastic organisation. I was talking to one of the parents whose child has survived six years. She said the service in Crumlin hospital was fantastic but when she hears some of the debates, she said, "I feel like ringing up Joe Duffy just to tell him of the experience we had". I encouraged her to do so.

He does not like good news.

That is how parents feel when they experience a terrific, successful outcome to their child's serious illness. Well-informed patients also have that perspective and the challenge for us in politics is to support the best outcome for patients whatever that involves for us as politicians. It requires courage and leadership but there never has been a better time to show that than in the Ireland of 2010.

I welcome the Minister to the House. I agree with the Leader's comment about the time she gives to the House and I thank her for that. She listens to the contributions we make and takes up the issues we highlight. She gives a response in so far as she can on the day on the issues we raise.

She referred to improved life expectancy as one of the factors that proves we have a better service. However, the overall social and economic context is a huge factor and not just the direct experience of the health service. We know that internationally, as the social and economic circumstances of a population improve, the health outcomes improve dramatically. That is one of the reasons good health policy means a focus on prevention as much as possible. I agree with the Minister that we have not focused on this enough and there is great scope to focus more on prevention of a range of diseases and illnesses to save money and to ensure better health outcomes, which is important.

She stated the health service is moving to evidence-based quality services with high clinical leadership and a monitoring of outcomes. She is correct and I support her move to specialties and excellence, the benefits of which can clearly be seen in breast cancer services. However, there has been slow progress overall in the move to cancer screening. Many counties had to wait a long time for the breast cancer service. I acknowledge we are there now but I would hate to think that when it comes to rolling out screening for colon cancer, cervical cancer or prostate cancer, it could take the time it did to deliver the breast cancer screening service nationwide. That was not acceptable because the political will and vision was there but the implementation of the programme was unbelievably slow. It was incredible that it took ten to 15 years from start to finish, which was too long. That issue must be taken on board.

The Minister mentioned reducing infection control, which is also important. The criteria she listed were evidence-based, patient safety, a quality service, high clinical excellence and monitoring outcomes. I can only focus on a number of areas but serious questions have been raised about each criterion even in the past few weeks. It is one thing for the Minister to say she wants quality patient outcomes, patient safety, clinical excellence and so on and I totally respect that is the model she is operating on, but questions arise about each criterion.

The Minister will acknowledge that is still a real issue. For example, maternity services were in the public arena recently. The very least a woman expects if she has had a miscarriage and goes for a scan is that it would be accurate. I had two miscarriages and like every woman in the country when this scandal emerged, my mind flashed back to the experience I had and I went through what happened to me. The Minister and I do not create panic because miscarriage is common. However, the very least one would expect when attending a hospital for a scan is standard routine procedures, clinical excellence and proper monitoring with information from around the country about the service available.

The Minister should compare what she said in her introduction with the experience of patients. The women concerned were intuitive but it is difficult to be that intuitive when one is dealing with a medical issue because one feels one should trust the medical information. I became involved in public life because of my concerns about maternity hospitals and the lack of voices women had. It sparked my interest in policy issues. The Minister must explain why, for example, when the HSE had the experience of an incorrect diagnosis of a miscarriage in UCHG in 2006 and set down a standard operating procedure following a review, that was not rolled out throughout the country. Why did the HSE not learn from that? This is one example, but there could be many more. Why did the HSE not move to the type of model the Minister is talking about, in that most recent example, which is quite extraordinary? It is a good example when putting it to the Minister that although she has the model and the approach, what about the implementation? We are talking about the delivery of services by the HSE. Obviously, the country is extremely concerned about the management issues that arise in relation to the HSE.

Take the child care issue and the lack of a death mechanism review. Again the Minister talks about the importance of having statistics. If one takes the social aspect and the child care area it is clear that monitoring, consistency and feedback were missing. What was also missing was having child care at an appropriate level within the HSE, in terms of reporting, management and budgetary levels. The Minister might confirm whether it is true that only very recently has child care been on the agenda of the board of the HSE.

If something like child care services is not an agenda item for discussion by the board of the HSE, that tells us all we need to know about why we have had the sort of problems we have seen. I have limited time, but I would like the Minister to inform the public on what plans exist in relation to prioritising child care issues so they are dealt with at the right management level, with appropriate budgets within the HSE. There is so much criticism of the HSE structure not delivering that she has to address this issue. The minute I say this we come up against a problem, because the whole question of the Minister's relationship to the HSE and the political accountability her office takes in that regard is one that seems very fluid. Again, I ask Deputy Harney as an experienced Minister for Health and Children, to outline how she sees that relationship. How can she be certain that she has the political accountability to ensure that what she said in her introductory words to this House, for example, happens in relation to child care or maternity services?

These are the key issues. It is about the relationship between the two. The Minister has the model and says she wants to see it delivered and yet, again and again on the ground, there are examples of where there are problems. Tallaght hospital X-rays is such a problem area, as is not knowing the number of children who died. The colonoscopy area is another example. I ask the Minister to update us on Tallaght, to reassure the House that those letters have now been read, systems are in place, we understand why this happened and that the lessons learned from that review will be spread to the other hospitals where the same thing could happen, and indeed, where there were reports to this effect. These are the key questions about delivery and the patient experience.

The Minister rightly says that what is important is the quality of the patient's experience, and I totally agree. However, the examples I am giving impact on and are at the core of patient safety. The statistics are still incredibly worrying. They are about the numbers still on trolleys and the loss of patient beds. I would like the Minister to return to the bed issue. On 23 May we were told that 333 beds were closed in hospitals around the country, owing to cost savings, infection control or refurbishment. The Minister is apparently planning also more than 1,000 closures, while originally she had promised 3,000 extra beds. Could she comment on that? If 300 people are on trolleys on a daily basis, 900 operations were cancelled in the first half of last year and more than 270,000 bed days were lost due to delayed discharges, what is the plan in relation to beds, and what is the Minister's estimate of the number of beds necessary to give people the services they need? Co-location was the Minister's plan, but clearly that is not being developed as she intended.

I want to move to the area of primary care. The Government programme is way behind in the delivery of primary care centres. Again, in the current economic climate what is the response to those who wish to develop primary care units? What state of progress is the Minister at in relation to the development of further primary care systems? A quick glance at the statistics will show that the rhetoric and the theory indicate that while we want to move towards the development of primary care, there is nothing on the ground to show we have anything like the level of units needed. If the Minister is going to close the beds and move away from a hospital admissions regime as much as possible, which is the right thing to do, obviously people must have a service locally. They must be able to avail of it in terms of primary care.

There is a problem as regards moving to specialist centres before the services are developed in the specialist hospitals. This will result in the same problem we saw as regards maternity services, namely, registrars, senior house officers and consultants who are so rushed and pressurised because of pressure from outlying hospitals being closed that they are not able to respond to the woman, for example, who needs to be given sufficient time if her scan is to be read properly. This is very problematic and I do not want to pretend that running our health services is easy since it is enormously complex.

Nonetheless, we are investing €20 billion a year, €16 billion of which is in the public health system. Fine Gael has looked at other countries. Ireland is investing an enormous amount of money in health, but it is not getting value in terms of the outcomes, despite the improvements the Minister has referred to in terms of extension of life etc. We are not getting the quality levels we should be, given the amount of money going into the health services, and everybody knows that. I do not, for a minute, want to criticise front line staff. I absolutely acknowledge the pressure that nurses, doctors and hospital staff are under and the efforts they make, but I would like the Minister to speak about the way the hospitals are being administered and the interaction between the HSE and herself.

The Minister commented on today's report on mental health and the closure of the hospitals. I too acknowledge the personal efforts of the Minister of State, Deputy Moloney, but where are the people whom the Mental Health Commission says cannot now be admitted to St. Ita's, St. Brendan's or St. Senan's, from January, going to get a mental health service, if the mental health teams are not at the levels that are needed? Is the Minister planning some emergency response for beds for individuals with mental health difficulties, because it seems to me there is going to be a crisis? Again, given that this is such a vulnerable group, and people with mental health problems can be so easily marginalised, it is absolutely critical that if those three hospitals are going to be closed and not be allowed to admit patients, we need to know that the plans are in this regard.

There are quite a number of other areas I should like to touch on, but I shall go back to the question of colonoscopies. Will the Minister inform the House as regards the waiting times, because this is an area in which she has taken an interest? She wants to see patients who need colonoscopies getting them in a speedy manner.

I welcome the Minister for Health and Children, Deputy Harney, and, like Senator Fitzgerald, thank her for spending so much time in this Chamber. I am sure all Members will agree it was a treat to listen to her excellent presentation. She has an incredible grasp of her brief down to the most minute detail and appears to deliver on it with such ease that I imagine, were Members to ask about paper clips on a hospital trolley somewhere, she almost would know about them. It is such a treat to listen to her that I told the Leader I wished she could speak for an hour because Members could have listened to her for that length of time. This particularly is the case when she speaks without a script. I noticed that although Senator Fitzgerald sought a script, there was none. Sometimes it is somewhat sad not to receive a script from the Minister because there always is so much to take from the speech and one must try to scribble as many notes as possible.

As one would expect, having listened to the Minister, I genuinely disagree with Senator Fitzgerald in her claims to the effect that there is not value for money. Sometimes the Opposition opposes for the sake of it and perhaps the glass is half empty rather than half full and Members are not looking for the positive outcomes. I acknowledge the subjects about which the Minister spoke do not always get the headlines on the "Six One News", "The Frontline" or "Prime Time" because they are positive and do not have a negative twinge to them. However, I was thrilled to hear the Minister's presentation and rapid round-up of the things that are happening. For example, Beaumont Hospital now treats more patients for less money, while 6,000 people are alive today who would not have been ten years ago owing to cardiovascular treatments.

The Minister has spoken of men whom I have encountered during my time on the Medical Council. Professors Daly and Kelly and Dr. O'Keeffe are all young men at the pinnacle of their careers who are Irish-trained, who went abroad to gain expertise and then returned home. They now are at the head of these wonderful units that have Ireland at the pinnacle of such research. It was great to hear the Minister state other countries were following our example. However, there still is a huge road to travel, on which we are advancing all the time. I was delighted to hear the Minister mention the training of nurses for various procedures, particularly cancer screening.

In common with Senator Fitzgerald, I take my hat off to the Minister of State, Deputy Moloney, as Members have done many times in this House. Like the Minister, he spends hours in this Chamber laying out his brief and usually comes without a script and speaks from the heart. In this context, the Minister has rightly pointed out that an independent Mental Health Commission has been established and that this sector can no longer be treated as a Cinderella. I note her acknowledgement that it had been so treated in the past. I again revert to my wonderful experience on the Medical Council, on which I served as a layperson representing the public interest for five years. I visited two new mental health units, one in Portlaoise and the other in Tallaght hospital, and look forward to the day when all the antiquated buildings are closed and mental health patients are treated in a unit within a general hospital. I ask the Minister to keep an eye on adolescent psychology services, particularly in the ring-fencing of beds for eating disorders which are a major problem and a silent killer. However, because they affect a small group of people, they do not have a strong voice. While they are wonderful people, perhaps they do not shout loudly enough. I, therefore, ask the Minister to keep an eye on them.

When preparing for this debate, I examined the entire list of activities covered under the HSE. One might conclude that it is no wonder things go wrong because there is a huge number of activities to cover. However, having listened to the Minister and read through some briefing notes I received through the Leader's office and that of the Minister, I take my hat off to the hard-working staff in the HSE. As the Minister has pointed out, at a time when they are almost battling a tsunami and although the budget has been cut back by €1 billion, there are positive outcomes. I will pick a few areas that I would like to discuss.

While Senator Fitzgerald has stated there still are lengthy queues in accident and emergency departments, they certainly are being reduced. They are 50% shorter today than five years ago. Sometimes, no more than our national broadcaster, a spin is put on the length of time people are obliged to wait in accident and emergency units. People such as the general secretary of the INMO, Mr. Doran, probably have a different slant on matters than the HSE. However, I have personal experience in this regard because one of my siblings was admitted when very ill with severe chest pains to the accident and emergency unit in Tullamore hospital. He was rapidly assessed and found to have a punctured lung. He was then admitted to a bed and well looked after. The following day he asked for a private room because he had VHI cover. His consultant kindly told him that while this would not be a problem, in so doing he would be obliged to cease treating him. He would be obliged to refer him to another consultant colleague because he was one of the new public service-only consultants. Because my brother had been getting such good treatment, he opted to remain in the six-bed public ward under the care of that consultant and sings the praises of the public health service. Consequently, I believe that if one gains access to the public health service and has a positive experience — there is no reason one should not — one will be well looked after. I would go so far as to state there is no difference between the quality of the public service one receives as opposed to that of its private equivalent. One probably is better looked after.

The other area I considered was the National Treatment Purchase Fund, NTPF. In 2002 waiting lists for operations ranged from two to five years. However, that time has been cut to between two and five months. In the eight years since 2002, 165,000 patients have been treated. When I went a little further and looked at the NTPF's website, it was interesting to find a list of people who had been treated. The names are not fictitious, as the website provides the names and addresses of those who have been treated. I took one example from County Sligo and one from my native county of Offaly. A lady in Sligo had knee surgery. Having been told she would be on a waiting list for 14 months, she rang the lo-call number for the National Treatment Purchase Fund which looked after everything. Within two months she was treated in St. Joseph's, Garden Hill, County Sligo. There was wear and tear on her knee and driving was a problem. However, she has now been restored to full health. She stated, "I was treated like royalty," and would recommend it to anyone. The lady from Clara, County Offaly, the Taoiseach's home town, needed a spinal decompression operation in Beaumont Hospital, which sounds specialised. She also faced a two-year wait but again was dealt with within two months. She also sings the NTPF's praises.

I do not care what way it happens, provided it happens. In what may not have been a throwaway remark, the Minister suggested one should talk about services, not about organisations. This is extremely important and Members should think about it when jumping up and down about matters. I do not exclude myself from those who jump up and down on hearing a headline on the "Six One News" or the "News at One" programme. I have been critical of the HSE and entered the Chamber this morning with a very different brief. I had intended to seek complete reform of the HSE, but having listened to the Minister, I have changed my mind.

The last subject I wish to discuss is something that has hit my own family, in that my mother-in-law has been diagnosed with Alzheimer's disease. It has been a very difficult time for the family. I am only her in-law, yet it has affected me and my children to a great extent. Well done to the Minister for introducing the fair deal scheme. I am delighted that the application my in-laws made for my mother-in-law has been dealt with speedily and effectively. She is no different to anyone else. Her application had nothing to do with me. My sisters-in-law were responsible for everything and I was not involved in any way. They are very pleased with how things have moved on for their mother. She is in a private nursing home. I am delighted to say that although she has only her old age pension she is being looked after in the same way as a person with much more money than her and who in the past could have afforded much better care but now everyone is on an equal footing.

I have a minor query about the fair deal scheme which came to me in the form of an e-mail. If a person such as my mother-in-law goes into a nursing home, thus leaving her house vacant, and the family is keen to let out the house rather than leave it empty with the risk of it being vandalised or burgled, it would appear that 100% of the rental income will go to the State for the care of the person in the nursing home and nothing is left for the family to put towards the upkeep of the house. The Minister will be aware that houses that are let out can run down. In this case the family would like to let the house but there will be additional costs for its upkeep. If they do not let it then they feel they are not being fair to the State either in so far as if nothing is done the State is deprived of the money. Perhaps the Minister would reply to that point. It might be the case that a bit of tweaking is necessary or I might not have been correct in my assumption.

By and large, the glass is always half full rather than half empty. At times, if there is not a positive spin on a story the national broadcaster will not want to run with it and it will choose the negative option. I am not being picky because I have complimented such programmes as "Prime Time Investigates" in the House. Perhaps the Minister will examine care for people with Alzheimer's disease and see how we can try to keep people at home for longer, especially those who are affected with early onset Alzheimer's disease. I wish we had more time to debate this issue.

I wish to share time with Senator Doherty.

Is that agreed? Agreed.

I agree with Senator Feeney. It is a joy to listen to the Minister who has no notes but is able to provide us with statistics during her contribution. The other reason it is a joy is because she brought us good news. I was not aware of the increase in life expectancy and of the improvements in patient safety, and in outcomes for breast cancer and prostate cancer. From those perspectives it is a delight to hear what the Minister had to say.

I am also pleased to hear about the efforts in regard to care in the home. I have been a big advocate of moving to care alternatives, including day care, primary care and community care. Hospital care should really be supplemented by alternatives. I am not sure we have done that to any great extent in the past. I read on Monday about this sort of initiative being introduced in several hospitals in Canada. They are calling it "culture change" and they hope it will result in so-called alternative level of care patients; that is, patients occupying a bed who no longer require the intensity of resources and services a hospital provides. Such patients are being moved more efficiently from the hospital to appropriate care settings in the community. This approach has not been properly examined in this country. We need to convince the public that the obvious savings made in hospitals will be to the benefit of the community and to long-stay care.

The Minister informed us that much progress has been made in the HSE in setting cancer care standards but, unfortunately, that fact does not make the headlines. There is still a lack of uniformity in the HSE organisation in many areas. For example, the child care assessment and protection guideline standards still differ across the country. I understand uniform guidelines in the assessment of suspected miscarriage in early pregnancy are only being drawn up at the moment for maternity units. Perhaps the Minister will bring us up to date in that respect. Senator Fitzgerald has referred to the matter also.

One can ask how all the problems can be addressed. The incoming head of the HSE, Cathal Magee, faces a difficult challenge. The small bit of advice I will give to him is to listen to what the customer says. I always refer to patients as customers. I told the Minister previously that when I was chairman of a hospital I made an effort to change "patient" to "customer" but the doctors did not care for it and I did not get my way. I have always maintained that a good leader should be an excellent listener. Mr. Magee can acquire much information on how to do the right thing by listening. Perhaps every customer could fill in an on-line form after visiting a hospital and the HSE could act on that source of information which is so easy to obtain and is right under its eyes.

The Minister did not refer to organ donation today. Currently, more than 600 people are waiting for life-saving transplant operations. A total of 243 organ transplants took place in this country in 2009. A Bill was introduced in the House but debate on it was adjourned as the Minister wished to consider the area more closely to see what could be achieved. The Bill related to presumed consent. I understand that on its own presumed consent will not solve the problem but a great deal can be achieved with transplant co-ordinators in hospitals. I accept the Minister is inquiring into the matter to see what can be done. I am hopeful that something would happen soon because it is almost two years since the Bill was introduced. I was pleased to see that more than 96% of the European Parliament voted for a directive aimed at increasing the number of organs available for transplantation among member states throughout the European Union. It will also facilitate the exchange of organs and expand the pool of organs available. Much can be done.

The reason I introduced the Bill was because I knew a number of people who required organ donation. Three people were affected in one shop. One young man died although his mother went to great pains to try to organise an organ transplant for him, but two others are still alive because they managed to get transplants. People are dying because we have not found a solution to the problem. Presumed consent is the right way to go. I accept the Minister has some reservations and she is carrying out an investigation in order to get support for whatever steps she takes in the area. Matters are dragging on and each month we delay, people are dying. I urge the Minister to take steps, whether by way of presumed consent or a different form of consent, because people are being put into the grave with organs they would be quite happy to have used. If families are not happy they can opt out. We would save lives on that basis. I urge the Minister to do something about organ transplants as soon as possible.

Gabhaim buíochas le Seanadóir Quinn faoin am a roinnt liom inniu ar an ábhar seo. It is clear that the HSE has failed miserably. It is no wonder that it has because it is a monster that was created by the Fianna Fáil-Progressive Democrats Government as a means of insulating itself from accountability and responsibility for the delivery of health services to the people. It was also set up to underpin a grossly inequitable two-tier health system. The failure of the HSE and the shirking of responsibility by Government are illustrated most clearly by the two recent scandals. The country has rightly been shocked by the revelations of the deaths of children in State care. Responsibility for that lies with successive Governments who have presided over totally inadequate child protection services. However, the Minister has remained virtually silent on this issue. Similarly, she has hidden in the background regarding the diagnosis of miscarriage. Just yesterday evening my colleague in the Dáil, Deputy Ó Caoláin, received a reply from the Minister in which she admits the Melissa Redmond case was brought to her attention in August last year. When Ms Redmond spoke about her experience in Our Lady of Lourdes Hospital in Drogheda, she was followed by other women from across the State who had similar experiences.

The Minister sits silent on this issue, which is of great concern. She has now admitted she knew of the Redmond case since August 2009, the month following the mistaken diagnosis of miscarriage. The Minister has described how her Department and the HSE handled the Redmond case but she has given no indication of whether the wider implications were considered by them or whether they even considered the possibility that women might have had similar experiences in other hospitals.

I support the call for the Minister to explain her silence and inaction and why it was only after this issue received widespread publicity that the HSE ordered a review of its cases of the past five years. This will be a very traumatic experience for perhaps hundreds, if not thousands, of women who may find their viable pregnancies were terminated after being wrongly diagnosed as miscarriages.

Let me refer to the effect the non-replacement of front-line services is having on the health service. Today there have been up to 1,900 non-replacements of front-line service providers, nurses and midwives in the main. This resulted from the recruitment embargo imposed by the Government. If the recruitment ban is to be maintained in the health service, in excess of 6,000 further posts will remain unfilled over the next three years, with a corresponding withdrawal in the order of 3,500 acute hospital beds in the public health sector. Is it any wonder that the INMO overwhelmingly rejected the Croke Park deal?

There is great fear in Donegal South-West that the Rock Hospital in Ballyshannon, the Sheil Hospital and particularly Lifford Community Hospital face closure because they are starved of HSE funding. I ask the Minister to oversee an injection of capital to those nursing homes and community hospitals so they can continue to provide a service. Lifford hospital has provided a service since the 1790s.

There are many thousands of excellent people working in the health service under the HSE. They are doing their best to provide first-class health services but their hands are being tied by savage Government cutbacks and a disastrous health policy that maintains a two-tier health system.

The health system must be replaced with a new system of care based on need, and need alone. The HSE must be replaced with a network of community health partnerships, as proposed by Sinn Féin. The first step is to remove the totally discredited Government once and for all.

I join my colleagues in welcoming the Minister to the Chamber. Like other Senators, I am always in admiration of her ability to speak so comprehensively on the health service without a note in hand. I welcome the progress she has outlined. I am very conscious that the HSE is a relatively new body for the provision of services. It is very clear from the Minister's contribution this morning that there are many areas of health delivery and health provision in which the HSE has excelled. There are areas where much work remains to be done.

We will always be talking about the work that needs to be done. It would never be acceptable for us to wake up some day and say everything is perfect. We should always try to be a bit better and strive for even greater developments.

The Minister spoke a lot about good practice. An essential component of this for any organisation is constant review and reflection. Given the relative newness of the HSE, and bearing in mind that we are nearing the end of the term of its first CEO, Professor Brendan Drumm, are there plans to take stock of and reflect on the executive's experience to date and consider how this might inform future practice?

I welcome the progress the Minister outlined, particularly the emphasis on education, upskilling, training and public awareness. These are essential to the HSE's effectiveness and patient safety.

The Minister spoke very eloquently and effectively on the emphasis we are now placing on early intervention and prevention. Sometimes the work we do on prevention can be very hard to measure and quantify. I have no doubt that any investment in prevention will be one for the future of our health service and for our citizens, the people we represent. Although we may never be able to quantify the impact of the investment, I am very honoured to be involved with Dr. Ken McDonald and the work he does with the Heartbeat Trust. I can see very clearly the progress being made on early intervention, assessments associated with prevention and education. These are having an impact on cardiac care. Cardiac disease is one of the main killers in Ireland.

There are a few issues I would like to refer to in the presence of the Minister, the first of which concerns vaccinations. I welcome the roll-out of the cervical cancer vaccine but I am concerned about the uptake under the childhood vaccination programme. I ask the Minister to consider launching a public-awareness campaign. Over recent years, there was much confusion caused in the public domain over the safety implications of vaccines, particularly in respect of the MMR vaccine and its alleged links to autism. It is really important that we send out a message today that there is no credible scientific evidence to link the MMR vaccine to autism and that there is very clear scientific evidence linking diseases such as measles, rubella and mumps to early and unnecessary death and the needless acquisition of disabilities. In the future, Ireland will have people with acquired intellectual disabilities that could have been prevented had they not contracted one of the diseases.

One of the issues we face as a consequence of there not being sufficient uptake of the vaccine is that we no longer have herd immunity in Ireland. This has implications for every infant under 18 months. It is not possible to administer the vaccine to those under 18 months. If we maintain herd immunity, it will mean children under 18 months will not come into contact with those diseases. If we do not have immunity among children over 18 months, they could unintentionally carry disease back home to an infant under 18 months.

From my professional background and having kept up to date with developments, particularly studies carried out in England, I am aware all the research linking MMR to the onset of autism has now been withdrawn and is no longer credible. However, I am not too sure the public is aware of this. I ask the Minister to consider an awareness campaign in this regard.

Concerns were raised recently in the news over developmental checks for younger children. This is a really important part of our work in the fields of early intervention and prevention. Developmental checks are often the first occasions on which it is noticed that things are not quite going according to plan for younger children. The checks comprise an essential component of prevention and intervention.

I very much welcome the fair deal. It has given peace of mind and reassurance to people and gives equitable access to older people who seek nursing home care. However, an issue has arisen for people who suffer the onset of Alzheimer's disease or an age-related disorder. The person's needs increase and they require a higher level of care. Often, they must be moved to a higher support corridor or wing, but they are no longer covered by the fair deal from the moment of the transition. That occurs in nursing homes where high support has been put in place for age-related disorders and part of the nursing home has become registered under the mental health institutions. In one week the person is covered by the fair deal but when they are moved the following week to a different part of the nursing home they are under the mental health section and are no longer covered. Families will then often face bills of between €1,300 and €1,800 per week.

I did not have a chance to speak about the protection of children, which is really important with regard to the HSE. I would welcome another opportunity to discuss that, if possible. I have previously sought the establishment of an Oireachtas joint committee on the protection of children and vulnerable adults. The Minister said it is really important to have inspections carried out without fear or favour, and that this is taking place at present in the mental health and elderly sectors. It is imperative those inspections take place in residential services for children with disabilities and children who are unaccompanied minors. We should also consider inspections in residential services for adults with intellectual disability, who are also quite vulnerable and whose residential settings might not be up to the standard we would desire.

I had hoped the Minister would give her views on the way the HSE conducts its business. My experience of the HSE matches that of many other public representatives, including Fianna Fáil Deputies and at least one of the party's former Ministers. The executive has been described by many public representatives as a monster and a bureaucratic glutton, gobbling up much-needed funds that could be used for frontline services. This is a cause of immense frustration to the public and the medical profession. It also leads to inadequate care for patients.

I accept that not everything that goes wrong with the HSE can be laid at the Minister's door, but that does not mean she can avoid accountability entirely. Yesterday in the Dáil, the Taoiseach again deployed his limited liability defence regarding his responsibility for the economic crisis. Considering the HSE's failings, which we hear about on an almost daily basis and which have been well outlined by Senator Fitzgerald, I hope to hear the Minster, who established it, today accept responsibility for its actions. It appears the HSE does whatever it wants and health Ministers assume the role of its public apologists. However, when the public wants answers from Ministers about the failings of our health service, the response is invariably: "It was not me, it was the HSE". The HSE's public accountability can only ever be limited. It is not a person who stands for election and it cannot be scrutinised in Parliament or voted out of office. Nor can its character be assessed by the electorate.

A Canadian documentary made in 2003, called "The Corporation", is potentially instructive. The film examined the conduct of corporations by applying the psychiatric diagnostics used for human beings. The diagnosis was that the firms in question behaved in the same way as a psychopath. If the same test were applied to the HSE, I believe the diagnosis would be that the patient is a pathological liar. Time and again the executive makes statements, either publicly or to stakeholders, that are demonstrably untrue. It happens so frequently that it cannot be an accident or incompetence. It is done with the deliberate intention to mislead. This reflects poorly on the Minister's political integrity.

Last year, the Minister told me and my fellow Oireachtas members in Tipperary South that we would be informed in advance of changes to our health service. However, just a month later, the HSE announced it was closing St. Michael's acute mental health unit in Clonmel, without the advance warning the Minister promised. The Minister did not break her word but the HSE did it for her. What are the Minister's views on that? What is her view on the fact the decision was made without the consultation process outlined in Vision For Change and without an option appraisal being carried out? I assume the Minister expects best practice to be observed in the administration of the health service. Does she stand over reconfiguration decisions in which consultation and option appraisal are not carried out?

Furthermore, the decision to close St. Michael's was taken without reference to the line Minister. Does she stand over this as well? If so, how many patients does it take to screw in a light bulb in the Minister's head? The welfare of over 50 patients is at stake at St. Michael's, yet the Minister saw no need to be involved in the decision over their future. Therefore, the answer is obviously not 50. Perhaps she might let us know if it is 100 or 150 before she decides to become involved.

I would also be grateful if the Minister would comment on the increase in bureaucracy since the HSE was established. Between 1999 and 2009, there was a 67% increase in the numbers working in administration and management in the health service. By comparison, the increase in nursing staff over the same period was 39%. Ten years ago there were nearly three nurses for every administrator in the health service. That ratio is now close to 2:1. The trend looks set to worsen. We already have an admission that there are not enough junior doctors in the system. Would the Minister accept that there are insufficient nurses as well?

The recruitment moratorium has led to the extraordinary situation in which the Minister is demanding that nurses carry out the cervical vaccination programme without any extra cost. That means public health nurses are being taken away from their normal duties forever. This is not like the H1N1 programme which has a prescribed lifespan. The consequence of this decision is that thousands of babies every year will not get their developmental checks at the optimum time of nine months. There was already an insufficient number of public health nurses to carry out this task to optimum level before the moratorium and the two vaccination programmes.

I pointed out the dangers of this to Professor Drumm at the time, at a health committee meeting, and he shared my concern. He will be returning to paediatrics in the near future and will no doubt be doubly concerned that there are now 120 public health nurse vacancies. These have not been filled and it is having a severe impact on the delivery of primary care. Can the Minister explain how a cervical vaccine programme, requiring the annual administration of 90,000 injections, can be run without affecting the health of babies?

Many people will find it perplexing that the HSE continues to use agency nurses, who cost 50% more than temporary and permanent staff. People could be forgiven for thinking that agency staff are hired to replace nurses on maternity, sick, compassionate orforce majeure leave. They would be wrong. These nurses are rarely replaced, meaning there are fewer nurses in our system than the figures suggest. I accept the Minister might not have the figures to hand, but I would be grateful if she could provide me with an average number for nursing staff absent from duty this year when we meet at the health committee next month.

Senator Feeney stated the Opposition opposes for the sake of opposing. That could not be further from the truth. I have experience as a nurse and midwife for over 20 years in the health service in this country and for more years in another country. Our sources are of the highest integrity. The Irish Nurses and Midwives Organisation has frontline staff who feed information to the executive council and tell the absolute facts relating to the statistics. The spin from the HSE totally removes them from this. I have put questions to the Minister today and I seek answers. In particular, I ask the Minister to update the House on exactly what will happen to the patients in St. Michael's unit. When will we have an update on the reconfiguration process? What is happening with that?

I wish to share time with Senator Dearey.

Is that agreed? Agreed.

I welcome the Minister, Deputy Harney. Health is one of the most crucial issues for everybody. Members discuss finance, education and many other issues a great deal but health is the bedrock of our society. A healthy society is crucial for the well-being of our people. I hope we will see more of the Minister and the Ministers of State in the House.

I commend the Minister on her progress with regard to primary health care. We can get extremely upset about the HSE. We can shout and roar about all that is wrong with it, but the reality is to put matters right we must start somewhere. The Minister is embarking on the adoption of what is very much a community-based approach which is the right one to adopt to health care in this country. We see it in A Vision for Change in providing mental health services in the community and the setting up of primary care teams around the country. Regardless of what party one is in, we should be working with the Minister to ensure the speedy roll-out of primary health care services. Unfortunately, this means that some of the health services people know and love must move or we must make changes in certain hospitals.

I thank the Minister for providing for a level of innovation in speech therapy services recently in Galway where she has initiated a pilot project to install a speech therapist in a school. I hope the project will work well. At a time when we have constant difficulties with budgets the only way we will have better health care services is by being innovative and trying innovative approaches to health care provision. Pilot projects are important in that regard.

There are so many matters I want to bring up with the Minister that I will not have time to raise them all. To mark World AIDS Day, I want to mention a few facts. According to the figures for 2009, there has been a 2.2% decrease in the number of new HIV cases diagnosed. In 2009 some 395 new cases were reported, down from 404. The total number of people infected in Ireland at the end of 2009 was 5,647. However, 33% of all newly diagnosed cases are between the ages of 15 and 29 years. Therefore, as well as continuing to inform people, a preventive approach to AIDS is needed.

We need to place much more emphasis on health promotion. When mayor of Galway, I had the pleasure to visit Finland where I met the Finnish health Minister. Finland has the best health service in the world and I heard how it had managed to move from a difficult situation such as that encountered in Ireland to having the best health service in the world. Believe it or not, it has a three-pronged approach to health care and is very much moving towards the community approach that we are trying to adopt in this country. It is important that we look at and try to adopt best practice models.

I want to mention midwife-led care services in maternity hospitals. There is nothing more poignant than the birth of our children. Some 70,000 children are born in Ireland every year and the number has been increasing in recent years. The birth of children is crucial to our society and as such it is important that we get the provision of services right. Most women who give birth do not suffer from ill health and it is important that women have as many choices as possible. Where they opt for midwife-led care services or Domino care — where care is provided before and after the baby is born within the home or a clinic setting — or home births, this works well in many countries. There are also potential cost savings. I urge the Minister to adopt what is considered to be best practice throughout Europe in the area of maternity services.

There has been much criticism of the HSE, rightly so in some cases. There has also been much criticism of the health service in general. The Taoiseach described it as Angola. Therefore, the Minister has an impossible job. Looking at the various things she has done, the mind boggles. What the health service is working on is extraordinary. I want to work with the Minister in completing the roll-out of primary health care teams to the greatest possible extent between now and the end of the Government's term of office.

I appreciate the opportunity to address the Minister directly. As I have only two minutes in which to do so, I need to cut to the chase.

I refer to what is probably the most intractable network, the north east, my own area, and my analysis of how the problem might be addressed by the Minister. I have looked carefully at Parts 7 and 10 of the Health Act 2004 which describe in broad terms the relationship between the Minister and the CEO of the HSE. It is the most important relationship in any organisation. Although I would like to see the ministerial functions strengthened in any review of the Health Act, under Part 7, it is the function of the HSE to provide advice for the Minister on its functions at the Minister's request. In that regard, I request the Minister to seek advice from the HSE on whether it considers Our Lady of Lourdes Hospital to be fit for purpose as thede facto regional centre which it was never intended to be. Obviously, a decision was made about the hospital in Navan some years ago. In fact, Our Lady of Lourdes Hospital is developing into a regional centre, but I do not believe it has the trust of the majority of people in the north east. I acknowledge that the accident and emergency department is opening next week. The facilities contained within are fantastic. It will change people’s experience of the accident and emergency service. However, according to Dr. Colm Quigley who is leading the transformation programme, Our Lady of Lourdes Hospital is now, by an accident of history and design, the centre of services. However, I do not think that is sufficient reason for it to be so. I, therefore, ask the Minister to seek the advice of the HSE on whether the hospital is fit for purpose because most people do not believe it is. I also ask her to issue a direction on foot of that advice to the effect that the transformation programme should be suspended should the hospital be found not to be fit for purpose as a regional centre.

There is an opportunity, with health services on both sides of the Border strapped for funding, to provide for the cross-Border delivery of regional health services. In the western part of Ulster the Strategic Investment Board of Northern Ireland has developed certain infrastructural projects that have cross-Border application. We could be much more ambitious in how we deliver health services on an cross-Border basis all along the Border but, most specifically, in the north east and south Ulster region. I would like to see the Strategic Investment Board of Northern Ireland and the HSE engaging in serious negotiations on delivery of hospital services on a cross-Border basis.

Debate adjourned.