Medical Practitioners (Amendment) Bill 2011: Second Stage

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

Minister of State at the Department of Health (Deputy Róisín Shortall)

The provisions of the Bill before the House will enable the Medical Council to register doctors in a newly created supervised register. The doctors registered will be assigned for a defined period of time not exceeding two years to identifiable, supervised posts to which specific criteria will be attached. Given the seriousness of the shortage of non-consultant hospital doctors, NCHDs, in our hospitals, the legislation is being debated within certain time constraints, in regard to which I appreciate the co-operation of the House. I make it clear that the problem of the shortage of NCHDs in Ireland is not related to funding, any recruitment embargo or moratorium, or any reorganisation of hospitals. It is due to an inability to attract enough doctors to work in our hospitals, in regard to which we are not unique, as many countries in Europe, including the United Kingdom, are encountering the same problems.

A total of 450 posts, including approximately 180 NCHD vacancies — mostly in service rather than training posts — are due to be filled from 11 July, when the next rotation takes place. The number of vacancies is decreasing on an ongoing basis as doctors are appointed via the HSE centralised recruitment process. Following an intensive recruitment drive by the HSE, just over 200 doctors from India and Pakistan have applied to fill these vacancies, but it is unlikely they will all be in a position to meet the new registration requirements of the Medical Council provided for in the Bill by 11 July, which means the take-up of duty will be phased over a period of weeks. The Minister for Health has stated in the Dáil that he will not oversee any process that results in the employment of NCHDs who are not capable of providing safely the services required. Certain specialties such as emergency medicine will be most affected by the NCHD vacancies. Together with my Department and the HSE, the Minister is working to devise arrangements that can be implemented in hospitals if required to ensure any resulting impact on services is minimised and that patient safety is maintained.

The current legislative provisions in the Medical Practitioners Act 2007 do not facilitate the registration by the Medical Council of doctors from Pakistan and India who have applied to work in Ireland. The reason for this is the requirement to sit the pre-registration examination system known as the PRES which is best suited to those who have recently qualified, rather than those who have been qualified for some years and have worked in specialty specific posts for the greater part of their careers. In recent weeks the Minister has been dedicated to determining how these doctors can be enabled to work in Ireland in a manner that will give complete assurance regarding the safety of patients and compliance with the regulatory standards required. The Medical Practitioners Act 2007 which provides the current statutory framework for the regulation of the profession is robust in terms of the protection of the public and great care has been taken in the preparation of the Bill to ensure it is not undermined in any way.

The Minister has been working intensively with the HSE, the Department, the Medical Council and the Forum of Irish Postgraduate Medical Training Bodies to introduce regulatory arrangements that will facilitate recruitment of suitably qualified doctors, particularly those from India and Pakistan, without delay. All involved have shown a great ability and willingness to work towards a resolution to this matter. It is expected that all involved will embrace and support the changes proposed in the Bill.

The Medical Practitioners Act 2007 provides for the registration and regulation of medical practitioners in four divisions of the register: the general division, the specialist division, the trainee specialist division and the visiting EEA practitioner division. The Bill provides a legislative basis for the establishment of a fifth division which will be known as the supervised division. This new division will allow the Medical Council to assess applicants under a range of headings and link a doctor's registration with an identifiable, supervised post in a specific specialty and for a contract specific period not exceeding two years in aggregate. This will enable the council to fulfil its core statutory responsibility as the regulatory body accountable for the protection of the public. It will also support the HSE in putting in place arrangements to facilitate recruitment on a basis that meets the objectives of service delivery and the provision of safe, high quality care. To further strengthen the role of both agencies in safeguarding the public, the council is finalising statutory rules to underpin the operation of the new supervised division.

I am acutely aware of the need to ensure any doctor from India or Pakistan seeking registration by the Medical Council should be proficient in the English language. The HSE has given written assurance that in respect of those selected for recruitment, the entirety of their medical education has been conducted in English and many have also acquired postgraduate qualifications in the English language. The people concerned were interviewed through English using the standard HSE interview, marking and scoring process but in this case, the pass mark was raised from 40% to 60% in each domain, including language and communication skills. In addition, language and communication skills will also be assessed in the course of the new knowledge and clinical skills assessment process particular to the new supervised division. When in post, the ongoing supervision criteria attaching to each post will also facilitate ongoing monitoring of language and communication skills.

Part of the solution in addressing the underlying problem of sourcing and retaining doctors in the health service is being addressed by the HSE which in recent years has created a significant number of additional consultant posts and will continue to build on this in parallel with reducing the number of non-consultant hospital doctor, NCHD, posts in the system, especially non-training posts. The HSE has also taken steps to improve the quality of all NCHD posts and continues to do so. As of 11 July, 80% of the 4,660 NCHD posts will be part of structured training schemes run by the postgraduate training bodies and funded by the HSE. This contrasts with the situation in 2007 when only 53% were in structured training, 31% in stand-alone training and 16% receiving no training at all.

The Bill is only part of the solution and the Minister for Health is committed to addressing the wider issues which have contributed to the situation confronting us. These issues include a requirement for a better skills mix, new and more flexible rostering arrangements and the reorganisation of health services, all of which form part of the ongoing reform of how we access and deliver health services.

Members have been provided with an explanatory memorandum which sets out in detail the contents of the Bill. However, I will briefly outline the Bill's provisions. In summary, it provides for a new division of the medical practitioners register which will be called the supervised division. Registration in this division will be limited to two years and is linked with employment in a post and the medical practitioners will be supervised by their employer. Medical practitioners who apply to be registered in this division will undergo an assessment and examination which differs from that for registration in the other divisions on the register. The assessment will be specific to their medical specialty and the fact that the post is supervised.

Section 1 sets out the definitions used in the Bill. Section 2 amends definitions in the Medical Practitioners Act 2007. Section 3 amends the functions of the Medical Council to allow it to approve posts for the purposes of the supervised division.

Section 4 amends the Medical Council's powers to make rules to provide that it can set criteria for assessing applications for registration in the new supervised division and to allow it to specify the examinations and assessments for registration in the division. It is envisaged that this will comprise a two-stage process. The first stage will involve providing documentary evidence in respect of medical education etc., while the second will involve a specialty specific knowledge and clinical assessment. Section 5 amends the Medical Practitioners Act to provide that the council can charge a fee for registration and retention in the new division.

Section 6 provides that the register will now have five divisions rather than four. The new division will be called the supervised division and registration will include the identifiable post to which each registration applies. Section 7 amends references in the Medical Practitioners Act to include a reference to the new division.

Section 8 is a key section. It details how medical practitioners register in the new supervised division. It provides that the medical practitioner must meet the requirements specified in the legislation and the criteria outlined in rules. It also provides that a person cannot be registered in this division if he or she can be registered in another division of the register. A medical practitioner can only be registered in this division for a maximum of two years. The registration is linked with identifiable posts approved by the Medical Council and posts must be certified as publicly funded. The HSE will not certify that a post is publicly funded unless the post is funded substantially by it. The council will only approve posts where it is satisfied that adequate arrangements are in place for the supervision of the medical practitioner and will take into account his or her experience, the seniority of the post and the duties to be performed. The medical practitioner ceases to be registered when he or she leaves the post and the employer must notify the council within five days of the person leaving. These provisions have been included to ensure the safety of the public by ensuring medical practitioners are supervised and can only work in specific posts.

Section 9 provides that a medical practitioner who removes himself or herself from the register cannot seek to have the registration restored under the provisions of section 2 of the Medical Practitioners Act 2007. Section 10 relates to fitness to practise. As the medical practitioners in the supervised division are only registered for two years or until they leave a post, the Bill provides that, unlike other divisions of the register, the Medical Council can investigate complaints made against these medical practitioners, even if they are no longer registered. This is to provide for due process for both the medical practitioner and the person who makes the complaint. This means that fitness to practise procedures will apply to the medical practitioners in the supervised division when they are registered in the division and they are no longer registered on the register.

Section 11 is another measure for the protection of the public. It provides that the Medical Council can apply to the court for an order to prohibit a medical practitioner who was registered in the supervised division but is no longer registered from applying for registration in any division of the register. This is only done where it is considered necessary to protect the public. The court can make any order it considers appropriate.

Section 12 provides that section 70 of the Medical Practitioners Act which provides for the steps to be taken by the Medical Council following a fitness to practise report, will include a reference to a new section to inserted by section 14. Section 13 inserts a new section into the Medical Practitioners Act to provide that the sanctions provided for in sections 71 and 72 of the Bill do not apply where the medical practitioner is no longer registered in the supervised division or in another division. This is because section 14 provides for the sanctions in these cases.

Section 14 inserts a new section into the Medical Practitioners Act to provide for sanctions in cases where the medical practitioner is no longer registered in the supervised division. These sanctions include advice, admonishment, censure, a fine not exceeding €5,000 or the attachment of conditions which would apply if the medical practitioner applied for registration, or a prohibition on the medical practitioner from applying for registration in a division or divisions for a specified period.

Section 15 inserts another new section into the Medical Practitioners Act. It is linked to the previous section in that it provides for the council to decide on the amount of the fine, the nature of conditions and the period a practitioner is prohibited from applying for registration.

Sections 16 to 19, inclusive, provide for amendments to sections 73 to 76, inclusive, of the Medical Practitioners Act 2007 which relate to sanctions and the right of appeal. The amendments provide that these sections now include a reference to the new section 71A inserted by section 14 of this Bill and relates to sanctions for those who were registered on the supervised division but are no longer registered.

Section 20, the final section of this Bill, provides for the Short Title of the Act and its commencement. Some sections of the Act will commence on enactment while more will require a commencement order. The sections which require a commencement order cannot be commenced immediately as they rely on rules or criteria to be set by the Medical Council prior to commencement.

In conclusion, this Bill will form a major part of the arrangement being put in place to attract doctors to Ireland, not just now but in the coming years as we continue with the ongoing reform of the health system and the arrangements governing medical manpower planning and medical education and training. I am seeking the co-operation of the House in the speedy passing and enactment of this Bill. I commend the Bill to the House.

Senator Marc MacSharry

I welcome the Minister of State. It is good to have her here again. Fianna Fáil will support this Bill and welcomes the fact it has been introduced so quickly in order to enable the recruitment of additional doctors from overseas. The Minister of State has discussed each section in detail and I do not propose to reiterate what she said, other than to welcome the broad thrust of the Bill and acknowledge that we have a problem with the recruitment of doctors throughout the country. I would like to get some ideas on the issue throughout the debate today. All groups will support the Bill. I would like to focus on why there is a shortage of doctors and how we can ensure it does not happen in future.

Given there are 450,000 unemployed people in the country, it is unusual that we are seeking to recruit anybody from overseas for whatever discipline, whether medicine or industry. In that context I want to suggest that perhaps it is because of academic elitism and the money grabbing policies of some of our medical schools that young people who are very capable academically of undertaking various examinations, studying medicine and qualifying in various medical disciplines if they were given the opportunity to do so cannot qualify as doctors. Instead we have a points system in which the points for medicine are so high that it leads to people who are good academically at sitting exams and scoring high grades studying medicine simply because it requires higher points rather than people who are perhaps more suited to it.

I recall visiting a friend a number of years ago whose father is a GP in County Wicklow. He told me when he studied medicine in the 1960s he saw an ad in a newspaper for the Royal College of Surgeons which stated that one needed two honours in the leaving certificate and a second language in order to study medicine. He put down Irish as his native language, English as his foreign language and had two honours. He has been an exceptional GP for the community in Wicklow since.

I asked him if he would have qualified to study medicine today, given the level of points and academic demands required, and he said he would not. Having said that, he said if he worked as hard for his leaving certificate as he did for his pre-med he would have qualified. I am not sure that our system is correct. It is rumoured that the points for medicine will go up again in the coming year. It is ridiculous in the extreme to think that there are Irish HSE personnel in India and Pakistan recruiting people to come and work here at a time when we have so much unemployment. We have a bright nation of people but a system that does not support channelling those people into the medical profession.

I ask the Minister of State to explore those possibilities with the Department of Education and Skills and officials in the HSE and the Department of Health. We are too elitist about a number of academic pursuits, in terms of qualifying to enter the various medical schools in UCC or UCD. A person of lesser academic ability can enter the Royal College of Surgeons because he or she has the money to travel to this country to qualify and get the best education we can supply from a medical perspective. Such people can go abroad which creates difficulties in terms of the shortage of non-consultant hospital doctors, a problem which we are currently faced with.

Another issue is the career path for those who qualify here. Many choose to go abroad to get experience. While it is not a bad thing in itself to broaden one's horizons and try to channel the best international practices through experience back into our system, the volume is not available because the current system is not designed to ensure that we do not continue to have these difficulties in future. While physicians from India and Pakistan are very welcome, our priority should be the education of our own people so we can fill these positions. There is nothing to oppose in the Bill other than to make those points.

I ask the Minister of State and the Department of Health or the HSE to make an announcement over the weekend as to the specific hospitals that will continue to be understaffed from 11 July, in particular the accident and emergency and emergency services that will be understaffed. The people in those communities are entitled to know that if there is an incident they need to make fresh arrangements. I would also like to get assurances from the Minister of State that if medical services are being curtailed as a result of a shortage of doctors it is not used as an opportunity by the HSE to fail to restore services. Services should not be stopped as a result of a shortage of staff and not restored when staff become available. It is important to get assurances in that regard.

Yesterday I said I wanted to make a couple of points in general and will use this Second Stage debate to do so. I am sure Senator Leyden will have some things to say on Roscommon. I want to talk in a general sense about the agenda of the HSE in terms of the last Government and this Government. When I was on the other side of the House — the Minister of State can check the record — I am sure the Cathaoirleach will remember that no one was more vociferous than me in criticising the then Minister and HSE for some policies.

In the context of the north west, I am based in Sligo. We have had the Roscommon incident this week and the removal of cancer services from Sligo. There was a major campaign and people in this House would have been sick to their teeth of hearing me speak about the issue. I appealed using different angles to the then Minister Mary Harney to try to maintain the services. The agency should have been celebrating the success of the implementation of the O'Higgins report in terms of the outcomes being achieved for women with breast cancer as a result of the improvements made with the multidisciplinary approach that was introduced following its implementation in Sligo. The outcomes matched those of Sloan-Kettering in New York, where Senator Crown came from. We chose to ignore that at the time, wind down a perfectly good facility and for purely political reasons crank one up in Letterkenny which is only a few miles from Derry.

I do not want to get too political about health but one must mention that during the general election campaign a series of commitments were made about hospitals throughout the country. It gives me no pleasure to say that in Sligo there was cynical campaigning by party leaders who used an issue people are very concerned about, namely, health. The Labour Party leader and now Tánaiste, Deputy Gilmore, said in a press release in the middle of the election on, I understand, 14 February that he had "reaffirmed his party's commitment to establishment of a ninth centre of excellence". Clearly that is not going to happen. The now Taoiseach, Deputy Enda Kenny, did something similar.

Then in an interview a couple of weeks ago, the poor man hung up on the presenter when asked the question. These are the kinds of things about which I could be very political, but it is cynical to promise these things when one knows they will not come about.

Underlying all of these issues is an agenda in the HSE to wind down services in that part of the country. While all Governments, and the HSE, will state their position as wanting to provide equitable services on a regionally sensitive basis throughout the country, one wonders what is the HSE's definition of equality. Is has been my experience that the people of Roscommon, Donegal and Sligo are beginning to feel it is George Orwell's definition in Animal Farm, where some people are more equal than others. For example, Professor Hannah McGee’s report on changing cardio catheterisation health which I gather is being implemented by Professor Kieran Daly recommends that there be a number of centres with cardio catheterisation laboratory facilities throughout the country, two in Dublin and one each in Galway, Cork and Limerick, although international best practice is that a high risk heart attack victim should have a stent inserted within two hours of a heart attack. If our plan is to have five of these centres throughout the country, none of which would be in the north west, what is the HSE strategy? Is it that the people of the north west should either move closer to a centre or die?

In the area of pathology, there are reports recommending that hot and cold blood facilities be centralised. It makes sense that routine blood tests be done centrally, as that would save money, but the same is not true of hot blood lab facilities. I understand it is planned to centralise hot blood laboratory facilities away from hospitals such as Sligo General Hospital which the HSE states it wishes to maintain as an acute hospital. How can one have an acute hospital with no hot lab facilities? I am not a clinician but what happens if a child presents with symptoms requiring a hot blood laboratory facility? Will the child's family be told, as happened with the child in County Leitrim who needed a liver transplant, the test cannot be done because it is the weekend or the laboratory is closed? Will the child have to move closer or die, as happens with cancer sufferers?

Senators from all parties agree that we should have centres of expertise and excellence, but we must be geographically sensitive. We must accept that people live in these parts of the country. I do not want services at every corner. That is not practical and we cannot afford it. However, it is reasonable to say people should have access to radiotherapy, a cardio catheterisation laboratory and accident and emergency services within a three hour commutable distance.

I was greatly encouraged when Deputy James Reilly became Minister for Health. I had supreme confidence in his initial moves, when he asked the board of the HSE to step aside and appointed an interim board. However, this is like firing the board of directors because the bottom line is not satisfactory. The entire management is still in place. What is the strategy? I have clearly outlined the problem in the supply of services in the north west. Is the strategy to slowly wind them down? Is Northern Ireland to be responsible for the health of the people of the north west? The people need to know.

We saw cynical campaigning with promises to restore cancer services within 100 days, maintain accident and emergency services in Roscommon and provide a ninth centre of excellence for cancer care in Sligo, as the Tánaiste promised. This maddens people and shows complete disrespect for them. I am not being party political. The people of the north west want to know what their future holds, who will provide services for them and what is the strategy to be pursued.

Senator Colm Burke

I welcome the Minister of State. I also welcome the Bill, as it addresses the issue of medical staffing, a critical issue in the health service. I regret the fact, however, that the Bill is being expedited through the House. This is not the optimum state of affairs. However, considering the time issue involved it is, unfortunately, necessary. Despite this, I hope we will scrutinise the legislation rigorously.

It is important that we deal with this legislation today to make sure the shortage of non-consultant hospital doctors, NCHDs, is addressed as speedily as possible. The situation in which hospitals will find themselves next week is concerning. Our primary focus must be on patient care. It should go without saying that having a large number of vacancies in the junior doctor ranks of hospitals is not conducive to providing the highest level of patient care we can expect in the health service. Whatever contingency arrangements hospital management and clinical directors have planned cannot guarantee the level of patient care that having a full complement of staff would provide.

I commend the Minister's move in creating the new division, the supervised division. It is a creative short-term solution to the problem and will, I hope, be a successful and effective means of addressing the issue. It should boost recruitment efforts. I am sure the HSE has undertaken a significant recruitment campaign across India and Pakistan which I hope will result in enough doctors being found to fill the vacancies that have arisen. This is a timely measure that will address the immediate and pressing issue of the shortage of non-consultant hospital doctors who play a significant role in the delivery of medical care in the health system. They do an excellent job in difficult circumstances. The provisions of the Bill are concerned with the creation of this new grade of medical practitioner in the supervised division.

While this comprehensive and satisfactory legislation, I will raise a number of issues with the Minister later. On the whole, I have no issue with it. However, it is a shame that we are in a position where the legislation is necessary. The situation is unfortunate and wholly unsatisfactory. How was it allowed to develop? I do not wish to criticise any individual, but while the shortage of NCHDs appears to be a worldwide issue, one must ask why the problem was not addressed sooner by the Department of Health, the HSE, the Medical Council and the medical training bodies. As far back as November, The Irish Times reported a huge drop in applications for NCHD posts that were to fall vacant in January. The report quoted an internal HSE document that read, “Recruitment problems may result in significant gaps in service areas this year”. It quoted another HSE memo that read, “The HSE national medical manpower managers are very concerned at the reduction in applications for NCHD posts ... The substantial reduction in the number of applications will lead to major difficulties in filling these posts”. If this was such as issue approaching the January rotation, why was it not addressed earlier in order to prevent the situation in which we now find ourselves?

The shortage of NCHDs has been a recurring theme for several years, mainly due to the structure of the system in Ireland. I trust the Minister has every intention of reforming this area. I noted that he acted swiftly and decisively to deal with the issue, bringing in all stakeholders to find a solution to the problem. He deserves to be commended for the manner in which he acted on the issue. The current set-up is crying out for change. We spend hundreds of thousands of euro training medical practitioners and then do not provide them with adequate possibilities for further training and career advancement. It is most regrettable and sad. The health system must try to ensure NCHDs have clear career paths. In 2009 the Medical Independent reported that recent changes in the NCHD contract, increased workloads and the dire economic conditions in which the country found itself did not point to the country being an attractive place for young doctors to live and work.

The plight of NCHDs, particularly from outside Ireland, was brought to my attention during the week in an email that outlined how NCHDs found themselves in the position where they were considered too old and too experienced for participating in specialist training schemes. The email reads:

Like many of my contemporaries, I came to Ireland with high hopes and expectations. After all, we were starting a career in a western country, a country of equal opportunities and merit based progression. This was the kind of optimism I came to Ireland with, so I got stuck in, doing the rounds, learning from great teachers and working across the country's hospitals at the expense of separation from my beloved family.

Five years later he finds:

To the best of my knowledge, I have tried to up skill myself by sitting relevant professional exams, taking up any available opportunity for practical learning and making myself available for fixed term contracts rather than going for higher remunerating locum opportunities. I am therefore dismayed to realise that this is all there is to my medical career and I cannot help but loose all my motivation and give up on a system I put so much hope in.

I have worked with excellent doctors and individuals who would change things if they could and Ireland has trained me and become my home but it is with a great sense of regret that I begin to contemplate uprooting my family to seek progression elsewhere. I may not be 100% sure of what lies ahead, but I am certain I do not wish to remain stagnant for the rest of my medical career, relegated to the position of permanent hard worker while I watch new intakes that I will probably teach a few things move on to complete their training.

So, reluctantly, like many of my contemporaries who have moved on and moved up, I may have to seek my completion and fulfilment outside of this beautiful green country.

This is written by someone who had worked in this country for five years who now finds he does not have a place in the Irish system yet there is a shortage of doctors for filling certain posts. This raises serious question about how the system is structured and managed.

In 2009, Dr. Mick Molloy writing in the Irish Medical Times, flagged that the system then being put in place would cause problems and this is now coming home to roost. We need to look at the way we are dealing with this area. There is a need for a number of major reforms to ensure that we can make it attractive to doctors. Another issue with regard to the role of junior doctors is that with the reduction to 48 hours of their working time they are considering that other countries offer them the opportunity of a more structured training process. Instead of a six-month or 12-month contract they can be offered three-year contracts, not necessarily confined to one hospital but to a number of hospitals with a common training programme. I agree that the Minister’s policy is the correct one in order to deal with the current issue but we need to look at how the system should be in five years time and in ten years time and how Irish medical graduates can absorb into the system to ensure they do not decide to leave the country within a year or two of qualification from the universities.

The Bill refers to a timescale of two years. There does not appear to be a provision to allow a person to come back into the system if for some reason his or her job terminates. I ask the Minister of State to clarify this proposal but I will revert to it later.

Senator Katherine Zappone

I welcome the Minister of State back to the House.

I have a question for the Minister of State which was asked last week during the Order of Business by my colleague Senator Mary Ann O'Brien. She is unable to be here today for which she sends her regrets. In response, to Senator O'Brien's question last week, Senator Bacik indicated that these could be raised again with the Minister of State when she came to the House. As the Medical Practitioners (Amendment) Bill is before the House and the shortage of junior doctors is causing one of many strains on our health system it is perhaps timely that Senator O'Brien is highlighting the issue of home nursing care together with its corresponding financial benefits. Senator O'Brien asked why it is that the Irish State does not have a national budget for paediatric home nursing care. It makes sense to care for children with life-limiting conditions at home and by doing so save millions of euro of taxpayers' money by keeping these children out of hospital and so avoiding unnecessary blocking of beds.

Last Monday, 4 July a spokesperson from the HSE said in the Evening Herald that, “The HSE is committed to enhancing community based care for its clients right across the health service and seeks to provide the best level of care for children and families”. If this is so, it would seem to make sense and to save public money by having a national budget for paediatric home nursing care. The HSE spokesperson was responding to the case of Leona Burke from Fortunestown in Tallaght. She is a frustrated and isolated parent, left coping alone with her seriously disabled four-year old son Jamie. Leona is the sole career of Jamie who suffers from a rare defective disorder and who is on the HSE priority list. However, so far, being on the priority list has not assisted Jamie and his mother, Leona, is now pleading his case through the media, along with other families. These stories leave the public asking why this is happening in Ireland in 2011.

While some progress has been made by means of research and policies, we are still without an action plan on care in the community and the funds to make it happen. The importance of respite care services is recognised in the national policy on palliative care for children with life-limiting conditions in Ireland. There is certainly no shortage of evidence from the Irish Hospice Foundation, the Children's Sunshine Home or the Jack and Jill Children's Foundation, which have all made the case for more investment in community care. Indeed, on the financial side, the actual return on investment in the community care model is clear, with home nursing care and respite care costing nine times less than hospital care. The average annual cost of hospital care is €147,000, which is nine times more expensive than the €16,000 cost of home care provision for those children supported by the Jack and Jill Children's Foundation. I ask this question for the consideration of the Minister of State.

Senator John Gilroy

I welcome the Minister of State. I am pleased to have the opportunity to speak on this Bill. I have high hopes for a constructive debate without any descent into a political row or any use of the Bill as a platform from which to hurl party political missiles. I say this without political bias.

I am surprised that anyone should be surprised at the latest crisis in the health system. Two weeks ago in the House we discussed the funding shortage which arose with regard to the nursing home support scheme, the fair deal scheme. I made the point then that crisis after crisis can be expected if we are to continue to operate our health services under the same set of assumptions on which the HSE was established.

We need to look in a rather fundamental way at the delivery of health services but this may be a debate for another day. There seems to be something terribly wrong with the system in this country when, despite warning after warning and crisis after crisis, we seem to be unable to learn the lessons and we seem to wait for the next crisis to be upon us before we act. When action is taken, it seems it is a stop-gap measure to glide over the crisis. We consider it fixed and then profess to be surprised when the next crisis arises. We seem to be almost paralysed in the face of challenges within the health service and we are often too deferential to those whom we regard and they themselves regard as experts. This has happened in the banking, construction and religion sectors and it is also evident in the medical profession.

Senator Burke referred to last November in order to highlight when this problem was first flagged but we can go back a lot further. We cannot say on this occasion that we have not been warned because report after report and committee after committee have predicted the difficulties we now face. I refer to internal memos within the Department of Health, reports from Comhairle na nOspideál, the Postgraduate Medical and Dental Board (Ireland), the Medical Council, the Royal College of Surgeons in Ireland, the Royal College of Physicians of Ireland, the collegiate members committee of the Royal College of Physicians, the Irish College of General Practitioners, the Irish Hospital Consultants Association, the IMO and the Association of Hospital Chief Executives. Herein may lie part of the problem. There is a proliferation of organisations and agencies controlling different elements of activity and categories of medical professionals which gives rise to a competing hierarchy leading to a difficulty in pinpointing the exact locus of responsibility within the health care system. This confusion has not been resolved in any of the changes which have taken place in the past ten years. There is a good argument to be made that the establishment of the HSE without proper reform of the underlying framework has compounded rather than clarified the issues.

I note a report published in July 2005, a career tracking study of the factors affecting career choice and retention of Irish medical graduates. This report notes the significant reliance on attracting large numbers of non-EU students to Irish medical schools. In 2003 the medical school intake for non-EU students was more than 60%, with the Irish Medical Council citing underfunding of undergraduate medical training as the reason. The 2009-2010 annual report of the Royal College of Surgeons in Ireland found that only 30% of medical students are Irish, at a time, as Senator Marc MacSharry observed, when demand from Irish entrants has never been higher. With no improvement in the numbers of Irish students attending medical schools, it is no surprise we are encountering a shortage of appropriately trained doctors to staff our hospitals. When non-Irish doctors are qualified and fully trained, it is natural for them to return to their country of origin. The Royal College of Surgeons in Ireland should examine whether its enrolment policies have contributed to this situation. The 2009-2010 report shows the college has an annual turnover of €180 million and will probably find itself increasingly reliant on the high fees payable by non-EU entrants. This will have implications for the future staffing of hospitals.

There seems to be no alignment of medical training programmes and trainee numbers to meet estimated staffing levels in health services on an ongoing basis. Added to our apparent inability to educate medical students in sufficient numbers to staff our hospitals, we are finding it increasingly difficult to retain doctors after they qualify. In 2005, for instance, 40% of graduates who qualified in 1999 were undertaking postgraduate training overseas. Studies show that concern about the permanent loss of Irish trained graduates to health systems in other jurisdictions is not wholly unjustified. A perceived lack of consultant posts at home, poor working conditions, inflexible working patterns, insufficient training opportunities and a poor work-life balance are cited by graduates as reasons for leaving Ireland. In 2005, 93% of interns indicated an intention to leave Ireland at some point for further training. The well-flagged structural challenges within the system are compounded by a worldwide shortage of junior doctors, with Ireland competing with the United Kingdom, United States, Australia and elsewhere to attract applicants.

We may now have hit a perfect storm. As early as 1993, the Tierney report indicated that non-consultant hospital doctor, NCHD, posts in small to middle-sized hospitals with limited training opportunities are the least attractive to candidates. These hospitals generally do not have a sufficient complement of consultants or the critical mass of work in each speciality to provide appropriate postgraduate training. Nearly 20 years later, this problem is evident in smaller facilities throughout the State, while hospitals where adequate training opportunities exist seem to have little trouble in filling their posts. For example, the paediatric emergency departments in Crumlin, Temple Street and Tallaght hospitals have been able to recruit all required medical staff, while smaller hospitals such as — if I dare to mention it — Roscommon hospital are experiencing severe difficulties. This alone will have major implications for how we deliver health care into the future.

The immediate difficulty facing the health system is the 475 non-consultant hospital doctor posts which must be filled by 11 July. An extensive recruitment drive in India and Pakistan has identified 439 potential candidates, but the Department acknowledges that not all vacancies are likely to be filled. This shortage was flagged some years ago, but the previous Administration did nothing on the legislative side to ensure the situation would not reach such an acute level. As early as January 2010, hospitals were reporting a significant drop in applications from junior doctors, including a reduction of 59% at Tullamore hospital; 56% at Connolly Hospital; 48% at Waterford Regional Hospital; 45% at Cork University Hospital; and 35% at St. Vincent's University Hospital. Eighteen months later we have a situation where only five accident and emergency departments record a full complement of staff for July, while 27 others are reporting significant shortages. Equally alarmingly, there is a shortfall of one in three middle grade doctors or registrars.

The Department has put in train a series of initiatives to address this problem, but it is an issue that must be tackled at a fundamental level. We should not, as was done in the past when other difficulties arose, apply a sticking plaster and pretend the problem is gone away until such time as it next raises its head. The legislation is welcome but it comes very late in the day. As Senator Colm Burke observed, it is of necessity that it is the case. However, legislation that is prepared in a hurry may precipitate some unintended consequences, so we must be careful to get it right. I hope Members will concentrate on this important work and resist the temptation, however strong, to engage in points scoring. That is all too easy to do in regard to the health service.

Senator John Crown

I am trying to compose myself and to wrestle with a dilemma I face in respect of this legislation. The rational side of me accepts it must pass if we are to have doctors in our hospitals next week, but the dreamer in me wonders, after 18 years of screaming about the problems in our health service, whether anybody is listening. This latest example of Ballymagash forward planning, where we are being called in on a Friday to pass emergency legislation for a problem that was glaringly obvious 18 years ago, makes me wonder about the processes of government and public governance in this country.

We are used to planning according to the politics of the last health care atrocity. When we have a sufficient number of major cancer scandals, there is an undertaking to fix the cancer service. When we have a little girl who misses a liver transplant, there is a commitment to put a proper service in place. When cystic fibrosis patients are dying because they are not receiving the right treatment, we are promised it will be addressed. This is not the way to run a health service. What is required is fundamental reform. The Government's proposal, which led me to support it prior to the election, was that there would be fundamental reform of how the health system is structured, financed and run. We are now told that will not happen until after another election. All the fiddling around the edges, all the bureaucratic adjustment in the world, will not deal with our core problems.

The core problem we are dealing with today sees yet another attempt to apply a Band-Aid to the gaping, malignant wound that is the health service. To appreciate how little sense the proposal makes, Members should replace the word "NCHDs" with "trainees". The Government is seeking to attract trainees — apprentices — from India and Pakistan. If any Fianna Fáil or Fine Gael Member lost his or her wedding ring or gold fáinne down a drain, he or she would call a fully qualified plumber, not an apprentice, to retrieve it. However, if the same Member's precious daughter has pneumonia, a blood clot or a belly ache, there is a high chance that the person who attends to her in one of our hospitals will be an apprentice specialist.

That is the core problem. Attempting to fix the problem by hiring more apprentice specialists exemplifies catastrophically bad planning. With great respect to the Minister of State, Deputy Jan O'Sullivan, I dispute her contention that the problems we face are not unique in Europe. The reality is that the context in which they exist is unique. There may be a shortage of junior doctors in other countries, but no other country depends on the labours of junior doctors in the way we do. It is a virtually unique Irish phenomenon. If it were not for the fact that Her Majesty's National Health Service has a similar structure to ours, though a little better resourced, it would make ours look truly deplorable. By setting the second worst country in Europe in terms of medical staffing as the bar, we make ourselves look slightly better than we are.

In addition to our incredible reliance on the efforts of junior hospital doctors, no other country in the world has six medical schools for 4.5 million people. We have twice the European average for the number of medical schools per head of population and nearly three times the North American average. It is crazy that we have so many medical schools but insufficient doctors to staff our hospitals. A Government back bench colleague of the Minister of State remarked yesterday that most of the training he received in medical school was, in the absence of consultants, provided by nurses. The reason consultants were not available to deliver his training was that there were insufficient numbers of them. In many of the hospitals in which this Deputy trained there may only have been one county physician and one country surgeon. If one is already doing the work of six or ten of one's European colleagues, how much time does one have left for training junior doctors?

I was invited to appear on "Prime Time" last night, although some hours later the invitation was withdrawn. There are no conspiracy theories here; the producers simply received a late acceptance from the Minister which was deemed more attractive than the contribution of this poor mumbling Independent Seanadóir. After accepting the invitation, I sought the assistance of colleagues to compile some figures which will be of use to the Minister of State in understanding what she is being told by her officials. I regret I was not in the Chamber for her introductory speech. Being one of those overworked doctors I had work to do this morning before coming into the House.

The Minister has stated there has been an increase in the number of consultants. That is correct, but what else has increased? The answer is the number of people. The population has increased dramatically during the past decade. Let us put some flesh on the bones of the increase in the number of consultants.

Malignant melanoma is the most lethal form of skin cancer. Sadly, it is often one of the most lethal forms of all cancers. The incidence of the disease has risen from 400 to 800 cases per year. The number of patients with spread malignant melanoma which is fatal in most cases has risen from 100 to 200. The people who carry out early diagnosis are dermatologists or skin specialists. Yesterday a dermatologist informed me that the HSE was very proud that the number of dermatologists in the Republic was increasing from 25 to 33. In Northern Ireland which is one third the size of this jurisdiction there are 22 dermatologists, while in Scotland, approximately the same size as the Republic, there are 60. We are again seeking to be the poor relation of the United Kingdom which is aiming to have one dermatologist for every 80,000 members of the population, whereas the European average is one for every 30,000 to 50,000. We are setting the bar really low for ourselves.

What is the position on urologists, the people charged with making the early diagnosis of prostate cancer? They also deal with elderly gentlemen who have this disease and ladies who have urinary problems. The European average is one urologist per every 30,000 members of population. In Ireland, there is one urologist per every 180,000.

There are six paediatric surgeons in the Republic. The position in Northern Ireland is the same, whereas in Scotland there are 22 such surgeons. There are 80 consultants at Our Lady's Children's Hospital, Crumlin, whereas there are 200 at Birmingham Children's Hospital and 800 at the children's hospital in Denver. The argument is advanced that we cannot increase the number of consultants in this country because they are paid too much and we cannot afford to hire more. We do pay our consultants too much, but I did not negotiate the contract. I remained on the old one. I am still operating on the same contract I signed when I returned to this country in 1993.

Let us consider the arithmetic. When the old contract was in place, there were as few consultants per head of population as there are on the renegotiated contract. Before the old contract — in the days when consultants worked almost for free in the public service because it was expected that they would make their living from private practice — there were still almost no consultants and we also had the lowest number of specialists per head of population. Is this because there has been a medical cartel blocking the appointment of doctors? As a previous speaker indicated, all of the professional organisations have been pointing to the manpower deficiencies. The only ones who can create consultant jobs in this country are the Department of Health, the HSE and Ministers.

Let us consider the nature of the jobs in question. We have been informed that some of the positions are unattractive because they are non-training, junior jobs. They should not be available. The only basis on which a junior job should be available is as a training job. If a job is not available for training purposes, it should not be available at all. If a hospital is not sufficiently muscular in the context of being academically resourced or if it is not adequately comprehensive in the clinical, academic and research services it can provide for potential trainees, it should not have such trainees. One would not license a school if it could not provide for a proper standard of teaching; why, therefore, would one license a hospital which could not do so?

All that I have outlined is part of a bigger picture. We have a real problem with the way we do public governance in this country. We also have a real problem with leadership and listening to people who actually know what they are talking about. We have a colossal problem with bureaucracy. It is extraordinary that, at a time when we have such staffing shortages and trained people who could occupy the positions for which there is a need, we still have PR consultants in the Department of Health, corporate affairs officers in our hospitals and large PR contracts for each of the multiple quangos——

Senator Marie Moloney

Hear, hear.

Senator John Crown

——which hop across the country in "quangaroo" fashion or whatever it is they do.

Senator Sean D. Barrett

Hear, hear.

Senator John Crown

That is just flat out wrong. With great respect to HIQA, talk about establishing a huge operation with a multimillion euro budget and 200 inspectors to state the blindingly obvious, namely, that there are no good hospitals in the country. I accept that there is a number of adequate hospitals. I have a quick chuckle on each occasion I hear people referring to centres of excellence. As someone who has served in the faculties of several such centres, I can inform the Minister that there is no facility in the country which is a centre of excellence. In the context of the plans being evolved, as we move deeper into the recession we will be lucky if we have centres of mediocrity or centres of competence.

There is a suggestion junior doctors are being somehow unpatriotic in leaving the country and training abroad. There are rather few medical oncologists in the country and those we do have are stunning. The other evening I met several individuals involved in research. We are privileged that a number of excellent people have left the best centres in North America, the United Kingdom and other parts of Europe to return to these shores to take up positions. These individuals are unparalleled anywhere else in the world. Of the 31 medical oncologists in the country, some 21 trained in the top five American centres — the Memorial Sloan-Kettering Cancer Centre, the MD Anderson Cancer Centre, the National Cancer Institute, the Dana-Farber Cancer Institute and Johns Hopkins Hospital. They are the top five cancer centres in the world and two thirds of our specialists trained there. The authorities in America and the United Kingdom cannot say this. They are lucky if their oncologists trained in small oncology programmes in local regional hospitals.

The Irish health care system has had one great strength during the years, namely, an extraordinarily well trained cohort of doctors and nurses. In the case of doctors, this was because they were, until recently, unofficially encouraged to travel abroad to the best centres to obtain the best training possible. They were then expected to return and compete for a tiny number of jobs. This tended to focus their minds and encourage them to work a little harder. What is happening now is a covert attempt to subvert international training by forcing our junior doctors to remain at home to plug gaps in a system which should not be relying on their services in the first instance.

I am extremely troubled by the discussions that have taken place in recent days on the closure of services in local hospitals. I am really conflicted in this regard because we have too many small hospitals. It would be better if some of these facilities were either closed or amalgamated. The degree of proposed closures is excessive. I can only speak with authority about cancer services, but I must indicate that what has been done has been handled extremely badly. The notion that we would have four cancer treatment services — not one of which could provide comprehensive care for cancer patients in the capital city — and none north of the line from Dublin to Galway spoke to something other than best international practice being the principal determinant of the way the system was configured. What is happening in this instance amounts to nothing other than a large dollop of big hospital and big medical school politics.

As someone who is a sort of political outsider and a sort of political insider, it is difficult to comprehend the way this issue has been dealt with. What has been done is so reflexive in nature. Those in opposition will always speak in favour of the maintenance of every unit, while those in government will, in general, articulate the case for closure. What always strikes me as being odd is how quickly these positions can change in the aftermath of a change in government. I am not sure how I am going to vote on this Bill. However, I am sure it is going to pass and that we will have junior doctors next Monday. A Government with a majority of the size enjoyed by the Administration will always be in position to pass legislation such as this. I am going to give consideration in the next short while to the question of whether I should register a symbolic protest vote. Somebody needs to say there should be no more Band-Aids, that we should fix the system and that we should not put off matters until they can be fixed by a mythical future Government following the next general election. In the context of all of the special delivery units, all of the tinkering with people's contracts, all of the adjustments to ER services here and there and all of the decisions to the effect that — because we want such high standards — we will ban temporary registration one day and reintroduce it the next, let us hope someone will actually state we cannot fix any of these problems until we address those of a more fundamental nature.

Senator Michael Mullins

I welcome the Minister of State. Most of those present would agree with many of the points made by Senator Crown and that, in the light of the fact that there are six medical schools in the country, it is extraordinary that we are being obliged to introduce this emergency legislation. I have heard Senator Crown speak on many occasions about the need for an increase in the number of consultants. Those of us who interact with our local hospitals know that he is correct in this regard. The huge manpower deficiencies throughout the system must be addressed. I agree with the Senator that the term "centres of excellence" is a misnomer. Most of us have major concerns about the facilities available at the so-called centres of excellence.

I have great confidence that the Minister for Health, Deputy James Reilly, will improve the health service. He has inherited a huge mess. Not too long ago a former Minister referred to the Department of Health as Angola. The previous Minister abdicated responsibility, to a great extent, and created the monster that we have in the HSE. The Minister, Deputy Reilly, in a few short months has hit the ground running and he is determined to make the major decisions that will start to deliver the best possible outcomes for the users of health services throughout the country.

This Bill is a positive development despite the reservations many of us have about it. It addresses an issue which has been a cause of anxiety and confusion in recent months, that of whether we will have sufficient doctors to continue the running of our hospital services, whether we can attract people into these services who will continue to work here, and whether we will have continuity of services. The fact that we will be in a position to have junior hospital doctors for a period of up to two years is a positive development. The protests in Roscommon in recent days have highlighted the genuine concerns people have. They are worried about whether they will have access to a safe service on a timely basis. I have confidence that the Minister, Deputy Reilly, from what he has indicated in recent days, will put in place a system in Roscommon that will deliver a safe, reliable and efficient service for all of the people. I am aware that a mandatory protocol for the safe inter-hospital transfer of patients from Roscommon County Hospital to an appropriate hospital within the HSE west network of hospitals has been put in place in recent days.

One of the hospitals that will have to pick up the slack is my local hospital, Portiuncula Hospital, in Ballinasloe, which expects to have a significant increase in activity. I was pleased to discover last night that it will have in place its full complement of NCHDs next week. That hospital must be given additional resources if it is to carry out this additional workload. I hope that staff can be redeployed, possibly from Roscommon County Hospital, to assist with the increase in activity that will occur there.

That hospital is a vital part of the health service delivery in my region. It is intended that it will have category three status but I am concerned that the hospital, through the non-filling of essential posts in that hospital by the HSE, is in danger of failing to meet HIQA standards. I call on the Minister to ensure that the vital positions in that hospital, which are not subject to the moratorium, are filled as a matter of urgency.

The availability of beds could become an issue in Portiuncula Hospital where the average stay is 4.5 days, but I have been told that there are currently 20 patients in that hospital who have a stay of longer than 21 days. The Minister will also have to address the issue of step-down facilities if sufficient beds are to be available to provide for the increased activity in local hospitals as a result of the reduction of services in other local hospitals.

This is positive legislation. The situation the Minister, Deputy Reilly, has inherited is not ideal but he has to address it in the national interest. I urge him to continue apace with the good work he has started. Our health services are in a dire state, as many Members have indicated. The Minister has an enormous task ahead of him but I have confidence that, with his experience as a medical practitioner, he has the ability to deliver a health service to the people that they deserve. We all want to see a world class service delivered. We are a long way from that now but, hopefully, during the lifetime of the Government we will see the sorts of changes and improvements, to which Senator Crown referred.

I am concerned that bureaucracy within the HSE will choke the positive progress the Minister, Deputy Reilly, is attempting to make but I urge him to continue on the path he is taking. I hope that by the time he leaves office the people of this country will have a much safer health service that our people deserve and that we can have the type of recruitment and numbers of specialists and doctors that are required to deliver a safe service for the people of Ireland.

I commend this Bill to the House. I thank the Minister of State for outlining in great detail what is proposed. I hope that over the next few weeks all the positions required to deliver a safe service will be filled.

Senator Sean D. Barrett

I welcome the Minister of State to the House. I will probably support the Bill. I note it is necessary that doctors must be in situ in the hospitals on Monday. I also note from the Minister of State’s speech, which she delivered so well, that we have trawled to recruit suitably qualified doctors, particularly doctors from India and Pakistan. Our GDP per head is nine times that of India and 13 times that of Pakistan. We are hoovering doctors out of the Third World and that is a shameful addendum to our foreign aid budget. People in Pakistan who ask where is the doctor to care for their sick people will be told that he or she was recruited by the Irish because they could not organise themselves. We will be sending doctors overseas with John O’Shea’s organisation and others and putting money into collection boxes to try to help people in Third World countries while taking doctors away from them.

Senators

Hear, hear.

Senator Sean D. Barrett

I have grave misgivings about that part of this legislation. That is no bad reference to the Minister who probably feels much the same on having been landed in this situation.

The important part of the Minister of State's speech, following her reference to this pretty dreadful gesture towards Third World countries, is that we must proceed with the reform agenda. She mentioned the requirements of a better skills mix, new and more flexible rostering arrangements and the reorganisation of the health service. We must proceed with that.

We discussed our legal service yesterday, with which the Minister, Deputy Shatter is dealing, and which is the third most expensive legal service in the world. Part of the IMF agenda is to deal with these sheltered services. I estimate that we have the second most expensive health service in the world. An bord snip has indicated a figure of €16 billion in this respect for 4 million people and there is private sector and over the counter figures of another quarter of that amount. The cost of our health service is second only to that of United States. It employs 111,000 people and employment in the service increased by 40% in recent years, as indicated in the Minister of State's most helpful document, Health in Ireland: Key Trends, which I hope she will circulate to the House. It shows there have been massive increases in staffing with 111,000 staff, which has increased by 40% in a decade, and massive increases in expenditure. Ours is one of the most expensive health services in the world and it does not deliver.

Senator John Crown

Hear, hear.

Senator Sean D. Barrett

For 14,000 acute beds there are 17,000 administrators. If one is given a so-called semi-private bed, a phrase which defies definition — it means a patient is given a bed in a corridor and may be moved somewhere else later — the total cost of that bed provision is greater per night than that of staying in the best hotels in the country. I had a constituent who was charged €10,000 for the cost of a bed for a seven-night stay. Our hospitals are massively uncompetitive. All the restrictive practices that the Minister, Deputy Richard Bruton, is trying to deal with in the hospitality sector exist in multiples in the Irish health service. It is a nest of restrictive practices from beginning to end. The first such practice we must address is access to medical schools. In my college we have received letters from women who got 600 points in their leaving certificate and were denied access. They could be working in those hospitals today. That is a restrictive practice. The deans of medicine, mostly men — I believe they are all men — decided that the leaving certificate favoured women applicants; they got away with that item of gender discrimination and designed another test, which allows more men to get into medical school. Keeping people out of medical school leads to the kind of situation we face today. Such reform is seriously necessary.

There is no demographic bonus being enjoyed by this country. There is Canadian research which would indicate that we should be able to get a bonus of 2.9% of GDP on health expenditure because, as has been said, our population is younger than anywhere else. Countries, which have a large number of old people who need to access the health service more, are able to do it on much smaller budgets than we are. The whole system must be taken apart. I agree with Professor Crown that the employment of PR consultants, quangos and bureaucracies has not served this country well.

One could ask how we can reform the health service. Politicians do so at their peril. That has been the case with every Minister for Health since Noel Browne. He thought it was the church that undermined him but I think it was the medical profession. Every Minister for Health has been undermined by the 111,000 people who work in the health service. They serve themselves very well. The cost is huge. We have 2 million taxpayers and a budget of €16 billion. Each taxpayer in this country is entitled to €8,000 in health services each year but is not getting it. I wish the Minister of State, Deputy Shortall, and the Minister, Deputy Reilly, every success, but it has been a political graveyard because of the opposition of the incumbents. The patient cannot introduce reform because the patient is ill and worried.

I thought that one of the ways we should have done it — I hope the Minister will consider the model as he moves towards insurance — was through competing private insurance companies. If the BUPAs of this world can insure both old people and young people for less than the VHI, I welcome that, but the Department has always defended the VHI as its in-house monopoly health insurance company. The insurance companies could extract some of the monopolistic rents out of inefficient hospitals and high-cost producers and pass them on to the consumer. The Department's stand was exposed in the Supreme Court when it decided against the anti-BUPA legislation but by then the situation had dragged on for so long that BUPA had left the country. We will need competing health insurance companies so the consumer can choose between people who are good at extracting monopoly rents out of the health services and those who are less good. Having a monopoly health insurance company owned by the Department, which is responsible for the high costs of the service in the first instance, never made economic sense and it should not have been the subject of so much legal proceedings by the Department.

We need a reform agenda. We will be most disappointed if nothing is done within the two years to which the temporary legislation applies to remedy the defects in medical schools and in de-emphasising hospitals. Why is there not a GP in every clinic on a 24 hour basis? It is just a normal service. Who mythologised general practitioners that they think they can go home at 5 p.m. and that nobody ever gets sick in the evenings? We should move towards a substantial transfer out of hospitals to general practice which would generate significant savings to the health budget. That should be considered. I agree with the remarks of my colleague that trainees should not be front line staff in some hospitals as this measure seeks to ensure on a temporary basis.

I hope the Minister of State, Deputy Shortall, and the Minister, Deputy Reilly, will not be blown off course because this is a major national problem. I am sure the IMF will tell us that our health service is a disaster in economic terms. It is way over the odds in expense and massively over-manned. It has doubled its staff numbers since the 1980s. I sometimes wonder — it is not an entirely rhetorical question — if that is the problem of the health service — the fact that 111,000 people are trying to do the job of the 55,000 who used to do it in the 1980s.

Senator Marie Moloney

I too add my voice of welcome to the Minister of State, Deputy Shortall. Before I add my views I must comment on Senator Crown's. Wow, what a speech. It was based on expertise and knowledge. He has not just done research, as many of us have done. He has worked in the system and he knows how it works. When he speaks, we listen.

Senator Sean D. Barrett

Hear, hear.

Senator Marie Moloney

A couple of weeks ago I asked myself what someone of Senator Crown's expertise and knowledge was doing in the Seanad when he could be doing what he has done previously, saving lives. Now I know why he is here. We are lucky to have someone of his calibre in the Seanad to give us the benefit of his knowledge in the Chamber.

Senator Sean D. Barrett

Hear, hear.

Senator Marie Moloney

I commend his speech.

I support the Bill. We do not have an alternative. If we do not introduce the Bill, it will have devastating effects on local hospitals, especially smaller hospitals. What on earth were the Minister for Health and the HSE doing in recent years that they did not see this coming and take steps to remedy the problem without having to rush legislation through at the 11th hour? The problem has been flagged for years. It has been coming down the tracks but nothing was done to divert it. I commend the Minister for Health, Deputy Reilly, on grasping the nettle and tackling the immediate problem. I am delighted that he is committed to addressing the wider issues which have contributed to the situation in which we find ourselves today.

The problem is that the public health system is heavily reliant on non-consultant hospital doctors, NCHDs, to provide the service. There is a major shortage of junior doctors. I am slow to call them junior doctors because many of them are well into their 30s and have received training up to consultant level. One can ask why there is such a huge shortage. The explanatory memorandum tells us that the reason for the shortage is complex. To me, it is simple. The lack of consultant positions results in prospective consultants doing their internship and without the prospect of a job at the end of their training they choose to emigrate to continue their training and get a consultant position abroad. We are competing in a free market. We lose our best and brightest to countries such as Canada, New Zealand, Australia and the United States where working conditions, pay and training are far superior. Although pay may be difficult to compete with in the interim we should compete by providing high-quality training in conjunction with a defined career path that would incentivise doctors to stay. NCHDs in this country are very service-driven. Doctors are often forced to work long hours, far in excess of the European working time directive. It is both dangerous to the health of doctors and patients alike. Instead, NCHD posts should be purely training posts supervised by consultants.

Senator MacSharry referred to the difficulty of students accessing medical courses. I agree with him because I have first-hand experience of the problem. My son was a medical student. My husband and I supported him through ten years of medical school, both financially and emotionally. We watched him go to work on a Sunday morning at 8 a.m. and work straight through until Monday evening at 6 p.m. He was expected to make life-saving decisions. He was so tired at the end of his shift that we disallowed him from driving home. We did not want him to drive from Cork to Kerry for fear he would go over the ditch. In the meantime he was expected to fit in his continuing studies around those working hours. Those are the young people who are expected to make life-saving decisions.

The Minister of State should be warned that we are facing the same problem in the GP service as the majority of GPs are scheduled to retire in the next ten years. We will be faced with a similar problem to that which we currently face with a shortage of junior doctors. We will have a shortage of GPs unless we address the problem now. The Minister must give his attention to ensure the provision of increased training places and to make the GP training scheme more accessible.

Today's debate should be taken in conjunction with realistic plans to increase the number of specialist posts for consultants. The health service should be driven by consultants with support from NCHDs. That would provide a better standard of care, reduce waiting lists, provide more training and support to NCHDs and would also offer a defined career path for NCHDs. The Bill will provide for the establishment of a new division to be known as a supervised division. It was said to me that it should be known as "the lack of foresight division". The shortage of junior doctors has been forecast and foreseeable for some time, yet we failed to act.

As Senator Crown pointed out, it is ironic that Ireland has the largest number of medical schools per head of population in Europe and we now have to pass emergency legislation to allow foreign trained doctors come her to take up the shortfall. We are just putting our finger in the dam.

Senator Terry Leyden

I am disappointed that the Minister, Deputy James Reilly, is not here today because I hoped to hand him the famous letter he wrote to the people of Roscommon but the Minister of State, Deputy Róisín Shortall, is here on his behalf and——

An Leas-Chathaoirleach

I remind the Senator that the Medical Practitioners (Amendment) Bill is not exclusively confined to Roscommon so be cúramach.

Senator Terry Leyden

It plays a role in regard to Roscommon because it is one of the factors involved in the future of smaller hospitals.

I welcome the Bill which we will support. On the point about Irish qualified doctors, Senator Crown has adequately pointed out the position from his experience but in the current crisis it would not be possible to put in place a requirement that they would spend at least some time here after they are qualified as the cost of qualification is very high.

I have another question on which the Minister of State and the officials might reply. There is a great emphasis on recruiting in India and Pakistan but Cuba, for instance, has tremendous medical services. Is there any recruitment of non-consultant hospital doctors taking place in countries other than India and Pakistan? Why is the concentration on those countries?

I concur with what Senator Crown said in his contribution, which was excellent and highlighted the variety of knowledge in this House. Future Governments should bear in mind that there is the potential of appointing Senators from this House as Ministers. It would have been a major move forward if somebody of Professor Crown's knowledge was made Minister for Health in this Administration. I hope he will be a Minister in some future Administration.

On the Bill, it is important to record in the Official Report of these Houses the absolute betrayal and misleading of the electorate in Roscommon prior to the general election of 2011. The Fine Gael commitment on Roscommon Hospital states:

Dear People of Roscommon,

Further to the recent public meeting addresses by Frank Feighan TD and Denis Naughten TD, I wish to confirm that Fine Gael has a very different view of the role to be played by local hospitals, like Roscommon County Hospital, than the Government, which seems intent on downgrading them through the implementation of the Hanly Report.

Yes, local hospitals must be safe, and patient safety must be our first priority. But on taking office we will immediately suspend the reconfiguration process.

While international research suggests that complex trauma and complex surgery is not appropriate in a local hospital setting, like Roscommon, nobody is looking for such a service at Roscommon County Hospital.

However, there is also a very strong argument that Roscommon and other local hospitals have the ability to deal with complex medical conditions and less complex surgery.

Safety is not simply about surgical competence, but is also about timely access. Time to treatment, particularly in remote geographical locations, is absolutely crucial.

This is key to allowing Roscommon Hospital, which does not have complex surgery, to retain the skillset required to incubate and ventilate and to have the ability to undertake less complex surgical procedures.

The big problem with our health service is that too much of the key decision-making is done at the centre. Under our plans, it would be up to each hospital to work out the best way for it to respond to a system where they are paid for what they actually do.

We will establish Roscommon County Hospital as a stand alone hospital. It will continue to be owned by the State, but will be governed and managed by a Local Hospital Board, made up of staff, management, community & patient representatives.

This will allow them to better meet the needs of our community and patients and to manage and operate the hospital to its best to meet the needs of the community it serves.

Therefore, instead of the HSE determining the future of Roscommon Hospital, its future will be in local hands.

We will reform the financing structure to ensure that Roscommon has significantly greater responsibility for financial and manpower management. It will be paid for every patient it treats, thereby allowing the hospital to develop new services which will bring in additional income, additional staff and new specialties.

These structures will provide for the development of telemedicine, which allows tests & scans to be performed locally but be read by the specialist consultant in Dublin or Galway.

I would like to confirm that Fine Gael undertakes, in accordance with the Fine Gael Policy on Local Hospitals, to retain the Emergency, Surgical, Medical and other health services at Roscommon Hospital which are present on the formation of the 31st Dáil.

Furthermore, in the event of the A&E being downgraded, we are committed to reinstating a 24/7 service, where feasible.

To this end, we are intent on addressing the current threats to the 24/7 A&E service, namely the Non-Consultant Hospital Doctors and theatre nursing staffing issues, by introducing a new structure for NCHD training which will recognise the time spent in RCH and change the legislation to facilitate National Treatment Purchase work to take place at RCH, which will enable the employment of the required theatre nurses.

To again reiterate, our core principle regarding health is that the patient be safely treated as close as possible to their home and Roscommon County Hospital is an integral part of this objective.

Yours sincerely,

Dr. James Reilly

Fine Gael Spokesperson on Health

That pledge has been broken.

In that regard, I was in a tough position in the 1980s when I stood in that area and supported and ensured the retention of Roscommon County Hospital as a general hospital. I did not walk off the pitch then. I commend whatever decisions people make politically but it is not in the best interests of Roscommon County Hospital that we would lose a Government TD and the Chairman of the Joint Committee on Health and Children. Those were crucial positions that could be of benefit to Roscommon County Hospital. I regret that a member of the Government has resigned on this issue. We have lost the influence he had, and I hope he retains his position as Chairman of the Joint Committee on Health and Children and that he will be in a position to try to assist the work in regard to Roscommon County Hospital. If I had taken the easy option in 1987 and walked off the pitch on this issue, Roscommon County Hospital would now be a district hospital but I would be a Member of Dáil Éireann.

Senator Marie-Louise O’Donnell

I welcome the Minister of State, Deputy Shortall, to the House. I am delighted she is here. I feel like an innocent saying that because I am a rookie Senator but I am aware she has an extraordinary political career and will be an extraordinary person in that role.

I have a simple question that the Minister of State may be able to answer. I listened carefully to the views expressed by all the other Senators. I have read all the material including the explanatory memorandum, the Bill and the explanatory notes. I have a son studying medicine and am guaranteed surgical stockings in my old age because that is probably all that will be left. Senator Crown is very well informed, knowledgeable and practised in this area. Throughout the material there is a reference to a magical two years. It suggests that after the two years and this fifth division, the supervised division, all will be well. How will the problem be solved after the magical two years? Is this another biscuit to the bear or the finger in the dam that was referred to by my fellow Senators? Why, after two years, will the problem be resolved?

Also, the Minister of State said in her contribution that the position is not related to funding, an embargo on recruitment, a moratorium or reorganisation of hospitals. The general question, therefore, which nobody has answered, is how this has come about. How will we ensure it never happens again, and how can we ensure that in two years? Is it the position that we have not prioritised the education of our own students in regard to medicine and that we have given them second place to others studying medicine here because we do not pay for it in the same way as other students who come here do? Why have we ended up having to pay for it now when we should have attended to the problem at the beginning?

Senator David Cullinane

I welcome the Minister of State to the House and agree with the Senators who expressed their disappointment that the Minister for Health is not present.

Along with previous Senators I, too, have struggled with the decision on whether to support this Bill but I will do so because in recent weeks many of us have called on the Order of Business for the Minister for Health to come into this Chamber to deal with the real problem of junior and non-consultant hospital doctors in our health services, the impact of the crisis that could develop in many regional health facilities and hospitals across this State and the potential closure of hospital wards and even more accident and emergency wards.

I join Senator Crown in describing this as a sticking-plaster solution — pardon the pun — given the Labour Party's involvement in government. It is high time that we moved away from such stopgap measures. What is proposed is precisely a stopgap measure. There is a very real problem with the system of medical staffing, training and the deployment of hospital services staff. It is absolutely appalling that a state that is still regarded as comparably very wealthy, in spite of its having gone through an economic crisis, has a crisis in its hospitals and must trawl through countries such as India and Pakistan which have their own problems and Third World countries to recruit junior doctors and non-consultant hospital doctors.

The Minister of State referred to the recruitment embargo. This is a blunt instrument and it is not working in our hospitals. I spoke recently to the clinical director of Waterford Regional Hospital about its issues associated with junior doctors, nurses and staffing provision generally. One of the problems in the hospital, which I am sure is repeated in others, is that because of the recruitment embargo, it is employing agency workers at premium rates to provide the required level of service. This is having an impact on the budgets of hospitals, putting them out of kilter. This is why the Minister has had to rein in some of the hospitals recently over their spending. It is despicable that we have these problems in the health service and that the issue of hospital consultants is not being dealt with properly. I refer also to the fact that we have a two-tier system and that many consultants can still run private practices in public hospitals using public money to do so. Many, through their contracts, are being paid exorbitant salaries and at the same time practising privately in the hospitals. Both Fine Gael and the Labour Party campaigned against this for many years and criticised the previous Government for not dealing comprehensively with the issue of consultants.

Many consultants are reluctant to change based on vested interests. If the Government were to take on the consultants, its doing so would potentially involve more costs or reducing the pay of consultants. The previous Government never grasped the nettle of reducing their pay. There are many examples in this regard. Deputy Ó Caoláin raised this issue in the Dáil yesterday with the Minister for Health. He implied that many consultants who had had their contracts renegotiated were still not fulfilling the terms of their contracts and doing the amount of public service work they should be doing.

I stated on the Order of Business recently that it was appalling and sickening to have to listen to representatives of Fianna Fáil in this House on this subject. Senator Leyden mentioned Roscommon County Hospital and stated accident and emergency services had been reduced there. I did not hear the same level of criticism from him and members of his party when accident and emergency services were axed in Dundalk, Monaghan and Ennis. Fianna Fáil is responsible for many of the problems in the health service. While I accept that the new Government must take on the problems in the service because of the failure of the previous Government, we need the revolutionary thinking evident in some of the points made by Senator Crown whose contribution was excellent.

One problem in the health service concerns accountability and the fact that we do not listen to experts. We do not even have a role for elected representatives. The talking shops set up to replace the old health partnerships are clearly not working. I would like to see proper community health partnerships with representatives of advocate groups, patient groups, elected representatives and experts who could provide information in the proper manner and exercise an oversight function with regard to what is occurring in the health service. It is appalling in the 21st century that the configuration of staffing in hospitals has led to a crisis such that we must again recruit doctors from other countries. We have still not dealt with the issue of consultants and are over-reliant on non-consultant hospital doctors in acute services. If we are to address properly the very serious problems in acute hospital services and the pressures the staff in these hospitals face, we need to invest in primary health care, a matter to which Senator Barrett referred. There is a real need to examine seriously primary health care provision. Senator Barrett referred to 24-hour supermarkets, a concept which has been raised on numerous occasions. One can go to a shop at 3 a.m., yet one cannot go to a general practitioner at that time. Twenty-four hour services are not available in all areas, except in emergencies. There is a lot the Government could do in this regard.

The Bill is necessary to prevent the collapse of some services in hospitals. For that reason alone, I will reluctantly support it. In supporting it, however, my party and I have very real concerns about the reconfiguration of hospital staffing, the recruitment embargo which is not working, consultants and the funding of public services generally.

Senator John Kelly

I welcome the Minister of State, Deputy Róisín Shortall. My only regret is that the Minister for Health, Deputy James Reilly, is not present, as he is the man to whom I should be addressing all my concerns about the health service.

This legislation, while welcome, is eleventh hour stuff. It has come too late for the accident and emergency department in Roscommon County Hospital. Most people in County Roscommon are asking where it has all gone wrong. Somebody famous once said that to solve the problems of the future, one had to look to the past. During the 1960s, 1970s and 1980s a matron ran Roscommon County Hospital. That was the only system people knew. There was one matron; the floors and walls were scrubbed and there were no infections, including MRSA, in the hospital. There were nurses and a consultant. Today there are consultants, directors of nursing, assistant directors of nursing, clinical nurse managers, grade 3, clinical nurse managers, grade 2, night duty administrators, night superintendents, clinical directors, etc. There were 11 grade 8 personnel in the country in the period to which I referred; there are 717 today. That is where it has all gone wrong and why we do not have an accident and emergency service. It is not a question of patient care but of the fact that we have no money. We have wasted money on the HSE. Since it was established, we have wasted taxpayers' money in the delivery of a second-rate hospital service and health service generally.

I totally agree with Senator John Crown. What we are engaging in is a Band-Aid exercise. However, I would accept a Band-Aid to fix the problems in Roscommon County Hospital in the short term in order that in the longer term it would be possible to deliver the service the people who live its isolated, rural catchment area deserve.

With regard to the word "reconfiguration" which the HSE has been using for the past seven years, no one from it has explained its meaning. No one knows what it means, although I have my own ideas as to what it might mean. The people are afraid. We are suddenly hearing the word "reconfiguration" again, but, unfortunately for the people of County Roscommon, it is when we are being told for the first time that their accident and emergency department is to be closed down. In spite of this, to date no one has explained the meaning of the word "reconfiguration".

I have said to Senator John Crown that if he has a better vision for the delivery of accident and emergency services, let him put it in place before removing other services. Let him deploy advanced paramedics and let us prove to the people that, as soon as one has a heart attack, there will be somebody on a motorbike or in an ambulance to ensure one survives. We should prove this service works in tandem with an accident and emergency department before proceeding further. If it works, the accident and emergency department could be downgraded. However, one should not take away a department and say something else will be put in its place.

I attended a meeting last Friday week in Hawkins House. I guarantee the Minister of State that no one from HIQA or the Department of Health had a plan for the provision of an advanced paramedic team when talking about shutting down the accident and emergency service in Roscommon. They had no plan but will look at it.

Another point being bandied about by the Minister at present concerns mortality rates in Roscommon hospital being five times higher than is the case in Galway hospital. While that may be the case, I genuinely believe these figures are based on the fact that people in County Roscommon are so distant from an accident and emergency unit in Galway that could save some of these lives. It is that people are dying on the way to Galway and not that they are dying in the hospitals. All people in my situation want their local hospital to be up and running for their safety and that of their families.

I have a question for the Minister of State in respect of HIQA, which was set up by the last Government via the HSE. Who directed HIQA to set the bar so high that hospitals, such as Roscommon hospital, cannot survive or did it do so itself? Such hospitals cannot deliver the service that will deliver patient safety. Who set that bar so high? Was this done under the previous Government or did HIQA itself do so? If hospitals such as Roscommon hospital are unable to reach that bar, it simply is because of lack of funding and resources within the health service.

Senator John Crown

Hear, hear.

Senator John Kelly

I reiterate my point that I do not believe this to be about patient safety but that it is all about money.

Senator Mary M. White

I apologise but I could not hear the Senator. Did he state it is not about patient safety?

An Leas-Chathaoirleach

Less than one minute remains to the Senator.

Senator John Kelly

It is not about patient safety. This is about money and in this case about saving it at the expense of the people of County Roscommon.

I note from today's newspapers that the Minister supposedly intends to put in place an urgent care unit in Roscommon hospital as a replacement for an accident and emergency department. However, neither the Irish Nurses and Midwives Organisation, INMO, nor the ambulance service are co-operating with it and this reiterates my point that no advanced paramedics system is in place. The Minister of State should enlighten Members as to the Government's future direction because I am here to bat for the people of County Roscommon and do not wish to see people dying on the roads to Galway. I will repeat a point I have made many times previously, which is that 50 years ago, the country had geniuses who knew it all, like the HSE today, and who decided to remove the train tracks because they thought they never would be needed again. They now realise they made a mistake. Will a similar realisation dawn in respect of the future delivery of health services?

Senator Mary M. White

I wish to make a few brief points on this issue. First, I note my formal disappointment regarding the absence today of the Minister for Health, Deputy Reilly, who is at the centre of the storm in respect of the health service. Having served on the previous Joint Committee on Health and Children with Deputy Reilly, I have stated previously my belief that he would be an outstanding Minister for Health. I say this without disrespect to the Minister of State, Deputy Shortall, for whom I have tremendous regard and with whose dedication and sincerity as a politician I am familiar from serving with her on the Joint Committee on Health and Children. Deputy Reilly should have been present in the Chamber today and Fianna Fáil Members were informed that he would be present for two hours. It is highly disappointing as I would have liked to have heard a contribution from him on the Bill's technical contents, on what has gone wrong within the system and on what he intends to do. I find sitting here to debate this Bill to be an embarrassment for Members. I do not intend to continue speaking if people——

An Leas-Chathaoirleach

Can we have silence, as the Senator is refusing to speak otherwise?

Senator Marie-Louise O’Donnell

She is right.

Senator John Gilroy

There is no disrespect.

An Leas-Chathaoirleach

Senator White, without interruption please.

Senator Mary M. White

I have a problem in this regard. I listened with pleasure to all my colleagues today and each contribution was outstanding. While Senator Crown undoubtedly is a professional in this field, I include all my colleagues and went across the floor to compliment one of my Fine Gael colleagues on his contribution this morning. I also wish to note this is the third time I have been elected to this House and the reason I am here is to give my contribution, based on my life and business experience. I find this Bill to be an embarrassment. It reflects this country's failure, shows up the difference between the private and public sectors and the lack of planning and strategy in the short, medium and long term. I mean no disrespect to those departmental officials who are present as on an individual basis, outstanding people are to be found in Departments. However, were a business to operate in the same manner as the Department of Health, it would be out of business. I sat on the aforementioned Joint Committee on Health and Children and noted the size of entourages accompanying the Secretary General of the then Department of Health and Children, the former Minister for Health and Children, Ms Harney, and the former chief executive of the HSE. I do not understand how we could have afforded to have people come before the Oireachtas joint committee or the cost of preparing to so do for weeks in advance. My point is that while Senator Kelly suggested this was about money, it is about the waste of money in what has gone on.

In my role as a Government Senator during the previous Seanad, I produced a document on suicide. I referred to the lack of money that was being put into this issue and the lack of priority or resources afforded to it by the then Department of Health and Children and the HSE. There were glaring examples of waste and inefficiency and a lack of services available to look after people who are mentally ill. Moreover, the biggest crime of all concerned the lack of services for children in society, who cannot afford to pay for private consultants. Some children aged seven and ten have suicidal tendencies and I consider the incompetence of the Department of Health, the HSE and the associated political failure to be akin to savagery. I agree with Senator Crown's assertion this morning on a lack of leadership and with all due respect, Deputy Reilly, of whom I am a fan, showed a lack of leadership in not being present in the Chamber, as well as a lack of respect to those Members who are present.

Second, I hate saying this but it is my bottom line. I believe in Deputy Reilly and over my political career I have voted for people of all political parties. I vote for them if they are good. However, the tragedy is that this carry-on and this undelivered promise to Roscommon hospital brings all politicians into disrepute. I was mortified when going out the other evening to speak to the people of County Roscommon. It is the same old story in that political promises are made but not delivered on. I also believe Deputy Naughten showed courage in resigning and share the hope expressed by my colleague, Senator Leyden, that he is allowed to retain the chairmanship of the Joint Committee on Health and Children because despite the protocols and rules that automatically take effect, leadership and innovation are required within Leinster House, the Department of Health and the HSE.

I will conclude by noting the real cause of the entire problem is the failure to deal with the issue concerning the numbers of people employed in the Health Service Executive on its original establishment. No one had the guts to bite the bullet and deal with the overmanning within the health service at that time——

Senator Sean D. Barrett

Hear, hear.

Senator Mary M. White

——and a gigantic problem now exists. In fact, we now have a monster. I state this with no disrespect to those who work there, because just as is the case with politicians, in each group within society some people do their best and work for their country while others bring the rest into disrepute. However, I am embarrassed by this debate and it is like being in a banana republic to be obliged to produce an emergency Bill to bring in young doctors from Pakistan and India. I was pleased when Madame Lagarde, the new chief of the IMF, praised Ireland internationally earlier this week. We have brilliant achievements in the private sector. We have got our act together, but the newspapers are spreading depressing news every day. One of the young people I met out on the Roscommon protest said "I'm getting out of this country on Monday. It's a failure". It is not a failure.

An Leas-Chathaoirleach

The Senator's time is up.

Senator Mary M. White

My point is about the media creating this idea that the country is finished. The country is not finished but the public sector needs to get its act together. We need the leadership, courage and guts to deal with the issues.

Senator Jim D’Arcy

Cuirim fáilte roimh an Bille seo, agus molaim an tAire Stáit. I have heard the Bill referred to several times as a sticking plaster solution, but there are only three things about managing any situation: keeping things going, coping with breakdowns, and doing new things. This Bill is coping with a breakdown in the system, which the Minister has inherited. I was looking forward to the Minister attending the House today but I will not criticise him on that account at this time. Perhaps we will get another opportunity to debate health matters with him. I hope we do but that is no reflection on the Minister of State.

Like Senator White, I think the Minister for Health will be a strong and reforming Minister. In 1987, Senator MacSharry's father had to break election pledges because of the state of the country. I will not rehash everything that has been said about the state of our health service but the Minister, Deputy Reilly, has to fix a broken system and he will have a big task ahead of him in doing so.

Following Senator Crown is a bit like following Beyoncé at the Glastonbury festival — one has no chance. I have a deep admiration for Professor Crown on a personal level, but Fine Gael did not promise to bring in the new system in this Dáil, even during the election campaign. It made it clear at all times that if it got back into power the Minister would introduce the Dutch model here. Apart from that, we all recognise Senator Crown's great wisdom.

On the situation we find ourselves in with non-consultant hospital doctors, Senator Burke hit the nail on the head — there is no proper career path for them. It should be conveyed to the Minister that we need further reform so that it will be seen as a proper career path. Traditionally, in popular culture, it was thought that non-consultant hospital doctors did the work while consultants were in the yacht clubs or on the golf course. That is the traditional, populist view of non-consultant doctors.

Senator John Crown

I am shocked.

Senator Jim D’Arcy

I do not know how true that is, but that is the popular view. Senator Barrett referred to Dr. Noel Browne being brought down by the medical profession or the church, but I thought it was the same thing at the time because the bishop's brother was the consultant and his sister was the mother superior or hospital matron. It was that type of situation whereby we had the elitism that Professor Crown spoke of earlier. I would like to see non-consultant hospital doctors having a proper career path here.

A year ago, the HSE reduced the number of training posts without consultation from 4,700 to 3,600, although it is now up to 3,750. That could form part of a further solution if the Minister considered it.

Senator Paschal Mooney

I welcome the Minister of State to the House. My enduring fantasy image of this debate will be of Senator Jim D'Arcy dancing to the music of Beyoncé at Glastonbury. It is interesting to know that the Senator has wide interests.

I too am disappointed the Minister, Deputy Reilly, is not in the House. It would have been an opportunity in light of all the controversy. It would also have given this House an enhanced status to have the line Minister present to at least hear this debate, particularly as the other House is not sitting. We are dealing with a current issue, rather than something that is being put in place for the far future. I mean no disrespect to the Minister of State. I know how the system works and I am sure she was given the rotation and told to get in there and man the barricades. I know she will do that very well. I also wish her well in her own brief within the Department.

I join other Members in commenting on the issues before us. One of the aspects of the junior doctor issue which I have raised more than once before now, is that we will introduce a significant number of junior doctors from India and Pakistan. I hope the Minister of State can reassure the House and the hospitals not only that they will be trained up to integrate into the Irish health system as quickly as possible, but that their language skills will be at the same high level as that required of their medical expertise. Without wishing to sound as if I am against the concept of junior doctors from the Asian sub-continent coming into Ireland — I am not — like many Members of this House I have been in and out of hospital since childhood. My memories of being treated by junior doctors from the Sudan, India and Pakistan have been, in the main, very positive. It is just that on occasions when I have visited emergency rooms——

Senator Marie-Louise O’Donnell

On a point of order, that was covered in the Minister of State's speech — that the doctors coming in would have a language proficiency.

Acting Chairman (Senator Terry Leyden)

That is not a point of order. The Minister of State will respond to that matter.

Senator Marie-Louise O’Donnell

I am sorry. I was unaware of that.

Senator Paschal Mooney

Was the Senator trying to be helpful or mischievous?

Senator Marie-Louise O’Donnell

No, I was trying to be informative.

Acting Chairman (Senator Terry Leyden)

Please continue, Senator Mooney.

Senator Paschal Mooney

With due respect, it is not necessarily the convention in this House that when a Member is making a contribution he should receive helpful interventions from other Members.

Senator Marie-Louise O’Donnell

I apologise but I did not understand the procedures of a point of order. I thought they were allowed. I was being informative and I would consider that to be extremely helpful to another Senator.

Senator Paschal Mooney

I think I have made the point about language proficiency.

Senator Cullinane is a fine fellow and I get on with him, but I was a little disappointed that he should now adopt the cloak of opposition that has been cast aside by Labour and Fine Gael as they have come into Government, in attacking Fianna Fáil Administrations for their handling of the health care system here. They have a proud record. The people of Roscommon are very much aware that whatever failings and shortcomings Fianna Fáil may have had in the health area, at least it not only kept Roscommon hospital alive but maintained the services there in the teeth of strong opposition from the then Opposition. C’est la vie. It is the way the system works — poacher turned gamekeeper. Those on the Government side are now defending the position, which is what Governments do. We all are getting a little tired of constant barbs being fired across the floor about what Fianna Fáil did and did not do.

Senator John Gilroy

Are they undeserved?

Senator Paschal Mooney

The health service in this country has faced very serious challenges over a long period that have involved other administrations as well as those of Fianna Fáil and to suggest we are entering some sort of Nirvana as a result of this Government is fantasy world.

I found the following going through some basic research to try to find out what was going on in other countries. If I were to state many of the familiar issues — crowded emergency rooms, lack of hospital beds, not enough doctors and nurses and patients suffering as a result — one's immediate reaction would be this refers to Ireland. In fact, this refers to Ottawa and British Columbia in Canada quoted by Dr. Raj Sherman, a New York physician turned Edmonton MLA. I was taken somewhat by the suggestions he made in the context of trying to fix the Canadian health care system, particularly as it relates to the ER or accident and emergency. He stated that home care, home care and home care are the top three ways to fix acute care, and that people need to be helped to remain in their homes far longer than is currently the case. He also makes the point that the health care system should stop stressing the acute care system by forcing it to do the job of other parts of health care, and that better primary care, including ensuring that every citizen has a GP and long-term care for seniors, will free up beds and resources for the critically ill. That comes from a Canadian. I just picked that out. It could have been any country.

Acting Chairman (Senator Terry Leyden)

Senator Mooney's time is up, although I know he was interrupted.

Senator Paschal Mooney

What also struck me is that junior doctors roughly make up one third of the medical work force in Europe and are among the main migrating group within the health care sector.

I wish the Department and the Minister well in trying to recruit more junior doctors into the system as a short-term measure to address the immediate challenges that are facing them. I hope they will be encouraged to come here when one looks at the comparative salaries paid in Britain and Ireland. I am grateful to the Minister's officials for giving me some up-to-date information the detail of which I will not go into now because of time constraints. However, specialist registrars will earn between €60,000 and €76,000 per year whereas in Britain, in trying to get a comparative scale, it suggests that the same specialist registrar would earn in the order of €60,000. Therefore, they are exceptionally well paid.

Acting Chairman (Senator Terry Leyden)

I thank Senator Mooney.

Senator Paschal Mooney

I understand that overtime is an integral part of the system here, which adds even further. When people talk about money, it is not that there is a shortage of money for junior doctors. The shortage of money seems to be in how the system is administered, and that is a debate for another day. Overall I welcome the Bill.

Senator Paul Bradford

I want to say a few words on the legislation. Like many speakers, my comments might stretch slightly beyond the terms of the legislation and I respectfully seek the Acting Chairman's understanding for that in advance.

I listened with interest to my colleagues. Everybody in this House wants to see a situation brought about where we have a health system which delivers to the public. During my time in politics — this is a fair comment across the political spectrum — every person who has held the portfolio of Minister for Health, from Mr. Barry Desmond, Deputy Michael Noonan, Mr. Brian Cowen, Ms Mary Harney and the current incumbent, set out with fine ambition to deliver a health service of which he or she could be proud and which would serve the needs of the public. For various reasons, unfortunately, it has never worked to the extent that all of those Ministers would have wished. We have invested significantly in the health service. A considerable proportion of the national budget every year goes on the provision of health services but, sadly, the results are not as had been hoped for.

The previous speaker mentioned the Canadian health system. During my time — I do not want to get into fadó, fadó — we heard about Nirvana, which was the Australian system, and the Canadian system, the Dutch system and the Swedish system. There have been so many models of health service presented to us that one would almost have a picture of a calendar with all of these health models, month by month.

The Minister of State, Deputy Shortall, is presenting to us legislation which is brief in nature but, hopefully, rather more deep in substance, which will be one small step forward.

I understand that next week in this House there will be statements on the Department of Health's A Vision for Change document. Of course, there is a big jigsaw of policy areas in the health field which we need to tackle. However, from a layman's perspective, it always strikes me as a concern that we in this country do not appear to have enough people on the ground delivering the service. Notwithstanding the vast budget which is being spent on health, it is difficult to see any further resources being provided. Let us be honest about that, we do not seem to have enough practitioners. From doctors in surgeries to nurses in wards and consultants in hospitals, it seems there is an inadequacy in numbers.

Of course, we need this great debate on pay and the cost of all of these staff in the service and we need a debate on the training aspect. For instance, I recall two or three years ago here we discussed the new system of training, not for GPs but for entry into medicine. Clearly, there is a supply and demand problem. This legislation is about trying to respond to the lack of professionals but our aim must be to try to ensure we are able to train sufficient people in this country to provide for the health care needs of our people.

Obviously, we are now in a crisis situation with a capital "C", and urgent and immediate short-term remedies are required. That, I understand, is what the legislation is about. That it why it must be supported.

Obviously, I bow to the much superior knowledge on medical and related matters offered by persons such as Senator Crown. However, what people are asking us is what will be the position in a week's time, in a month's time and in six months' time. Hopefully, this legislation will be able to offer some degree of positives in that regard.

When the legislation is passed and when we all go home this week, the Minister of State and her colleagues in the Department of Health must give the most serious attention to looking beyond the short term and to at least the medium term, asking the substantial questions as to the numbers we train for medicine across the spectrum, how we pay for it and how we ensure we do not have this crisis in future.

It seems difficult to accept that in a county as modern in every respect as Ireland, in an advanced European Union, that from the perspective of a health service we are not delivering the first world service required. We are able to deliver first world education services, legal services and accountancy services, and yet we do not seem to be in a position, whether financially or in personnel terms, to deliver it in sufficient terms in the medical services.

The legislation is a necessary, small step forward. I look forward to next week's statements on A Vision for Change but also to the crucial next few months where, hopefully, the Minister of State, Deputy Shortall, and the Minister, Deputy Reilly, will come before us to present a broader vision of the future of the health system in this country, be it on the Dutch model or whatever. I hope thereby we can have a substantive debate on how we deliver to the people of this country the services that are not only expected but, in a modern economy, can be provided.

Minister of State at the Department of Health (Deputy Róisín Shortall)

I convey the apologies of the Minister for Health, Deputy Reilly, for his inability to attend this debate. He is attending a funeral in the UK and, on that basis, I trust Senators will excuse him. He regrets he is not in a position to be here given that he was in the Dáil throughout yesterday's debate.

I thank Senators for their thoughtful contributions, many of which were based either on the valuable experience of public representatives who worked at the coalface to respond to issues raised by constituents, or the more specialist expertise exhibited by Senator Crown in particular. That 20 Members contributed to this debate on a Friday morning is a measure of the importance they attach to the health service and its reform. Notwithstanding the small number of political points scored, I welcome the wide agreement across the House on the need for significant reform. There is agreement that our health system is seriously dysfunctional in a number of aspects and needs urgent and radical reform. The big regret is that the opportunities to address some of these fundamental problems were not availed of during the boom years when plenty of money was available to conduct a root and branch examination of the health service. I wonder almost every day why these problems were not tackled when the money was available to do so.

I do not suggest that the Bill is a panacea. It has been described as a sticking plaster and it represents an immediate and urgent response to a specific problem that has to be solved in a matter of days. It does not purport to address the wider problems in the health system. These problems have been known for many years and analyses of them are provided in umpteen reports. There is no question about the need for better planning in our health service. Manpower planning is an area that has been identified by several speakers. I was shocked at the lack of data available to me to examine the kind of services we want to provide in the future, and I am not satisfied by the roll-out, planning and forecasting of manpower and levels of services. This is an issue I want to address at an early stage with the Department of Health and the HSE.

There is no question that we need to reform fundamentally the way we deliver health services. The system does not at present provide an acceptable level of service or achieve best outcomes for patients. This model of health care is not fit for purpose. The challenge is to meet the best interests of patients and, to do so, we must remove the vested interests. We must take an evidence-based approach to decision making and tackle the huge bureaucracy that is clearly not responsive to the needs of patients. We must also be cognisant that we are in the process of introducing reform at a time when there is no spare money. Achieving good value for money should always be an important consideration but it is to the forefront of our thinking now. We have to achieve value for money across the system and there can no longer be protected or vested interests. Everyone must be made accountable for the level of service they provide.

The programme for Government gives a clear commitment to fundamental reform. We are committed to introducing universal access on a single tier basis in order that people have access to an appropriate level of health care based on their medical need rather ability to pay. We must switch to a system in which money follows the patient rather than continuing to pay block grants to hospitals irrespective of their efficiency or activity. By making the money follow the patient, service providers will be incentivised to increase activity and provide services that are more efficient and cost effective. It is a misrepresentation to describe what we aim to achieve as the Dutch model. The model which we propose in the programme for Government is a hybrid and cannot be compared exactly with those of other countries. It is based to a certain extent on the Canadian and French models and it draws from a number of different systems around the world. It is an insurance-based model involving competing companies.

I appreciate Senator Crown's frustration about the time required to implement fundamental reform. It cannot be done in the short term and the Government is realistic about the timescale that will be required to introduce the reforms that everybody agrees are required. For this reason, we have set out a timescale of five to six years to introduce full universal health insurance. It would have been easy for the parties that now make up the Government to have promised short-term reform during the election campaign but, given the size of the health service, that is simply not possible. We want to turn that ship around and fundamentally reform the way in which services are provided. That cannot be done in the short term and this is why we have set out medium-term objectives for what we want to do.

This does not mean nothing will happen over the coming five or six years. Immediately after entering Government, the Minister, Deputy Reilly, and I set about ensuring no time would be lost in introducing reform. The special delivery unit which we have established is expected to make rapid progress in addressing the blockages in the system that prevent the reduction of inpatient and outpatient waiting lists. I hope we will start to reap the benefit of these reforms in a matter of months. In the longer term, the special delivery unit will investigate ways to deliver services across the hospital system and in primary care settings through changes to work practices and hours of operation which will allow us to get better returns for our huge investment in the health service as well as better outcomes for patients. That work is under way and we will see its outcome over the coming months and years.

In terms of moving towards an insurance-based system, an implementation body was recently approved by Cabinet and will be set up in the coming weeks. It will carry out the short, medium and long- term planning required to provide fundamental change to the delivery of health services.

The results of an examination of the health insurance market being undertaken by Goodbodys——-

Acting Chairman (Senator Terry Leyden)

As it is now 1 p.m., I am required by an Order of the House to put the question on Second Stage. The Minister of State may resume her contribution on Committee Stage.

Senator Maurice Cummins

I propose that the debate be extended by five minutes.

Acting Chairman (Senator Terry Leyden)

Is that agreed? Agreed.

Deputy Róisín Shortall

I apologise because I was not aware there was a time limit. I thank the House for the extension. I was talking about what is under way to achieve long-term reform. We are waiting for the report from Goodbodys on the health insurance market, which is due within weeks.

In the short term, plans are under way to introduce changes in the primary care area. This relates to the issues raised by Senator Zappone about what needs to be done at community level. Everybody involved in the health service, including the experts and clinicians, say we should significantly move activity out of acute hospitals into the community. We should also move some of the activity from the community to the individual because we need to encourage people to have a much stronger role in taking responsibility for their own health. They should examine their lifestyles, exercise, diet, smoking, drinking and so on. The individual must also take responsibility. Everybody has been saying that for years but it has not happened.

I am conscious that there are powerful interests in the hospital sector such as chief executive officers, consultants, boards of management and so on. We frequently see reports of people marching in support of their local hospitals but we never see them marching for improved primary care services. It is not until we ensure the clout exists at this level in terms of senior management within the HSE and the Department of Health that services and, critically, budgets will switch from acute hospitals into the community. People should receive the vast majority of services in their communities and the aim is to ensure 95% of health services can be delivered at community or primary care level. The commitment to doing this is evident in the programme for Government. The very fact that the new post I am very proud to have been given — Minister of State with responsibility for primary care — has been created is a strong statement that the Government wants this to happen. I am working with the HSE and the Department to ensure priority is given to, and management authority and muscle is devoted to, primary care in order that developments can take place.

In addition, fine work is being undertaken by Dr. Barry White to develop clinical care programmes, which will improve the standard of care for everybody. The aim is to achieve best international practice in the care of chronic illness both at hospital level and, critically, primary care level.

The issue of out-of-hours services was raised. Where there are issues regarding the need to close local hospitals because of safety concerns and because there may not be the critical mass to support them, a range of community and primary care services should be in place. Unfortunately, that is not the case in many parts of the country. Out-of-hours GP services are working well in some areas. I have availed of such a service on the north side of Dublin several times. The DDoc service is very good. I am amazed that every time I have attended the clinic, nobody else has been there. These services need to be promoted. They cost quite a bit of money, they make sense but people are not aware of them. I was in Temple Street Hospital on a Tuesday at 8 p.m. recently and it was packed, yet out-of-hours services are available all over the city of Dublin, which are under used. We must ensure people are aware that good quality out-of-hours services are available throughout the State. We work on the basis of the services in place and building on them. Many services could be provided at community level, which would mean people not having to attend acute hospitals. That is the intention and the Government is committed to honouring the proposals set out in the agreed programme for Government. Work on that is being progressed on a weekly basis and the Minister, the Minister of State, Deputy Kathleen Lynch, and I are determined to see the reform programme through.

In addition, I concur with many of the comments on the provision of training for hospital doctors and on their career structure, which is outdated and not fit for purpose. Reference was made to the fact that this small country has six medical schools. That makes no sense and needs to be addressed. I am also concerned about the low intake of Irish students. Hundreds of thousands of students who would make fine doctors would love a place in medical school. We need doctors in both the hospital and primary care sectors. It is nonsensical that numbers are restricted to the extent they are when there is a shortage of doctors in both sectors. That issue is being addressed and I recently received the go ahead in the Department to undertake a major study on medical manpower planning over the next five to ten years because we have little data in this regard.

It is positive that Irish trained doctors spend time abroad and experience other systems and that needs to encouraged but it is regrettable that many of them feel they have to leave the country because of the lack of satisfactory opportunities to continue their training or the failure to be given an acceptable status within our hospital system. I am conscious that the manner in which the system works could be described as "inhumane", given the hours people and conditions are expected to work in and the manner in which they are treated by their seniors, which is not acceptable. We have to consider the career structure hospital doctors should have and that needs to be reformed urgently. Currently, we have an all or nothing system with people either being consultants or non-consultants. It is as ridiculous as having teachers and non-teachers or architects and non-architects. It has been suggested there should be a middle tier.

Acting Chairman (Senator Terry Leyden)

I would love to listen to the Minister of State all day but I am afraid I am tied to the order of the House. She can conclude her contribution on Committee Stage.

Deputy Róisín Shortall

I assure the House that this work is under way. I recognise the difficulties. The IHCA needs to play a part in bringing forward proposals. I asked its representatives recently whether they had proposals for changes to the career structure of hospital doctors. They did not have them readily available but we need to tackle that issue. I will address the other issues on Committee Stage.

Question put and agreed to.

Acting Chairman (Senator Terry Leyden)

When is it proposed to take Committee Stage?

Senator Maurice Cummins

At 1.30 p.m. today.

Sitting suspended at 1.10 p.m. and resumed at 1.30 p.m.

Seanad Éireann debate - Friday, 8 Jul 2011

Medical Practitioners (Amendment) Bill 2011: Second Stage

Senators

Seanad Éireann debate -
Friday, 8 Jul 2011