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Seanad Éireann debate -
Thursday, 27 Oct 2011

Vol. 211 No. 3

Health Services: Statements, Questions and Answers

I welcome the Minister for Health, Deputy James Reilly, to make a statement on the health service and answer questions already submitted by Senators.

I thank the Leas-Chathaoirleach and Senators for providing me with this opportunity to brief them on a broad range of health issues that they indicated they wished me to address. First, however, I wish Ms Finola Cassidy who is in the Visitors Gallery a happy birthday. I will begin with some remarks about the financial crisis which the Government is tackling and the resulting challenges for the health service. At the beginning of the year hospitals had overrun by €70 million their budgets carried over from last year. In the first three months of the year, for whatever reason, there was a massive overrun in hospital budgets, as activity outstripped normal levels. In addition, because of the general financial position in the country and the fact that we must now report to the troika, we must save €1 billion on the health service. Given that background, we are trying to maintain services and, at the same time, institute a reform programme.

People are always exercised — rightly — about various facilities and different aspects of the health service. They want these to be fixed, rightly so. However, these matters do not arise in isolation. John Donne said, "No man is an island entire of itself." Similarly, no part of the health service works on its own. If a hospital has a problem in its emergency department, it cannot solve that problem within that department.

The problem must be dealt with. It arose as a result of the mishandling of the health service and the economy by the Senator's party in the past 14 years.

The Minister closed the accident and emergency department in Roscommon County Hospital.

We inherited that legacy and we shall deal with it. Not for the first time, a Fine Gael and Labour Party Government will clean up the mess left behind by a Fianna Fáil-led Government. A hospital must fix the problems in its emergency department by addressing their cause. What causes them are the actual numbers coming to the emergency department and the lack of primary care facilities. That is an issue we are addressing. We are putting in place a strategy on which we will deliver, unlike the strategy of 2001 which was left on a shelf.

Equally, one must change the way a hospital operates in order that more patients can be admitted quickly. In order to do this one must provide services in the community to allow patients who have finished the acute phase of their treatment to continue their journey back to full health, if that be the case, or in longer term care, if that is what is required. There is a range or host of possibilities between short-term convalescence, longer term convalescence and other initiatives. If a diagnosis of pneumonia is made, for example, when the patient will need intravenous antibiotics, the first dose can be given in hospital and the patient can then go home where he or she can be visited by a competent nurse to administer the antibiotics while the patient is monitored by his or her general practitioner. There is also home help and home care packages available. All of these possibilities must be addressed.

When the Government came to power, I promised to set up a special delivery unit. The reason I was so keen to do this was that I had seen what had been achieved in Northern Ireland where there was an information system that allowed full visibility throughout the health service. One could see Mr. Murphy's waiting list in Ulster Hospital with the touch of a button on a computer, or Mr. Walsh's list in Belfast. If one was a two month list and the other was a two week list, the man with the two week list was left alone while the man with the two month list received a visit to find out what the problem was. This was not used as a big stick with which to beat people but rather as a tool to help them to address the problems they were experiencing. Was the reason for the delay the fact that the man concerned was undertaking too many reviews, or was it that he was so popular that everybody wanted to see him? In such a case perhaps some patients could be moved to another list. The key point is that the Minister is in constant touch with the special delivery unit which reports to him weekly and sometimes daily. This has had two effects, as I noted at the time. First, people know there is help available and, second, that there will be consequences if they do not change their habits.

My adviser was told that it would cost €10 million and take 18 months to introduce such a system here. The special delivery unit, under Dr. Martin Connor, a doctor of philosophy, not medicine, in conjunction with some excellent people from the HSE and the National Treatment Purchase Fund, has managed to put in place a system in 98 days for less than €250,000. It is not yet complete, but they are getting there quickly. Of course, the final bill will be higher, but the point is that the team has managed to do in a very short time what it was said would take much longer and cost much more to do. We are now in a situation that allows full visibility across the system. We can see how many are waiting for access to inpatient services and for how long they have been waiting in emergency departments at any given moment. This does not yet apply to all emergency departments, but is to be found in 27. We can now monitor what is happening and intervene. Similarly, we can now see Mr. Murphy's waiting list. For the first time, instead of driving around in the dark, we are driving with full beams. We can see what is happening, plan and react much more quickly. Instead of finding out months or a year later that there is a problem, we know now and can address it.

We are also putting in place a similar type of IT system for financial matters in order that we can monitor a hospital's financial performance at two and four week periods. This obviously gives us more monitoring ability because many more parameters can be measured. We will be able to see very quickly when a hospital is moving away from budget and intervene, something it was not possible to do in the past. Generally, what happened was that in the middle of February things would begin to look a little funny and one waited to see how they looked in March. In May one realised that half the year was almost gone and budgets had gone seriously astray. That will not happen again.

Many Senators have issues concerning their local hospitals. Eight are problematic, while another seven are considered high risk. They are receiving intensive support. I will take questions as Senators raise them, if they have a particular interest in a given hospital.

I wish to discuss, briefly, the position of smaller hospitals and the pervading fear that they will be downgraded and, ultimately, put out of business and lost to their communities. Nothing could be further from the truth. We are obliged to preside over the safe provision of services — that is an absolute — and will do so. Where we can make a hospital safe, we will do so, but where we cannot, or if there is a facility within the hospital that is not safe, we will not preside over it. In the midst of all the negativity, however, I wish to point to some positive facts about smaller hospitals. The Government is developing a framework for such hospitals, the first draft of which has already been delivered. The Cabinet Sub-committee on health met to discuss this strategy and is due to meet again in the next week or so in order to give further consideration to it.

An example of a small hospital that has flourished is Louth County Hospital. In 2009 there were no care of the elderly cases at this hospital, in 2010 there were 162 and to date this year there have been 388. In 2009 there were 535 episodes of venesection for haemochromatosis which requires removing units of blood at a time, in 2010 there were 800 and to date this year there have been 1,783. There was no colposcopy service at Louth County Hospital in 2009 but in 2010 some 3,083 cases were dealt with there. The number of surgical cases at the hospital has risen from 3,416 to 3,659 in recent years. The number of radiological examinations increased from 534 in 2009 to 1,519 in 2010 to over 3,000 this year. The number of outpatient sessions has increased from 933 to 974.

These are the types of services which can be provided safely, conveniently and in a far more cost-effective way in smaller hospitals than in their larger counterparts. I accept that there has been a great deal of controversy with regard to what has happened in smaller hospitals. I warrant, however, that there will be a great deal of controversy when we transfer from the bigger hospitals the type of procedures which more rightly should be carried out at smaller facilities. People should make no mistake — we will move those procedures. I have stated on previous occasions that obliging people to attend in larger hospitals for a varicose vein ligation procedure or the repair of an inguinal hernia is similar to sending one's ten year old Volkswagen to the Ferrari testing centre. There is no doubt that a great job will be done but this is hardly a good or efficient way to use resources.

I do not want to take up too much of the time because I am aware that Senators have many questions to pose. However, I wish to state that we are determined to make our health services better. We know that we can do this and we have gathered around us the expertise to allow us to proceed. The clinical care programmes were already in existence when I entered office. They are now flourishing and are playing a major role in addressing many of the inefficiencies that exist in the system. It is worth noting, particularly in light of past controversies, that it will not be possible to do things as they were done in the past, especially as our way of operating has not delivered. I will give some credit where it is due. The previous Government threw a great deal of money at the health service. It is clear, however, that money alone will not solve the problems. What is required is change, particularly in respect of the way care is delivered.

The underlying principle of our policy is that a patient should be treated at the lowest level of complexity in a setting that is safe, efficient and as near to his or her home as possible. We intend to ensure that this principle will be adhered to. We have already begun our journey on this road by allowing patients the option of having flu vaccinations administered in pharmacies. This gives them greater choice and increased access due to the fact that pharmacies have long opening hours. Similarly, we want to bring those with chronic illnesses out of hospitals and back into the community, where they can be treated in a far more cost-effective and convenient manner.

I recently visited Mallow primary care centre, at which over 2,000 people with diabetes are being treated at 20% of what it would cost to treat them in hospital. The results achieved by the centre are excellent and I understand that in four years not one patient has been obliged to undergo an amputation procedure. Patients' blood sugar levels are monitored at the centre and the level of control is excellent. In addition, attending there is far more convenient for patients. Some of the larger hospitals in Dublin have 8,000 or 9,000 people with diabetes attending their outpatient departments. Why are these individuals attending hospitals when they could attend their GPs and be cared for, in the main, by practice nurses?

These are the matters to which we are giving consideration. We are determined to make the changes to which I refer. I accept that these will require alterations to the way in which consultants, NCHDs, nurses and GPs work. The country is in a difficult position — although in light of the progress that has been made, the position is not as difficult as was the case when the Government entered office — and it is incumbent on all of us to put our shoulders to the wheel. It is particularly incumbent on those who are leaders in institutions such as hospitals, etc., to put their shoulders to the wheel, to lead by example and to show others the way. We are all in this together. As stated, no part of the health service exists in isolation, no man is an island and no body in society can state that it does not have its own share of responsibility to bear in the context of rectifying the situation in which we find ourselves.

I thank Senators for their time and look forward to answering their questions.

The contributions of each of the spokespersons for the various groups will be limited to seven minutes. That is a limit which I will strictly enforce. Thereafter, other Senators will have one minute in which to pose their questions. They should not make speeches because that would not be fair to other Members. On a previous occasion, I wanted to ask a question on fisheries but I did not get the opportunity to do so because the time ran out owing to the fact that everyone who preceded me was too leadránach. It is important, therefore, that spokespersons should make all their points in the seven minutes available to them and that other Senators should use their 60 seconds to ask questions rather than making speeches.

On a point of order, surely all Senators are entitled to make comments on the health service.

The Senator is already wasting time.

I will waste time if I so wish. Is the Minister afraid to answer questions in the House?

This has nothing to do with the Minister. It is a question of the way the business for today was ordered.

Is the Minister being protected? Is he afraid to answer questions about Roscommon County Hospital.

The Senator is wasting time.

I am being silenced.

The Senator makes a great deal of noise for a man who has been silenced.

I call Senator MacSharry.

I want the Minister to answer questions in respect of Roscommon County Hospital. However, I am being prevented from asking those questions.

The Senator has already wasted most of a minute. His time is exhausted.

I welcome the Minister. I have never doubted his personal commitment in the context of transforming the health service, nor did I doubt the commitment of the previous Minister, Mary Harney, or that of her predecessor in that regard. When I sat on the opposite side of the House, I had no difficulty uttering robust comments if I perceived that things were not being done correctly, that something was unfair or that money was being wasted. I assure the Minister that my position will be absolutely consistent in the context of what I am about to say in respect of the health service.

I fear that the Minister's pre-election position and that of many of his colleagues has changed. Both the country's budgetary position and the difficulties in the health service have been clear for some time. As the Minister correctly pointed out, if money alone could solve the problem then we would have the best health service in the world because we invested billions of euro — more than 50% of the tax take — in the health service over the years.

The first criticism I wish to make — I made it on a daily basis when Mary Harney was Minister — is that it is inconceivable that we give more than 50% of our tax take to a third-party organisation that operates at arm's length and tell it to run the health service with that money. That is wrong. The Minister replaced the board of the HSE when he came to office. I am of the view that he should now assume responsibility for the budget to which I refer because he, as the people's representative, should have control of it. When I write to the Minister in respect of a budgetary matter relating to the health service, it is not acceptable that I receive a reply which states that under the Health Act 2004 which, I accept, we all supported, the CEO of the HSE now has responsibility for such matters and that the Minister has written to him to ask that he respond to me. That is not acceptable to people who are members of Fine Gael, Fianna Fáil or the Labour Party or those who are apolitical. I believe in the Minister's commitment to change the system. I want him to change it and I would be doing no one a service if I did not attempt to hold him to account in that regard.

I am not interested in political point-scoring. However, the commitments given in the lead-up to the election — regardless of whether these were made by Senator O'Keeffe, in respect of a centre of excellence in Sligo, the Minister for Education and Skills, Deputy Ruairí Quinn, or the leader of the Labour Party and Tánaiste and Minister for Foreign Affairs and Trade, Deputy Gilmore — were reprehensible. The commitments relating to Roscommon County Hospital and many other aspects of the health service were also reprehensible. It was patently wrong for anyone to make the type of commitments to which I refer. I recall people going around wearing T-shirts with the legend "Save our cancer services" emblazoned on them. Such T-shirts also exhorted people to give their first preference to party X or party Y because it was going to do its supporters proud and return what had been stolen from them.

That was wrong. It is politically criminal not to state it should not have been done. Unlike other colleagues, the Minister of State, Deputy Perry, hung up the telephone on a radio interview when it was put to him. I know the Minister will not do so. I ask him to do justice to the people and state it should never have been said that a centre of excellence for cancer services would be built in Sligo when it was never going to happen.

What is the up-to-date situation on follow-up mammography in the parts of the country where people are expected to travel many miles for services? Commitments given by Professor Keane and countless people in the national cancer control programme have been welshed upon as have pre-election commitments. The women of the north west and other parts of the country need to know the position on this. The programme for Government includes a commitment to extend the age limit for BreastCheck to 70 years. This needs to be done; when will it happen? Medical politics, intra-hospital, intra-discipline and from one professor to another, would put the politics and internal hand-to-hand combat in political parties such as Fianna Fáil and I am sure Fine Gael and the Labour Party in the ha'penny place. It is reprehensible. I have no doubt Senator Crown could give us an insight into some of this because he has great expertise in the area.

The report written by Hannah Magee on changing cardiac catheterisation health throughout the country has the ambition to have a stent in place in heart attack victims within 90 minutes. Professor Kieran Daly of UCHD is implementing the recommendations made in this report and it is honourable that it is being done. Again, centres of excellence are proposed in Dublin at the Mater Hospital and St. James's Hospital and in Galway and Cork with stepdown facilities in Limerick and Waterford and the usual gaping void north of the line from Dublin to Galway and in the south west. Is it the policy of the HSE and by extension the Government that the people of these parts of the country should either move or die? The people in Limerick had better make sure their heart attacks occur between 9 a.m. and 5 p.m. from Monday to Friday as otherwise their survival chances are reduced. I always use the analogy from George Orwell's Animal Farm that all people are equal but when it comes to health in this country some are more equal than others. This is wrong.

With regard to pathology, where is the report which stated pathology services would be centralised? This would make sense as blood tests taken by GPs would be sent to a centralised location. It also proposed that pathology services in many hospitals throughout the country would be wound down. I am not a physician and I look to Senator Crown and others with medical expertise, but I must ask how it is possible to have an acute hospital in an area without pathology facilities. I am told this is being proposed and I ask the Minister to clarify it.

It may well be a good idea to bring in outside managers to hospitals but people are already in place to manage them. Granted, this is not the case with regard to the CEO of UCHD but other hospitals in the HSE west area have management in place. What will happen is that other managers will be brought in to show them how to do the job. This is ridiculous in the extreme. At the outset, the Minister clarified that the budgetary situation is dire. I agree with him and I do not envy him his task nor doubt his commitment, but how in God's name can we keep a straight face while telling people the budget is a problem but the HSE will pay from its own resources to bring in management consultants to explain to people how to do their jobs? It is ridiculous. The money is needed for the 429 patients on trolleys throughout the country today.

Some hospitals are better than others in dealing with budgetary constraints put upon them and one of these is Sligo General Hospital and I would like the Minister to acknowledge this. Today, only two patients are on trolleys in this hospital. It has managed its budgetary situation exceptionally well in recent months. It is probably not there yet but it is getting there. The former Deputy, Eamon Scanlon, announced Sligo General Hospital was one of the 15 hospitals short-listed to be a colonoscopy centre. The Minister of State, Deputy Perry, went further and announced it as one of the 12 centres for colonoscopy screening throughout the country. When will this screening begin and from where is the money coming? It is estimated it will cost the hospital €250,000 to bring its facilities up to scratch and another €250,000 a year to run the service. Capital expenditure is required and no doubt if the money is available within HSE resources for outside management consultants I am sure it is there to facilitate this service.

The Minister stated that small hospitals throughout the country will not be downgraded in any way. It is appropriate to use the example of a hospital in the Leas-Chathaoirleach's constituency. What does the future hold for Bantry General Hospital? Will the medical assessment unit continue to operate on a 24-7 basis? Will similar hospitals continue to operate in the manner outlined by the Minister at the beginning of this debate?

I thank the Leader of the House for facilitating this debate. I love what he is doing with the Seanad and he knows I am his biggest fan. However, a general debate on health requires 20 minutes for spokespersons. I know the Minister has a busy schedule and that there is an election on today but two hours is not sufficient for a general debate on health.

I acknowledged Finola Cassidy of the Irish Thalidomide Association who is in the Visitors Gallery. The issue was first raised in the House almost 50 years ago in 1962. As stated in the programme for Government to which the Labour Party contributed, I hope the issue can be dealt with and advanced decisively.

I welcome the Minister to the House. I ask the House to bear with me as I have the flu. I hope I will be able to finish my speech.

As a member of the Oireachtas Joint Committee on Health and Children for the past six months I can confirm to the House that very constructive debate has taken place on a number of policy areas and the Minister has attended and briefed the committee on a number of occasions. Many issues face the health care sector and it is important to highlight a report presented to the committee. According to this report, in the period 2000 to 2010, the annual number of patients treated in public hospitals increased strongly, reflecting an increase in population. The key statistics confirm that the number of inpatients and day care patients treated increased by 67% from 788,000 to 1.32 million per year; outpatient attendances increased by 78% from 2 million to 3.5 million per year; and births increased by 36% from 54,789 to 74,729 per year.

The report also states the number of acute hospital beds per 1,000 population in Ireland has decreased since 2000, as has the average length of stay. Given the increased demand for acute hospital care the occupancy rate for acute beds in Ireland is much higher than the OECD average. Also according to the report, the resources available to acute hospitals to treat patients have suffered significant reductions in recent years and this is making it more difficult to treat the increasing number of patients presenting for care.

The total number of doctors working in Ireland is significantly below the OECD average on a population basis. This gives rise to significant pressures in the delivery of primary care and acute hospital services. This is what the Minister inherited along with a shortage of junior doctors and a serious reduction in the number of applicants for new consultant posts.

It was wrong that the HSE encouraged junior doctors to travel to Ireland without first having in place an agreement with the Irish Medical Council as to how they would be registered to practise. I make no apologies for having highlighted this issue in the past four months. I was delighted to see that on the day the Minister, the Irish Medical Council and the HSE appeared before the Oireachtas Joint Committee on Health and Children a memorandum of understanding was signed between the Irish Medical Council and the HSE on how all future recruitment and registration of junior doctors would be managed with clear boundaries agreed between the respective organisations.

The key issue that needs to be tackled is why the vast majority of the more than 500 graduates per year we produce from our universities leave the country within two years of graduation. I am delighted some progress has been made in that all of the parties involved including the HSE, the Irish Medical Council, the medical training organisations and universities together with the consultants and NCHDs are to meet in the coming weeks to look at developing a long-term strategy to deal with this issue. I wish them well in their deliberations and I urge the Minister to do everything possible to ensure we reverse the trend of Irish graduates leaving the country so soon after graduation. On the issue of hospital consultants it appears that we may be facing another crisis. In 2008, 130 consultant advertised posts received 649 applications, or more than five applicants per post. There were only 214 applicants for the 133 posts advertised in the first six months of 2010, or an average of 2.2 applicants per post. In the second half of 2010 the number of applicants for jobs decreased further. In 2003 the national task force on medical staff recommended the establishment of 3,600 hospital consultant posts by 2013 and a reduction in the number of non-consultant hospital doctors. The most recent HSE figures submitted to the Joint Committee on Health and Children on 6 October indicated that the number of consultant posts in the public health system stood at 2,506 in September 2011. Based on the 2003 recommendations there is a deficit of 1,100 consultants compared with the target set for 2013. In the interim the population has increased above the level anticipated in the 2003 report.

I thank the Minister for the work being done in Cork but I will not speak about this issue in depth because I wish to speak about health care reform. A number of targets have been set by this Government to reform the health service, including the introduction of a universal health care package. Despite the many problems which the Minster has faced over the past six months it is important that there are no delays in the implementation of this long-term policy. It is also important that we continue to develop new strategies to provide a more efficient health care service and, in particular, we should put in place a comprehensive policy to deal with computerisation of GP practices and hospitals to make sure that over the long term each sector of the health service can access information without delay. The patient medication card which in Denmark offered savings of over €1.8 billion by 2008 is now being introduced in Germany, which has a population of 82 million. There is no reason we should not set similar goals so that GPs, nurses and hospital doctors can access medical information at the touch of a button, provided they have patients' consent. We can access our bank accounts wherever we travel in the world. We are living in an electronic era and we must move with the times in terms of how we store and access medical information.

Before I conclude I would like to put five questions to the Minister. In June 2011, the HSE agreed to set up a working group to review the current structures for the employment of non-consultant hospital doctors. Did this group meet and has it reported? It was to file a report with Cathal Magee within three months. In view of the difficulties experienced in recruiting junior doctors will the Minister agree to revisit the status of junior doctor posts and work towards increasing the number of training posts? Does he agree that we require a clear target for the recruitment of consultants and will he set out a new five year target?

Given that the majority of nurses have academic qualifications, does he agree there is a need to review the scope of the work they can perform?

There is an urgent need to increase the number of people who are available to provide home help. Many cannot work in this area as they do not have the required experience. Does he agree that the barriers could be tackled by allowing these people to train in local community hospitals under the JobBridge programme? This would increase the number of people available to provide home help and reduce the number of those who require full-time nursing home care.

I thank the Minister for giving up his time to debate these issues in the House.

There are widespread concerns about the adequacy of the home care services offered by the HSE to geriatric, adult, mental and pediatric sectors of society. I am sure the Minister will agree that the standard of service on a small island with a small population is unsatisfactory in the 21st century. There is grave concern about the lack of governance over the standards applied to services once they are put in place. It appears that joined-up thinking and communication are lacking between the Department of Health in Hawkins House and the HSE. This is causing breakdowns in the operation of health services and the implementation of the Minister's objectives.

In my area of pediatric disability, I am only too aware that parents have to fight sections of the HSE every step of the way to obtain the care to which their sick children are entitled from the State. I ask the Minister to imagine what it is like to be a sleep deprived parent who cares for an adored and seriously ill child. The child may be tube fed, which requires 22 hours of attention per day. He or she may need postural drainage every hour or else will be vulnerable to chest infection, reflux or more serious implications. A parent in this situation must fight to arrange meetings with the HSE.

I am not the only person to argue that if the HSE contracted to private care agencies the provision of first rate services the State would make considerable savings and all the stakeholders would benefit greatly.

Will the Minister consider extending to the families of children with serious chronic illness an automatic entitlement to a medical card? Persons over 70 years of age are able to renew their medical cards by signing an affidavit that their circumstances have not changed in the previous year. Ireland's position on medical cards flies in the face of the last two reviews by the United Nations of the provision of child care in Ireland. Both UN reports recommended that any child with a certified illness or disability should be provided with an automatic medical card. In Ireland, however, the child's parents or guardians are means tested and if they fail the test they must either cover medical bills that can cost thousands of euro per annum or call on the support of charities. The parent of a sick child must still pay the ESB bill and television licence. This is a disgraceful state of affairs given that the well-off receive children's allowance without means tests. The moment these children turn 16 they will be granted medical cards in their own right as citizens. Surely a sick child should be regarded in his our her own right.

The only conclusion I can draw is that the Government will protect people over 70 years through legislation but are prepared to let chronically ill children suffer. I might be bolder by suggesting it has something to do with the fact that children do not have a vote. This reform would create a great deal of good will for the Government at no great cost to the Exchequer.

Why does the HSE not have a similar national home care budget for sick children as it has for the elderly? Why are there glaring inconsistencies in the home care packages offered by various HSE areas to the parents of severely ill children? Such services include nursing hours, carers' support, home help and out-of-home respite services.

I could speak about a myriad of cases, such as J. J. Ryan from Tipperary or Matthew McGrath from Gorey, County Wexford, whose mummy wrote to me the other day. To give Senators a feel for her struggle with the HSE, I will quote from parts of her letter. Matthew McGrath, who is now eight years old, was born a beautiful little boy but was infected with meningitis when he was two and ended up with severe brain damage to the point that he cannot see or hear, has to be tube fed and suffers epileptic fits. His mother writes:

In a long battle, I have battled with the health service to secure funding for the last few years to take our son home. It is my constant dismay that parents have to fight for this when firstly, the health board have no alternative arrangements for our children .... absolutely nothing and secondly, when 90% of families want desperately to have their chronically ill children at home, within the family unit, as their basic human right. I am astounded, 6 years on, to still read stories in the media of families fighting to get support to bring their children home. Why does the wheel have to be reinvented each time and at what expense? The meetings held in the hospital with our local community health professionals were a fiasco. Each meeting saw 4 or 5 professionals travelling up to Dublin (at, I suspect, an above average mileage rate) arriving with no suggestions, or proposals and basically saying ‘no' to everything the hospital or family proposed (not that we, the family, were ever included in the meeting process). They show no regard or respect for parents or families of chronically ill children. At the end of the day it was a matter of standing firm and them realising that we were not going to go away so they had to come to some sort of package deal. At this stage of the game these packages should be fairly straightforward and should be offered up to parents .... The list of waste, negligence and sheer apathy goes on and on. Our fight to keep our son at home with the level of support we need to function as a family goes on and on.

I could continue to read from the letter, but I conclude by asking the Minister a final question. According to an internal document reported on in the national media on 14 October last, the HSE is considering radical cuts — cutting home help hours by 600,000 and personal assistant hours by 400,000, providing no further appliances or aids for patients and freezing the issue of new medical cards between now and the end of the year. The same internal document states that these radical measures "will require discussion with the Department of Health before implementation". I ask the Minister to set out the Department's position on these dramatic proposals. According to the HSE assessment, these cuts will increase the demand on the acute sector and the demand for long-stay care in fair deal beds and the number of delayed discharges, will lead to longer waiting lists and accident and emergency waiting times, and will reduce the ability of older people to remain at home.

I welcome the Minister for Health to the Chamber. He probably has the most difficult job in Ireland, if not the world. He has started extremely well. His decisive early decision to disband the board of the HSE sent a signal that he and the Government were serious about health service reform. The previous Government spoke about reform but, in the main, failed to deliver it. The development of cancer services is a possible exception in this regard. As the Minister said, credit must be given where credit is due. One of the problems facing the HSE is that too many people seem to be almost intractable. I have a view on this. Crisis after crisis has emerged since the formation of the HSE. We can expect more crises to emerge as time goes on.

The HSE was established on the basis of a set of assumptions that were not consistent. When it was established, it was considered that the imposition of a centralised system of management and administration onto an unwieldy set of services, without paying much attention to how this new arrangement might work, was all that was needed. A fundamental reorganisation of the services should have taken place at the time, but it did not. I am afraid the legacy of this lack of bold decision-making remains with us. I am glad the Minister has set his face towards reform. It will be a difficult road. All of us should show political courage in this regard. Difficult decisions lie ahead, not only because of this country's financial position but because the health service needs to be reformed.

It is not good enough for politicians from all parties in this and the other House and outside the Oireachtas to start raising fears among the public for narrow party political ends. We have seen too much of this. There was an example of this earlier in the summer when some of the public comments of politicians were nothing short of disgraceful. I understand that all politicians strive to protect the services of their local hospitals and fight to ensure services are not taken away from them, but surely their arguments must be evidence-based. If evidence suggests that a particular hospital needs to have its services reduced, all honest politicians have a responsibility to support such a decision.

It would be easy for me to stand up here and criticise the HSE. The temptation to do so is not easy to resist. I will not criticise it. The time has arrived — it was long overdue — for us to deliver real improvements in these services. I am aware that longer term proposals for a universal health care model are in the offing. We need to achieve real results on the ground. We cannot wait for two or three years to see these real results.

There have been some very good improvements recently. Things seem to have improved significantly at Tallaght Hospital, which had been the subject of some fairly bad or poor public comment earlier in the year. In his response, perhaps the Minister will comment on how these improvements have been achieved. He mentioned the appointment of a special delivery unit, which is a very positive step. We look forward to early results in this area. I smiled when the Minister mentioned that the director of the unit was a philosopher. I think the Minister and the director will need to be fairly philosophical in their future dealings with the health service.

The staff of the HSE are doing tremendous work. I was a front line worker until I was elected to this House. I know what it is like to hear everyone criticising the HSE and its staff. It is very demoralising for people who often work in very difficult areas, to hear constant and mostly uninformed criticism of their endeavours.

I will focus on two issues. The moratorium on staff recruitment is having a considerable impact on front-line services. I am particularly concerned about mental health services because many people, especially nursing staff, are expected to retire from those services by next February. It is feared that the exciting plans outlined in A Vision for Change will be put on hold or will not be realised in their entirety. Given that mental health services have historically been underfunded and neglected, we should show purpose and intent by considering exempting the mental health services from the worst of the cutbacks coming down the road.

I have already mentioned the universal health care model. It is vital that we end the two-tier health care system that has been allowed to evolve here. It is inequitable and downright unfair. The two-tier system is not becoming for a country that proclaims itself to be a republic. We need to drive on from here. We need to face down the powerful interests that are at work in our health services and would prefer to maintain the status quo. We need to show political courage when we do this.

Some of my colleagues will put some questions to the Minister later in this debate. I congratulate him on his good start and wish him well. I offer him my support and that of Labour Party Senators in this House. He will continue to enjoy that support as long as results are being achieved. However, I should mention that the Minister is not entitled to that support in the absence of results.

I give the Minister, Deputy Reilly, a particularly warm welcome. It is critically important to understand that he has a set of credentials that distinguish him from his three most immediate predecessors. I will not personalise this other than to say that the aggregate work experience, in any part of the workforce, of the Minister's three predecessors in this portfolio was four years. I do not refer to their experience of working in the health service — I refer to their total experience in the workforce as a whole. Although I am totally in favour of the concept of civilian control of all technical aspects of health care, it is a very positive development to have a Minister who understands the problems in the health service at first hand — he does not need to have them filtered by the opinions of the professional bureaucracy — and has a clear set of plans to address them.

I will use several matrimonial analogies during my brief speech. The first of them is to remind the Minister that we are on our honeymoon. I wish him all the best. He will hear little harsh criticism from me during the first year after his ascent into office. I think he needs a full year to get all the ducks in a row. I will strongly support him as he tries to address the various problems. If I sense during our honeymoon that the Minister has been taken captive by the Civil Service, I will be available to ride to his rescue. He might find the odd criticism being addressed along those lines.

I will make an historical point before I ask some questions. I have made it in this House previously. Much has been said about the advances made in cancer care in recent years. Those advances were made by Deputy Noonan. He was the first Minister for Health to announce publicly — he did so on his first day in this portfolio — that this country's cancer services were a shambles. The speech he made was inspired by one I had made and published in a previous circumstance. He made a number of very telling points that needed to be made. He set the wheels rolling for the reform of cancer services.

The first of my questions relates to the reported management deficiencies in the HSE. They led to the Minister's decision to appoint private management consultants to oversee the functions of Merlin Park, Portiuncula, Roscommon and Ennis hospitals, and to run the day-to-day operations of the university hospitals in Galway and Limerick. I have a specific question and a more general one. Is the Minister at liberty to go into some of the details concerning some of the specific management deficiencies he found which needed this rather radical surgical intervention?

My second question brings me to an issue which I believe and hope will be a theme of the Minister's tenure, that is, the difference between management and leadership. Those of us who have studied for MBAs have come out of them with varying degrees of enthusiasm for what we learned. One lesson that stuck with me when I did the health care MBA was that there was a real difference between management and leadership. Historically, we have had zero leadership in our health service. It has been top heavy with management but has been heavily deficient in leadership. The difference is, as they say, that leaders do things right while managers do the right things. Leaders make policy while managers implement policy. Much of what passes for leadership in the health system has, in fact, been a cult of high-end managerialism. I refer specifically to the issue of clinical directorates. I believe that we have constructed no leadership positions for doctors within our health service. We have constructed a series of management positions for doctors where they may have authority over who does what outpatients' slot or who has access to which operating theatre, but no doctor in Ireland can hire or fire another doctor. This is wrong. It is not the way that the best health systems, hospitals or academic institutions in the world work.

The most classic example was given by the former director of the national cancer control programme who famously said, when he refused to meet local representatives who were discussing the deployment of cancer services, that he was not there to make policy but to implement it. That is fair enough but we do need people who can lead and develop policy, people who have some inspiration and vision to do this.

Setting up a new bureaucracy — the special delivery unit — is not the answer to waiting lists in the health system. The Minister speaks eloquently of the new systems that will identify those areas where there are waiting lists, but I can tell him where they are: it is in Ireland. We have a six year waiting list for obesity surgery. We have up to two year waiting lists for some elective specialist appointments in different geographical areas. These problems are not of the Minister's creation but they all have one core item. There is a grotesque deficiency of the specialists who are needed to provide those services and a grotesque deficiency of the facilities they need to do them. There is no contractual reason for this; it is simple arithmetic.

We have heard that we are below the OECD average. I would like to tell my esteemed colleague, however, that we are not below the OECD average, we are at the bottom of the OECD average for all these medical ratios. The only thing which makes it look better is that we have such an inflated number of junior doctors which are counted in those.

With great respect to the Minister, it is widely felt that the reforms that were introduced in Northern Ireland were not durable in their outcome. There was a short-term bump in the efficiency of certain aspects of the system, which is also grotesquely under-resourced. I am sure the Minister understands that the only thing which saves the reputation of staffing levels in our health service is that the second worst in the OECD are our near neighbours and the only country with which we share a land frontier, Her Majesty's United Kingdom. The UK has the second worst provision for the number of specialists per head of population of any major health system. We need to set our bar higher than to say that if the British have done it in Northern Ireland, then we can do it here.

I have a few quick technical questions for the Minister. I will not read the entire text for my colleagues although we can make it available. I have asked the Minister to clarify the future plans for the redeployment of paediatric diabetic services. This is in response to multiple overtures which I have received from concerned professionals who believe that the care and future health of young diabetics in Ireland is being compromised because we do not have this.

My next point relates to a matter on which the Minister could make his name internationally. The former Minister, Deputy Micheál Martin, did a very good job in introducing the original smoking ban which was a policy-changing event which made world headlines. We should go one further by picking a date sometime ten to 12 years from now and say it will be illegal to import, manufacture, sell or distribute tobacco products. If we invented tobacco tomorrow it would be illegal. The only reason we tolerate it now is because of the existence of a large number of addicts who are fed by very well-off pushers in the tobacco industry. There is no ethical obligation on us to sustain self-destructive addictive behaviours for the benefit of drug pushers. That, distilled to its core, is what the current discourse on tobacco is all about. I urge the Minister to pick a date and agitate with our European partners to do the same. Make it 2025, or whatever deadline, to make Europe tobacco free.

I ask the Minister sometime during his tenure to get colleagues in the Department of Education and Skills to pay attention to the notion that we have a profound abnormality in the way we structure our medical schools. We have six medical schools for a population of 4.5 million, which is approximately twice the European average and three times the North American average. I believe it is the highest average in the world with the possible exception of some small Caribbean islands whose economy basically revolves around one or two medical schools.

On the flip side, none of these schools has anything remotely approaching the faculty levels which we would find in international medical schools. Although I am having trouble getting the numbers, on aggregate, Ireland has approximately 100 to 120 full-time consultant level positions to staff the six medical schools. The Harvard medical school has 1,500. This is a health education system which is cobbled together on the basis of voluntarism. The system is not immune to the criticism of being extremely self-interested and one which I believe outside agencies will need to examine.

I have one last technical question. Why is the Department of Health's administration budget expanding by 16%, with a 92% increase in travel and subsistence, at a time when the numbers of officials are supposed to be decreasing?

I wish the Minister the best in reforming the health system. It is a fantastic challenge and I will do everything I can to support him in it, but I ask him to try to set the goal of reforming it in the lifetime of this Oireachtas. The plan to introduce universal social insurance mixed with private health insurance is not the Dutch model, but is really the German model. A mixture of public and private insurance is being proposed. I am sorry if I am being vulgar, and I have made this analogy before, but stating that this will not be introduced until after another election is like promising a young bride that one will be faithful to her after the first five years of marriage. We need to make it a policy that we will do it within this Oireachtas and will reform the health system while the current Minister has control over it. He will have my 100% support at every stage along the line in trying to implement that level of reform.

As about 17 Senators are offering to speak, will we take some more questions first?

I think I had better deal with the questions that have been posed.

If the Minister so wishes, bearing in mind that we have one hour and there are 16 questions to be asked.

I thank all the Senators for their contributions, including the questions they have asked. Many of these questions are of considerable interest to people. Even though I know it has not been raised directly, I would like to address the issue of thalidomide survivors. I know the question will be coming from Senator White in any event. I also know that some of them are here today in the Visitors Gallery, as we have already acknowledged. I welcome them to the House. I met the Irish Thalidomide Association and, separately, the Irish Thalidomide Survivors Society in July. I informed both organisations that my main concern was to address the health and personal social care needs of survivors living in Ireland. I have now written to both representative organisations to inform them that the parameters of a HSE health care package are being drawn up by officials in my Department and in the HSE. My Department will be in touch with the organisations when we are in a position to discuss the details involved.

As I have previously outlined in the Oireachtas, Irish survivors of thalidomide receive a monthly payment from my Department. Because the thalidomide drug was manufactured by a German company, they also receive a monthly payment from a German foundation. All these payments are tax free and, on average, they receive a tax free payment of €26,000 each year or €2,166 per month. The commitment in the programme for Government is to reopen discussions with survivors and that is what I am committed to. At my meeting with the Irish Thalidomide Association I said that I would have to be guided by legal advice regarding the State's liability. The Attorney General has confirmed that the State has no legal liability in this matter. Notwithstanding this position, however, I want to enter into meaningful discussions around the financial gesture of good will towards Irish survivors of thalidomide. This would be in addition to the health care package already mentioned.

However, none of us can ignore the severe financial challenges that the health service is facing. The likelihood is that these challenges will increase next year and continue, unfortunately, for the foreseeable future.

May I be forgiven if some of my replies do not reflect the chronological order of the questions asked? If I were to answer them chronologically, I would have to cross-reference them with my notes.

Senator MacSharry raised a number of issues. I thank him for support. He mentioned taking the Vote back. I am certainly considering the restructuring of the HSE and its abolition. In the course of doing so and in creating a new structure, the Vote may well return to the Department, to be disbursed thereafter to organisations responsible for smaller budgets.

Professor Hannah Magee's report, Changing Cardiovascular Health: Cardiovascular Health Policy 2010-2019, was produced in June 2010. This policy established a framework for the prevention, detection and treatment of cardiovascular diseases so as to ensure an integrated and quality-assured approach in their management, and to reduce the burden of these conditions. The policy proposed that cardiac and stroke services be reconfigured on a network basis at hospital and emergency care levels. It also involved an improved ambulance service so 80% of patients would be brought directly to the appropriate centre for initial treatment within the accepted critical timeframe.

Central to the network concept was the principle that every hospital should deliver a range of cardiovascular services either on site or in formal partnership with others. Acute and national specialty services would be provided in a smaller number of comprehensive centres to ensure the high-volume 24-7 throughput that is required to support rapid, responsive and accessible quality care.

The report recommended that emergency percutaneous coronary intervention, PCI, be delivered within 120 minutes of first contact with the patient and that this service be available on a 24-7 basis in a small number of centres, sited to maximise patient access and workforce expertise and coverage. Where it is not possible to meet this deadline, patients should be assessed for thrombolysis as soon as possible. The report recommends that designation of cardiac networks providing diagnostic and interventional services include non-invasive diagnostic imaging facilities, in addition to echocardiography, catheterisation and angiography.

The report referred to the role of comprehensive cardiac care services providing interventional investigation — intervention refers to cardiac catheterisation and stenting — and treatment over the working day, and stated some will provide 24-7 catheterisation, including stenting and PCI for acute myocardial infarction. The facilities needed in addition to those for general cardiac centres include two cardiac catheter laboratories as a minimum, with 24-7 availability.

The national clinical programme in the HSE has considered the requirements for patients in the north west. The population in the north west needs a permanent catheterisation laboratory to allow for local diagnostic angiography and initial assessment of non-ST segment elevation myocardial infarction acute coronary syndrome, non-STEMI ACS, patients. Based on 2008 HIPE data, there are 225 patients from Letterkenny and 162 from Sligo per annum. The laboratory should be located in the north-western region.

The number of patients with STEMI — major heart attack — is small, amounting to 47 patients from Letterkenny and 46 from Sligo per annum based on the 2008 HIPE data.

The national clinical programme for ACS is developing a clinical protocol with the ambulance service for the country to allow the appropriate treatment and transfer of patients. The protocol will set out the clinical circumstances where patients are safely treated locally — I refer to thrombolysis if the history is short — and the clinical need for transportation to a primary PCI centre. The primary PCI centres available for patients from the north west will be located in Galway and Dublin.

The available data for the affected population militate against a justification for a 24-7 primary PCI centre in the north west. It should be noted that such a centre would require two catheterisation laboratories, along with at least five cardiologists, on-call nursing and technical staff. In view of this, the HSE is considering cross-Border co-operation, in respect of which discussions are ongoing with Altnagelvin Area Hospital. This is one of many areas of cross-Border co-operation I have discussed with the Minister of Health, Social Services and Public Safety, Mr. Edwin Poots.

On mammography services, we are committed to ensuring that quality and optimal care are paramount in decisions on the provision of services throughout the health system. I announced in June that a follow-up mammography service would resume in Sligo for women who had previously had a diagnosis of breast cancer. In the region of 20 to 25 women in the Sligo catchment area require this service each month. The service will be provided on an outreach basis from University Hospital Galway to Sligo. It is intended that one radiographer will attend Sligo General Hospital on one day a month to undertake follow-up mammograms for women in this area who currently travel to Galway. To do so, it is necessary to increase the complement of radiographers in the Galway service.

While a recruitment pause is currently in place within the HSE, it has introduced an exemption process to enable priority posts to be advanced. The HSE has advised that two radiographer posts for Galway have been exempted from the recruitment pause. I am advised that interviews for these positions are scheduled for 21 November. The date for the resumption of follow-up mammography will clearly be determined by the date on which the additional radiographers are appointed and able to take up their positions.

A number of Senators asked about Galway and Limerick university hospitals. The HSE has identified a need to have available from time to time senior executives, either team-based or individuals, on a short-term basis to strengthen executive teams, lead a project or programme, provide an injection of skills that are required, or assist in the transformation agenda set by Government.

In June 2011, the HSE invited tenders from potential service providers to compete for appointment to a four year framework agreement for personnel placement and supply services. Under the framework agreement, service providers can be asked to source and supply either senior interim managers or more long-term senior management candidates. At present, the HSE is focusing on putting senior interim managers in place. The tender process was completed and approved in late August 2011 and the framework agreement was established on 8 September 2011. Five companies have been appointed under the agreement. On 10 October 2011, the five companies were invited to participate in a mini-competition to source and propose candidates for an interim management support structure for HSE west. These are being evaluated. The competition closed last week and we hope to make decisions very shortly. This is a HSE process rather than a departmental one and is about strengthening the performance of acute hospitals, which play crucial roles within our health service.

I do not want this to be misinterpreted by anybody. I am fully supportive of this initiative. I said the SDU would support clinicians where they are having difficulties meeting targets and where their lists are growing longer. The SDU should be in a position to provide recommendations on helping management. It does not involve a witch hunt but a method of supporting management and filling gaps where they exist, as they do in Galway where there is no CEO. We need to bring our management up to speed.

Senator Crown spoke about management versus leadership. The real problem is that of management versus administrators and of administrators being promoted to management without having been given the necessary skill set to do the job. It is not their fault but we need management. We will support management by bringing in outside management to help. The SDU has at its disposal the National Treatment Purchase Fund. The moneys therein will be used in very different ways than they were used heretofore. Some may still be used in the normal way, that is, to buy services for patients, but other moneys will be used to fund initiatives to address underlying problems, in emergency departments, hospital management, etc., to make the recommendations that work. It is a matter of thinking differently, thinking outside the box and examining circumstances before acting. That has been the real boon of the SDU.

I take on board what Senator Gilroy said and thank him for his support. I agree that I do not deserve that support if I do not deliver. The SDU is key to delivering what I have promised.

I have full confidence in those involved. They have made great strides to date. I will attempt to explain much of what we are doing now from a gardening or farming point of view. One does not realise that one did not do things correctly in the autumn until the spring when the crop does not grow. We must do things now to reap the rewards in January and February next year and further down the line. I am pleased that this arrangement is now in place and I hope people will learn from the process and will be empowered by it rather than intimidated or undermined.

I have dealt with questions Nos. 29, 27 and 26 but if I have left out any answers I will come back to them. I was asked specifically about the future of Bantry General Hospital. It is in a particular, isolated geographical area and it requires a different approach to that of other hospitals. It is part of the smaller hospital framework document, which has not been finalised. However, I gave an undertaking that there would be proper communication. By this I do not mean sending out leaflets informing people what is happening, I mean consultation with the doctors in the hospital and the community and with politicians. We will lay out clearly for people what exactly is happening so that they can be satisfied that their concerns have been taken on board and that there is an organised plan with timelines that can be adjudicated on. This is not 100% complete and I am not in a position to go into the detail because that would undermine the process I have just outlined.

Senator Burke asked a question about non-consultant hospital doctors, NCHDs, and how to reduce the numbers leaving. I have a particular interest in this area and I have a formal answer to the question as part of question No. 35. I am concerned that we have many young doctors in the country who believe this is not the place for them to pursue their career. There are myriad reasons for this. Part of the cause is down to their senior colleagues and the way they are treated. Part of it is down to management and they way they are treated. Part of it is down to the lack of a clear career path.

In this country people must wait for someone to die or retire before a consultant post becomes available whereas in other countries they go through a training procedure and then they are qualified to practise as a specialist consultant. I want that to happen here and I want to create a new specialist grade in order that when one finishes one's specialist registrar training, one is eligible to apply to become a consultant. If no consultant posts are available the people concerned are forced to leave these shores. They leave at a time when their families are growing and then when it is time to come back their children have reached the critical age of 12 years. I gather from talking to most people who have gone abroad, that once their children become teenagers most of them have no wish to come back to Ireland because they believe they belong somewhere else and this makes life difficult.

Apart from that, there is the idea that we should consider some form of retention of our medical students when they qualify in order that we get two or three years during which they would repay the taxpayer's investment in them. It costs approximately €150,000 to train them. Let us consider how much money we invest by the time they become specialist registrars. It is closer to €1 million but we are not holding on to them; we are pushing them away. I wish to cease this and bring in a specialist grade whereby they can become autonomous clinical specialists answerable to the clinical director but independent of other consultants. Such people could have a clear career path whereby in four or five years they would become consultants. That would be subject to peer review and publications in journals and so on. In other words, I wish to make clear to people here and to any doctors who might be listening to the debate that this would not be like the English grade which is a no man's land where one never gets out. This is something entirely different, another step along the path to becoming a consultant and one that would be beneficial to our doctors and service. We will have the expertise of these highly trained individuals here. I need not say a gret deal more about it.

The issue of medical students and the number of medical schools in Ireland was raised. Senators will forgive me from crossing over ahead. The allocation of college places to prospective students is not within the remit of the Minister for Health. Under legislation, the universities are autonomous and academically independent institutions and they reserve the right to determine their own selection and admission criteria.

In 2006 the Government agreed to a programme of reform of medical education and training which included a phased increase in the EU intake in Irish medical schools at undergraduate level from 305 to approximately 725 students. The current EU intake in Irish medical schools is 705.

Under the Medical Practitioners Act, the HSE has responsibility, in co-operation with the medical training bodies and after consultation with the Higher Education Authority, to undertake appropriate medical practitioner workforce planning for the purpose of meeting specialist medical staffing and training needs of the health service on an ongoing basis. This includes assessing on an annual basis the number of intern training posts, the number and type of specialist medical training posts and the need for and appropriateness of non-consultant service posts required by the health service.

The career path of a non-consultant hospital doctor, NCHD, following graduation normally involves one year for an intern, two to three years for a senior house officer, SHO, one or two years for a registrar and up to seven years for a senior or specialist registrar. Typically, doctors who graduate from Irish medical colleges undertake a one year internship in the public hospital system. Following their internship they can apply for senior house officer posts. Alternatively, they can choose to leave the system at that point or at a later stage. The HSE has advised that there is currently no shortage of interns in the public hospital system. However, as Senator Colm Burke adverted to, we have had to recruit doctors from overseas because of the shortage of SHOs and registrars. Some 450 posts were due to be filled in July this year. Most of these posts were in service rather than training posts and it appears that the posts are not attractive to Irish doctors. I am afraid this may be the understatement of the year. They are not attractive to many doctors at all. This is what the new Medical Practitioners Act sets about addressing. We have training posts that everyone is happy to apply for except in the case of one hospital, which I will not name and shame, because no one wants to work there although it is a training hospital. The word has gone out among NCHDs that it is not a nice place to work.

The special delivery unit has been tasked by me to bring in a protocol on behaviour for senior clinicians with regard to how they deal with their peers, juniors, other staff and patients. This is the least we should expect. When I was in Holland I was most impressed by a 500 bed hospital I visited. There was no one waiting in the accident and emergency department, there were no hand washing facilities because they were not necessary since everyone was admitted to a room. We do not have that luxury here but we will work towards it. The hospital has four full-time staff working in customer relations. Every year it runs a day course for everyone in the hospital from the neurosurgeon down to the porter and from the matron to the cleaning staff. They are informed that they represent a business card for the hospital and they had better not let down the hospital.

We need some of this outlook and this is what the special delivery unit will focus on as part of its work. There should be standards of appropriate behaviour. I put it to the staff in my surgery that no matter how bad a day they might be having they should remember that the person on the other side of the desk is there because he or she is sick and he or she is having a worse day. This is the way it must be and we need more of it. Many of the problems arise with those who are unhappy with the service they receive because of the attitude demonstrated, despite the fact that many doctors and nurses work under considerable pressure. It takes only one or two people to give many others a bad reputation. The vast bulk of our people do an amazing job in horrendous conditions and it is my job to ensure these conditions change as part of the reforms.

Senator Burke asked about the group which is to deal with NCHDs and the new specialist grade. The group will meet and I will appoint a chair and it will get on with its work expeditiously. I have referred to the training posts and the clear targets for consultants. This is another issue related to the work and the clinical programmes are assessing it. The acute medical programme has assessed the number of new posts needed. Approximately 25 posts in specific areas will be needed to get the maximum benefit and this work is ongoing.

I am keen to explore the scope of the work nurses do with my Department and the nursing profession. I believe those in the profession are up for change as well. I am pleased that they are beginning to deliver rosters. I am aware that certain people suggest this is a distraction but it is core to the way we do our business. It is not possible to run a health service when someone works their entire working week in three days; that cannot be done. That is from a different time and place. I look forward to co-operation in that regard.

Consultants must change the way they work as well. We have to have an arrangement where consultants are available on Saturday and Sunday to do ward rounds and read X-rays and diagnostic results to ensure patients can be discharged 24 hours a day, seven days a week, not 24 hours a day, five days a week. I am sure there is a great deal of good will and it is forthcoming. I encourage people to co-operate in that regard.

To deal with Senator Mary Ann O'Brien's questions, under the medical card scheme, medical cards are made available to persons and their dependants who would otherwise experience undue hardship in meeting the cost of general practitioner services. Eligibility is based primarily on means and the overall financial circumstances of the adult or civil partner, as well as any dependants.

The review process is an important quality assurance aspect of the general medical services, GMS, scheme which distributes in the region of €2 billion of public funds each year. Two years is the average period nationally for which an individual or a family holds a medical card before a formal review under the GMS scheme. The medical card review process for the over 70s is based on separate legislation and the process has been simplified to facilitate older persons who have not had a change in their circumstances. Where changes in circumstances have occurred, the case is reviewed in the normal way.

I have also taken the initiative to inquire about what happened to the discretionary medical cards issued in the past. Under the previous health board system, the chief executive officer had discretion to issue a medical card where undue hardship was being experienced, typically where somebody had a serious illness, either terminal or otherwise. This extended to children. That facility is gone. Therefore, we set up a new group within the Health Service Executive in the PCRS consisting of four doctors, including general practitioners and community health doctors, to review applications and issue discretionary medical cards. That avenue is now open.

On the broader question of including specific groups which comes up not just in the case of children but in the case of other groups such as the terminally ill, we are trying to move to a position where everybody will have a medical card. We will endeavour to examine and expedite the cases of those who are considered priorities such as the individuals the Senator identified, but I have come to this House having spent an hour with the Minister for Public Expenditure and Reform. We are between a rock and a hard place. Some €1 billion has been taken out of the health budget for this year and we have been tasked with taking more out next year. I am doing my best to minimise this and as such, will not get engage in megaphone diplomacy here. We all have our role to play in that regard, but I am trying to explain that we are not in a position financially to do what we would like to do and that we are not in a position to do what we will do as quickly as we would wish. The situation is unacceptable for many. Many have made legitimate arguments, but, unfortunately, the money is not available to address all the issues identified.

According to the order of the House, we must conclude at 1.45 p.m. Between 16 and 20 Senators have indicated their wish to ask questions. I am conscious, therefore, that we need to start that process by 1.20 p.m. at the latest, if at all possible.

I am sorry; I am trying to deal with the questions raised as best I can.

The Minister should not apologise.

In other words, we are not closing the door to the suggestions made. We will examine them and try to expedite them.

Regarding the national home care budget for sick children, a question was asked about a draft document which indicated we would cut left, right and centre. There is no question of medical cards being taken from people who are still entitled to have them. That would not make sense.

I will try to deal with the remaining questions asked as quickly as I can. Senator John Gilroy asked about Tallaght hospital. I want to be clear about this issue. Everybody knows that the hospital was in dire straits. Representatives of the Health Information and Quality Authority, HIQA, and the special delivery unit were in the hospital in which we now have new management. I pay tribute to Ms Eilish Hardiman because last month the hospital stayed within its run rate for the month, notwithstanding the legacy issue. However, the hospital is in dire straits in regard to its budget. It is way over budget and there will be changes in that regard. As a result of the changes Ms Eilish Hardiman has made, on one day there were no patients on trolleys, while for several days the number on trolleys was four. When I last checked the position yesterday, there were 13 patients on trolleys at 8 a.m., nine of whom had been in the hospital for less than six hours and four for longer. By 2 p.m. there were five patients on trolleys. Therefore, great work is being done in the hospital. What we want to do — what the HSE failed to do in the past — is transpose excellence from one hospital to another. We have the team in place to do this, the SDU, which can show how things have been done in one hospital and transpose the lessons learned to another.

There is a moratorium on staff recruitment. However, we have always said we will make exceptions in particular areas where there is a need. We have done this in the case of mammography services in Sligo. We will examine the mental health issue, but there is a need for change in that service also. There are many psychiatric nurses working in institutions. We could achieve a far better effect and efficiency if institutions were closed and the nurses mentioned were working in the community. I believe they would agree with me in that regard.

I should blush at Senator John Crown's honeymoon comment.

The Minister need not worry; he is not exactly my type.

I believe I covered the question about services in Limerick and Galway in my opening remarks. I cannot go into detail, as it would hamper the work of the SDU. When its representatives go into a hospital, they receive great co-operation and there is honest engagement. As such, if we were to start publishing reports or making public what has been found, people will start to clam up. I do not want to interfere with this.

I have referred to management and leaders. I accept what the Senator said about the deficiency in specialists and also his comments about there being too much reliance on non-consultant hospital doctors, not on senior doctors. That issue is being addressed.

I had intended to cover this issue in my opening remarks, but I will deal with it now because it is very important. The effect of the special delivery unit in the North of Ireland was not sustained for a host of reasons. First, direct ministerial involvement disappeared and, second, the underlying reforms required were not introduced. We will not make that mistake. We will institute the underlying reforms and leave the SDU in place as the guarantor of quality.

The Senator raised another issue about the Dutch——

There are certain elements of the Dutch system that we like, but there are other elements that we do not like. We have looked at the system in Holland in terms of the underpinning of a universal health insurance system. We have looked at the system in Denmark when it comes to having a patient safety authority. We have looked at the system in the United Kingdom when it comes to the hospital model trusts and in the north of Ireland in regard to the waiting list initiative. We are taking what we believe is the best from these systems for use in ours.

The Senator referred to diabetes. An initiative is on the way which, contingent on the availability of funding, we hope to roll out. Diabetes is one of the chronic diseases that must be addressed as a matter of urgency and tackling it is a top priority for us. However, I am not a fan of piecemeal contract negotiations. I want the new contract for general practitioners to be all-embracing and introduced in one fell swoop. I do not want to have to ask what people want to look after patients with diabetes, hypertension and so on. We are not going to go there.

If I have not answered any Senator's questions, I apologise.

In the interests of allowing every Senator to contribute to the debate, I ask Members to confine themselves to questions, not statements.

I will be brief. I seek an update on the 20 bed palliative care unit proposed for Waterford Regional Hospital. When will we see work start on this much needed unit?

In the last capital programme St. Brigid's unit in St. Patrick's Hospital was to be replaced by a 50 bed unit. However, it was removed from the capital programme in the interests of political expediency to allow a similar unit to be built in Kenmare. This was done at the instigation of Deputy Healy Rae in order to gain his support at the time. When will we return to dealing with issues properly and without political interference? When will work on the 50 bed unit in St. Patrick's Hospital included in the last capital programme commence?

I thank the Senator for his brevity. I call Senator Terry Leyden and remind members that brevity is the order of the day.

I thank the Minister for coming to the House. He sent to the people of Roscommon before the general election a letter, in which he gave a commitment to retain the accident and emergency service in Roscommon County Hospital. How does he feel about that now, in view of the fact that 44 patients are on trolleys in UCHG and 429 throughout the country? Dr. John Barton, the Minister's dear colleague who wrote his policy document, has suggested he must resign or leave the country because he is not getting enough money for the service at Portiuncula. Is the 24 hour accident and emergency service safe there? In the light of the experiences in Roscommon and elsewhere and in the light of the commitments given by Labour Party and Fine Gael Members, will the Minister consider restoring an accident and emergency service on a 24 hour basis, seven days a week to Roscommon County Hospital? Deputy Denis Naughten resigned, but neither Deputy Frank Feighan nor Senator John Kelly has done so. The commitment given has been broken by the Minister who should feel embarrassed and ashamed.

I will allow two more brief questions before I allow the Minister to respond.

The length of time taken to process medical card applications is outrageous and simply not acceptable. What proposals does the Minister have to remove the significant delays in the central processing office dealing with medical card applications?

Since the cutbacks in dental treatment services in 2010, does the Minister propose to increase the funding available given the extra 120,000 people who have subsequently acquired a medical card? Why is there such a long waiting list for orthodontic treatment for children?

Does the Minister plan to revamp the home help scheme in order that in all cases the needy will receive sufficient hours of care to avoid the necessity of being institutionalised? Home helps have recently been prohibited from administering medication or providing drinks via a peg feed, leaving people in danger of dehydration. Why has this been allowed to happen?

I thank the Senator for her brevity.

I welcome the Minister. Will he clarify his plans to avert the impending staffing crisis in mental health services caused by the loss of 1,000 posts in 2009 and 2010 and the inability, owing to the public sector moratorium, to replace any of up to a further 1,200 staff who are retiring?

I will allow the Minister to respond to the questions put by those four Senators, if he wishes to do so at this stage.

In response to Senator Marie Moloney's question on medical cards, the Health Service Executive has centralised the processing of all new and renewal applications at Primary Care Reimbursement Services, PCRS, in Finglas with effect from 1 July this year. The executive has stated it does not expect major delays in processing applications. Completed applications are processed within 15 working days. Delays occur where applications are submitted without the supporting documentation required.

I am sorry, but that is an outrageous statement. I can guarantee the Minister that an application submitted on 18 September will not be processed until 8 December.

The Minister to continue, without interruption

It may be an incorrect statement, but it is not outrageous.

With due respect to the Senator who asked the question, it was put to Primary Care Reimbursement Services and this is the response it gave.

Is the Minister accepting that answer?

The Minister to continue, without interruption.

As I listened to the Senator, I ask to be allowed to speak.

There is a revolt in the camp.

We will not say what is revolting.

My assistant telephoned the PCRS this morning to check the veracity of this reply. Some 83% of applications are dealt with within 15 working days. However, there can be delays because the information required is not provided. If there are delays of the nature mentioned by the Senator and she can cite a specific case, if she gives me the details, I will be delighted to inquire about it. I am not in the business of misleading the House or the Senator. At the same time, however, I have to accept what is written in black and white.

I will provide the names for the Minister.

I will certainly inquire about the case. I know there were a lot of difficulties, but it is my understanding — I have spoken to the Minister of State, Deputy Shortall, who was also very concerned about delays — the position has improved considerably.

On the long waiting list for children who need orthodontic treatment, this has been a long-standing problem. I could read a long answer, but the bottom line is that we have inherited a problem, which is unacceptable; initiatives put on the table in the past have not been availed of and we are looking at implementing them to shorten the waiting time to at least have assessments made and treatments provided more expeditiously. There is a shortage of orthodontists, but we need to use those available in a more clever fashion than in the past. There have been initiatives taken in the mid-west which have resulted in a significant improvement. I will revert to the Senator on the issue.

Senator Leyden mentioned Roscommon County Hospital. He is right that before the election I gave an undertaking to retain services in the hospital and I did so in good faith. Since the election, however, HIQA reported in that regard and stated it was unsafe. I inquired of it, the clinical programmes, the Department and the HSE as to how we could make it safe and was told we could not, that it was not possible to make it so. Therefore, there was no option but to remove the service. I do not want to get overly political with the Senator, but the bottom line is that while money was spent on upgrading the front of the accident and emergency department, as has been explained time and again by clinicians, what one sees at the shop front is not what makes the shop work. What a person sees in an accident and emergency department is not what makes it safe, but the services that back it up — the presence of a cardiologist with the ability to put in a stent, someone to deal with a fracture or a limb that has been severely compromised as a result of a burst blood vessel, or a stabbing. That is what makes it safe, not the new surroundings. It was not possible to provide for this in Roscommon County Hospital and I have no problem putting my hand up on that point. I told the people that I would take that responsibility and I do.

I will follow up on the other undertakings given and ensure Roscommon County Hospital has a bright future, that it will start to deal with more day surgery cases and have new services. Since we last spoke in this House, plastic surgery services have commenced, with outpatient clinics and day surgery cases being dealt with. There will be capacity to provide for endoscopies and colonoscopies. There are a number of other initiatives planned, into which I will not go because I do not want to go down the road of promising what cannot be delivered. I am now in a position where I have full sight of the system. I know what can be delivered safely in smaller hospitals.

This is part of the framework document on which we are working. When we know which of 24 or 25 services listed that can be safely delivered in a smaller hospital, we have to make them fit the geographical and demographical requirements identified. There is a great future for the likes of Roscommon County Hospital, Portiuncula hospital and the hospitals in Ennis, Nenagh, Bantry and Mallow, as well as all other smaller hospitals, but it is of a different type. We cannot have an emergency department operating 24 hours a day, seven days a week in every hospital. That is not possible and it would not be safe. Let us be sure that when we put up a sign with the words "emergency department", patients can expect to receive care to which they are entitled, not a service with significant variations that have consequences, depending on the hospital one attends.

There are two issues relating to the hospital in Waterford. On the provision of palliative care in St. Brigid's unit, a new unit was promised by the HSE, but it was removed from the waiting list. However, it is now being reviewed again for inclusion in the capital budget. It will be examined in the coming months.

With regard to palliative care, the Government's policy is based on a report of the national advisory committee on palliative care and is primarily concerned with quality of life. It is dedicated to a form of active treatment designed to ensure that patients are enabled and encouraged to live their lives to the greatest possible extent in the manner and the setting of their choice. I propose a vote of confidence in the palliative medicine and hospice movement in this country. Before this movement developed people went to the hospice to die but that is no longer the case. Many people go to the hospice and receive the level of care they need that allows them to return home. Extraordinarily good work is done. The Government is very much committed to providing more palliative care in the community.

The capital proposal is at an early stage and not in the HSE plan. An outline development control plan for the Waterford Regional Hospital site has been produced which sets out proposed future developments at that hospital and where they will be located. Phase 1 components of the plan have been identified and are currently at business stage. This will require approval by the HSE capital steering committee before it can be recommended for the national HSE plan. As the phase 1 indicative development cost is in excess of €35 million, it will have to go through a cost benefit analysis. I could give the Senator a full answer later but——

Perhaps for today's purposes the Minister might hear our views first. We will try to fit in everybody's questions and if there is time at the end we can hear more of the Minister's views.

I nearly made a fatal error, one that would have dire consequence, namely, not reply to Senator Marie-Louise O'Donnell.

The Minister is very perceptive.

Her question primarily addressed the recruitment moratorium, the numbers of people who have left and those who may leave before February. The moratorium is a blunt instrument but we are trying to refine it to make special exceptions in areas where we believe they need to be made. We are caught between a rock and a hard place, given the IMF-EU troika and its requirements of us. It will not bring any comfort to this Chamber but health has led the way in that this area has reduced numbers more than others have. We have also got close to the budgetary requirement of €1 million in cuts, in a manner that most people would not have believed possible. That is cold comfort to patients lying on trolleys and children waiting for surgery. As Minister for Health and as a member of a Cabinet that must live under the troika arrangement, I have to live with a hard reality. This is because of a previous Government that lost us our sovereign financial independence.

There is a great deal of confusion about the February date. The Acting Chairman will forgive me if I spend two minutes on this issue. This is not an early retirement scheme but the ordinary entitlement of any public servant to retire. People reaching a particular age will do the sums and say to themselves, "In February, if I go, I'm going to get my lump sum untouched and X, Y and Z in terms of pension. If I wait till after February the Government has said it will change the rules and we don't know what those rules are yet". They may jump or they may not.

I asked the HSE to do a study on the risks to the system looking at the age profile of people who might choose to leave and further looking at the numbers who made inquiries about pensions, who would be considered to present a higher risk of leaving. I asked the HSE to look at the impact this would have in the various areas and it is doing so. It is impossible to say with absolute certainty what will happen but we are getting a handle on likely scenarios and will make provision for them. In other words, we will not end up with a situation where the entire senior nursing management of a particular institution leaves, with the consequent closure of the institution for that reason alone. There might be other reasons certain nursing units have to close, financial reasons that have nothing to do with this aspect. I will be honest, as I have been in this House and the Lower House. I will tell people when an issue concerns safety, when staffing, when finance. It may not be nice to hear but we will be honest.

In the interests of other Senators, I ask the Minister to reply to my questions regarding home help in writing.

I just received an e-mail; I do not know if any other Senator received the same. It states, "Jesus is back in Ireland". I do not know whether he is but the Minister is doing a good job in the health service. I understand his point about Louth Hospital, Dundalk, doing well. What about the trolleys in Our Lady of Lourdes Hospital in Drogheda? We hear there are 40 patients on trolleys every day.

Last week there were 58.

Senator D'Arcy to continue, without interruption.

A great number of patients are on trolleys every day in the hospital in Drogheda. What is happening in that regard?

I thank the Senator for his brevity.

I welcome the Minister and wish him well in a job that proved so difficult for so many of his predecessors. His problem has more to do with resource allocation than with budgets. I refer, briefly, to an bord snip's report. On page 76, in regard to the health service, it states:

The Group observes that restrictive agreements and work practices, involving trade unions and professional staff organisations, have been a major inhibitor to staffing and pay efficiencies in the health sector, and a block to good quality patient-focused care. The Group considers that such practices have no place in an efficient, modern health system which is operating under severe budgetary constraints, and in which the needs of patients should be of paramount consideration.

Will the Minister respond to that? The numbers in the health service were increased from 68,000 staff in 1997, to approximately 113,000, an extra 45,000 staff, yet the Minister complains in this Chamber that he is short of staff. Who is winding up politicians? The Florence Nightingales in the Irish health service are not serving themselves other than in a very narrow way.

A budget of €17 billion, with 25% added when we pay privately, is a large one by OECD standards. I put it to the Minister that there is too much specialist pleading by the medical sector, all 113,000 of them. The Department did not realise that competing health insurance companies would save it money. Its hostility, towards BUPA in particular, was wrong in terms of the efficiency lost by going for monopoly in that field.

I acknowledge that we are going through a financial crisis but there is one good deed the Minister could achieve in the forthcoming budget. It would not cost much. He should grant medical cards to cancer patients without their having to go through a rigorous means test. From years of experience as a community welfare officer I know that general practitioners wrongly advise cancer patients they have an automatic entitlement to a medical card only for them to be told by a welfare officer that a means test is required. Ultimately, most are granted on discretionary grounds but I would like the Minister to legislate for all. Community welfare officers never wanted to have to ask very sick people how many hens they had and how many eggs they laid.

Does the Minister accept that we have a two-tier health service and that health care may depend on ability to pay rather than on need? Does he support universal health care provision? What steps will he take to put in place a more egalitarian health service?

I welcome the Minister's support for the abolition of the HSE. Will he take on board the Sinn Féin proposal of replacing the HSE with community health partnerships which would be made up in equal thirds of locally elected representatives, advocate groups that campaign on behalf of patients and State bodies? What is the Minister's position on the public service embargo and the impact it is having on health services? Rather than driving down costs in hospitals, hospitals are forced to take on agency staff. We have seen this in Waterford, in the community care hospital in Dungarvan and in St. Patrick's Hospital, where services may be curtailed because of the use of agency staff. Rather than reducing costs the public service embargo has increased them. What measures will the Minister take to address that situation? I advise him to ease the embargo in the health service to enable hospitals to budget their departmental funding in a better way.

I can understand Senator D'Arcy's concern about Drogheda hospital. It is a serious concern for us too. We have put in place this week initiatives around that hospital to support the earlier discharge of patients and more home care. We are considering one or two other options also. The Senator will see an improvement in Our Lady of Lourdes Hospital in the next few weeks and I will keep in close contact with him.

Each of the hospitals of which there are eight — one of them is Galway hospital — have been asked to put forward their plans to resolve their difficulties in terms of what they believe is needed to address the issue because it is important to ask the people who are working at the coalface what they need. As always in life, unfortunately, there is some gilding of the lily. We have examined their proposals and are supporting those that are reasonable and properly costed, and sending back those that are not. It is quite simple.

I can tell the Senator as an aside, that one hospital spoke about an extra four hours in its acute admissions unit, the medical assessment unit, that exceeded another hospital's pricing for increasing its medical assessment by 12 hours a day. There is a little bit of horseplay going on and that will be resolved but the SDU, special delivery unit — people have gone to all these hospitals — asked them for their plans and have gone through the plans with them. I signed off on the ones that were reasonable two days ago in regard to initiatives that will alleviate the situation. We have left the door open for them to come back with their other proposals, but properly priced.

Senator Kelly raised the issue of medical cards for cancer patients. I addressed that in the context of the issue raised by Senator O'Brien. It is an area that should be looked after. Cancer is a terrifying diagnosis for people although, thankfully, not as bad as it used to be in terms of outcomes. Many more people survive now than did previously, but we will do anything we can do to alleviate the problems for people, given that regardless of how wealthy one is there are certain services one cannot access without a medical card. We are examining that and the discretionary group has been instructed that people who are terminally should be considered. However, we must remember the difference between people who are terminally ill and those with cancer. As Professor Crown will tell us, many people who have cancer will outlive the Senator and me. That is not to minimise the diagnosis, but, thankfully, it is not the death it was previously.

Senator Cullinane asked if we had a two tier system. I agree with him 100%. He asked me what I intend to do about it. We have laid out a five to seven year plan. Senator Crown talked about his matrimonial analogy but I take it the other way. This is the first time we have had political parties and a Government mature enough to say that we would love to fix it in one term but we will not be able to; it may take us two terms. We are being honest about that. If we can do it quicker we will, and there is nobody more keen to do it quicker than me. I abhor the two tier system. The American health economist, Mr. James Tussing, who was here when the capitation came in to the GMS for general practitioners, returned six years later and said he was pleasantly surprised that it had not resulted in a two tier system in primary care, yet we have it in secondary care. We are hell bent on addressing that. We are also hell bent on addressing the issue of waiting times.

I want to be positive. I do not want to ignore Senator Kelly's question which I did not hear properly. I am told it was the restrictive work practices and the bias against people. There is no bias against BUPA or Aviva. We want to regularise the insurance market because there are other people coming into it. We want more competition because we believe competition gives better options for the customer. If we introduce universal health insurance one of the things we want to do is reduce costs. I have made it very clear to the chairman of VHI that this must be the focus this year. There will be new negotiations with hospitals and consultants in the coming year and they must focus on reducing costs, and not just reductions to go 10% across the top or to say that those procedures belong in hospital but we want better value for them. Those procedures should not be done in hospital; they should be done in general practice. What are we paying them — a side room fee as well as a consultant's fee? No. We are not paying a side room fee for those procedures; they can be done in general practice. We might even consider, and this may shock some of my consultant colleagues, that they will be paid less if they do them in a hospital than in a primary care centre. We intend to bring the service to the patient and get the best value for money for the taxpayer as well.

There are positive things happening. I thank everybody for their time and interest in this area. They say all politics is local but all health is local too.

There are three or four Members who wish to contribute. Would it be possible——

I cannot, I am very sorry. I have to take two Adjournment matters and then I must be somewhere else at 2.15 p.m.

Unfortunately, there are at least eight Members who have indicated their wish to contribute. That concludes statements. I thank the Minister.

Could our questions be given priority by the Minister's office?

Absolutely. I will respond in writing to all the Senators who did not get an opportunity to ask questions. There is no question about that.

Positive things are happening. We have now a new colposcopy unit in the Coombe hospital. We have allocated it the money to do up its labour suite and its theatre, which were located on two different floors. That was unacceptable. We have the new unit for cystic fibrosis opening in St. Vincent's hospital in April next year but, equally, we have sent the message to the hospitals that no patient should be left waiting longer than 12 months. Anybody who was put on a waiting list last December has to be treated by the end of this December. We are very near achieving that. Next year we will make it nine months and the year after that we will make it six months, then three months. We intend to go about this in a methodical fashion.

As I have said in the past, the special delivery unit has given us the headlights. We are no longer driving around in the dark. Next year will be a better year although a very tough year because at least we will have full visibility over our fair deal money from day one. We will keep it centralised and watch what is happening with that. We will have the monthly and fortnightly reporting on finance systems within hospitals to ensure that if they start to go off we will know very quickly. Equally, we have full visibility over waiting times. I do not want to pre-empt anything but we are making very good headway with consultants in regard to changing working practices that will allow us discharge patients on Saturdays and Sundays, make more patients have access to treatments and more patients treated more quickly.

I thank everybody. I restate my commitment and that of the Government to the health reform programme. Even if we did not have the financial morass we have to endure we would still have had to change the health service because it would have broken us if we were to continue along the same lines.

Thank you, Minister. When is it proposed to sit again?

At 2.30 p.m. on Tuesday, 8 November 2011.