SELECT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 5 May 2005

Vote 40 — Health Service Executive (Revised).

Chairman

On behalf of the committee I welcome the Tánaiste and her officials. We are meeting this morning to consider the Revised Estimates for the Department of Health and Children and the Health Service Executive, Votes 39 and 40. A proposed timetable has been circulated for today's meeting, which allows for opening remarks by the Tánaiste and the Opposition spokespersons, followed by an open discussion on the Revised Estimates in a question and answer session.

I call on the Tánaiste to make her opening statement.

Tánaiste and Minister for Health and Children (Ms Harney)

Thank you, Chairman. I am accompanied today by Mr. Dermot Smyth, assistant secretary in the finance division of the Department of Health and Children, Mr. Paul Barron, assistant secretary in charge of the acute hospitals division, Mr. Pat McLoughlin from the Health Service Executive in charge of the National Hospitals Office, Mr. Aidan Browne from the Health Service Executive in charge of primary, community and continuing care and Ms Frances Fletcher, who has responsibility for intellectual disabilities at the Department of Health and Children.

I do not propose to read an opening statement. I have circulated a statement among the committee members and I will make a few preliminary remarks on it. We will then have more time for engagement at the end. The Estimates take a different form this year as we have two Votes, Vote 39 for the Department and Vote 40 for the Health Service Executive. The HSE has its own Vote for the first time and the creation of this separate Vote brings the highest level of direct accountability for the delivery of health services. The Revised Estimate for 2005 for both Votes shows a total gross Estimate of €11.941 billion for health services.

Vote 39 contains funding for my Department and allows a level of gross expenditure of €401 million and net expenditure of €233 million. The difference is in appropriation which is mainly accounted for by excise on tobacco products. Vote 40 contains the funding for the Health Service Executive, the gross provision of which is €11.54 billion while the net Exchequer funding is €9.555 billion. The total consists of €11.356 billion in current funding and €584.5 million in capital funding. Of the €11.3 billion in current funding, €543 million relates to HSE income not previously included in the Vote. This is due to the move away from an accrual accounting system to a cash-based system which will lead to greater transparency. It consists of the public charges that are raised with charges levied on insurers for private beds in public hospitals. That amounts to €543 million. A further €217 million relates to once-off technical adjustments as the HSE has to show a balance of zero at the end of the year. Excluding these items, which allows us to compare like with like, the increase in current funding over 2004 is 10.8%.

The success of our economy has allowed us to treble health spending in real terms since 1997.

We are fortunate that the success of the economy has allowed us to increase substantially funding for the provision of health services. The OECD reports that Ireland had the fastest growth rate of all OECD countries in spending per capita on health in the period 1997-2002, at 67%. Cross-country comparisons are difficult, but the latest OECD data show that Ireland’s spending per capita on health exceeded that of the United Kingdom in 2002. These data were calculated using the technical measure of US dollar purchasing power parity. The 2004 spending review in the UK showed that total public sector health spending will be £88.6 billion for 2005-06. This equates approximately to €2,200 per person in the UK. Ireland’s total public sector health spending is now about €3,000 per person. Even if technical adjustments are made for relative price levels and to exclude certain categories of spending for cross-country comparisons, our per capita health spending is significantly higher than that of the UK. Our capital budget for health this year is about €146 per person. That is nearly 60% higher than the UK, which will invest about €92 per person.

The governments of major developed economies are discussing what the appropriate level of spending should be. Countries like Germany and France are trying to keep growth in spending to about 2% in real terms. In the UK this rate is approximately 6%. Our growth in real terms was 8%, which is four times the level of that in Germany and France. In Ireland we sometimes underestimate the considerable taxpayers' resources that are being invested in the delivery of health care. The reform programme under way is about ensuring that we have a clearer streamlined way of administering and managing that resource to ensure that we get the best possible value for money and outcome for patients.

There have been record levels of activity in the acute hospital system over the past few years. People are living longer, getting new treatments faster and seeing more specialists. We are living and working in a healthier atmosphere. People with disabilities are finally getting the priority and the support they deserve. We want to ensure that patients are at the centre of all the decisions we make. It is easy to talk about patients coming first, but that must mean that no vested interest can stand in the way of change. We must question those interests that are not prepared to change.

Everyone must participate in this change process, including the Minister for Health and Children, the Department of Health and Children, the Health Service Executive and all those involved in the front-line delivery of services. The clearer role between the Department of Health and Children and its Minister, on the one hand, and the Health Service Executive, on the other, will make it easier to have clear lines of accountability and greater transparency regarding respective responsibilities to measure performance better. I will discuss this point later.

As far as the acute hospitals programme is concerned, €50 million of additional funding has been provided for the commissioning of a number of new units. Nothing annoys people more than seeing new state-of-the-art facilities which are not in operation because the staff are not available to open them. In the context of public expenditure, this does not make sense and probably annoys people more than not having the facilities in the first place.

Inpatient and day case discharges from acute hospitals amounted to 1,040,181 in 2004. This figure represents approximately 2,850 patients being discharged each day. Total discharges for 2004 show an increase of over 33.4% since 1997. Significant investment has been made in additional specialists and diagnostic and investigative processes. Accident and emergency departments in our hospitals deal with approximately 1.2 million cases per year, or 3,300 per day. That is an extraordinarily high figure and given that those are supposed to be accident and emergency units, it is unusually high. To a large extent, the situation in accident and emergency departments is a consequence of some of the deficiencies in the wider health care system.

Frequently, accident and emergency units must compensate for the fact that no out-of-hours GP service exists in certain parts of the country, GPs cannot get easy access to diagnostic facilities or people are waiting for long periods for outpatient appointments. These factors are among the reasons accident and emergency figures appear to be higher than should be the case for a young population.

This year we invested heavily in a number of initiative focused on the resolution of the difficulties — the Deputies present are more than familiar with them — in accident and emergency services. We are making enormous progress with those initiatives. For example, we have acquired 90 intermediate beds to deal with 500 patients which will allow people move to a more appropriate setting from an acute hospital to an intermediate dependancy bed, before going to either long-term care or, more hopefully, back home. We are engaged in discussions with GPs, particularly on the north side of Dublin, with a view to establishing badly-needed out of hours services. It is intended that these will be established this year. The director of the National Hospitals Office is finalising arrangements for the establishment of a national audit and inspection process to measure and improve cleanliness in all acute hospitals. This should be a basic feature of the hospitals.

We are also installing a new MRI scanner in Beaumont Hospital and the provision of acute medical units is currently being discussed with Tallaght, St. Vincent's and Beaumont hospitals. The tender process for the provision of high dependency beds is in its final stages and we hope to make some of these beds available shortly. Similarly, provision has been made for 500 additional home care packages. Effectively packages will be customised to suit the needs of individual patients to allow them to return to their own homes.

I have stated on many occasions that there are no easy solutions to the problems with accident and emergency services. Only the implementation of focused measures dealing with inflows and outflows to and from the hospitals will resolve permanently the difficulties experienced. For example, Dr. Conor Burke of Blanchardstown Hospital has stated in a recent paper that had it been possible to discharge everyone who was sufficiently medically fit to be discharged, there would have been no problem with accident and emergency services at that hospital. In addition to the measures I have outlined, we must ensure that we have different and more effective discharge policies and alternative settings, particularly for elderly patients who frequently do not need to be accommodated in the acute hospital system.

I have issued a text dealing with cancer services. Approval has been given to roll out BreastCheck to both Galway and Cork and the tender will be placed in the EU Journal in the coming days. The national treatment purchase fund has received an additional €20 million. This will bring the amount available to the fund to €64 million. This is a new, focused initiative and is performing extremely well. At the end of March 2005, almost 28,000 patients had been treated. The additional funding will enable the fund to arrange for treatment for 17,000 patients in 2005 alone, a 30% increase over last year. As far as the bed capacity initiative is concerned, the announcement in September 2004 of the opening of new units included a further 200 beds, bringing the total number of additional inpatient beds or day places since 2002 to 900. At the end of March 2005, 713 additional beds were in place. Funding is being provided this year to enable the remaining beds to come on stream before the end of 2005. In the area of renal services, additional revenue funding of over €8 million is being provided. The number of patients on dialysis increased from 641 to 1,210 between 1998 and 2004, representing an increase of 88.7% in six years.

An additional €5 million of funding for child care services is being made available in 2005 to allow for the further implementation of the Children Act 2001, additional staff for the Special Residential Service Board and more community based programmes such as the Springboard project, youth advocacy programmes and the teenage parent support programme.

In the context of this year's Estimates, disability services are a major priority for the Government. As the Deputies are aware, we have moved to a system of multi-annual funding in this area. An additional sum of €40 million is being allocated to services for persons with intellectual disability and those with autism. This new funding will provide 270 additional residential places, put in place approximately 90 extra respite places, provide 400 new day places, improve specialist support services for people with major challenging behaviour and provide €2 million towards meeting the costs associated with moving individuals to more appropriate placements.

An additional sum of €15 million is being allocated to provide approximately 60 new places for people with significant disabilities who are currently placed in inappropriate settings, approximately 200,000 extra hours of home support and personal assistance, additional funding of €3 million for aids and appliances, approximately 90 extra rehabilitative training places and additional funding for voluntary organisations. An additional sum of €15 million is being allocated to mental health services.

The development of services for older people must be an increasing priority for the Government and society. A total of 12,000 additional people each year reach the age of 65 and a total of 850 people reach the age of 80. This requires more supports, particularly at community and home level, but also, unfortunately, at institutional level. The implication of taking an average of approximately 5% requiring institutional care is that we must provide additional places. As far as policies for older persons are concerned, the Government is anxious to have a clear, coherent and understandable policy. Briefly, the Minister for Social and Family Affairs, the Minister for Finance and I have established a working group, to report to us by June 2005, regarding the important matters that must be dealt with. We are in possession of the O'Shea and Mercer reports and have issues concerning how the services will be funded in future. However, in the first instance, we must decide what the policy approach should be.

Clearly, the controversy surrounding the long-stay charges has dominated much of our activity in recent weeks. The memorandum to establish the new regime will be with the Government within the next fortnight and the proposals will be published thereafter. We intend to make it as easy as possible for the individuals affected, such as the elderly or those in long-term care in mental or psychiatric units, to access their entitlements. This will be a central feature of our approach. We have set aside €40 million for the ex gratia payments that were announced by the Government before Christmas 2004. Much of that money has been paid and was provided for in the Estimates.

We have provided an extra €1.4 million for tobacco control. One of the greatest successes of recent years has been the smoking ban in the workplace, with the compliance rate as high as 94%. People in every foreign country I visit are amazed at our success and many states are emulating the Irish example. It is an area where Ireland has been considerably ahead of others and with great success. Clearly, success in terms of reducing cancer and the effects of smoking on the health service will take a considerably longer period to achieve. However, early indications regarding the numbers of people smoking and the volume at which people were smoking are very encouraging.

Since the launch of the cardiovascular health strategy, €60 million, which has been provided for the appointment of approximately 800 new staff, has been invested. Death rates from coronary heart disease are decreasing steadily and in the under 65s are approaching those of the then 15 EU member states.

There are many other issues that affect the Department of Health and Children but I do not wish to take up too much time. There is considerable interest in medical cards and the new doctor-only medical card that the Government has introduced. The HSE is making arrangements to place advertisements in the national press with regard to these new cards. It is intended that approximately 1.38 million will have access to either full or doctor-only medical cards.

Huge increases in the general medical scheme have been experienced in recent years on the doctors' side. The sum of money going to doctors doubled from €158 million to €300 million between 1998 and 2004, even though the number of medical cards decreased by 100,000. We must ensure that, in the context of providing resources to those most in need — particularly low income families — these cards are issued and used very quickly. I look forward to the co-operation of Irish Medical Organisation in respect of this matter.

Many people are aware of the enormous investment that has been made on the capital side in respect of the nursing degree programme. Over €240 million has been invested in 13 new nursing schools, which has a revenue implication of €90 million per year. We will experience some difficulties this year because we are moving away from the apprenticeship-based three-year model to the four-year degree model. This is the reason there is a major recruitment drive under way overseas. I will deal with other issues in the context of questions and answers.

Dr. Twomey

I thank the Tanáiste for giving the committee a good overview of what she intends to do during the next year. With regard to what she was saying about health spending in the UK, would she agree that costs in the UK, such as the wages of consultants and doctors, would be also significantly lower? Over the years, the infrastructure in the NHS has been significantly better than the public health infrastructure in Ireland. It is not surprising, therefore, to discover that the UK is spending less on health when one makes that direct comparison. The Tanáiste should look at the overall percentage of what the British Government spends in this area rather just relying on straightforward figures.

The Tanáiste appears to be saying that providing additional services would too expensive. She more or less implied that having additional people in the health workforce would be too expensive. She cannot have it both ways because the Government's policy has driven up costs and we must provide for these additional services. Even if we have made them more expensive, we must still provide them. As a Government Minister, the Tanáiste should be able to give us clearer answers.

The Opposition is often accused of not being able to provide concise policies when it is asked to do so. However, the Opposition does not have the benefit of 400 or 500 people working in Departments to supply it with more accurate figures. The Tanáiste should give the committee more accurate figures because she has the benefit of being able to call upon the expertise of the people to whom I refer. She referred to vested interests in the health services. Who are these vested interests and what problems are they causing? This is something that crops up regularly and the position should be clarified.

Regarding the accountability perspective from the HSE, I believe the regulations regarding accountability in the health services have not yet come through. This is quite important and we have seen it in this committee, the members of which are the only public representatives that have any control over what is being said or done in the health service. However, we find it extremely difficult to obtain information at committee level which will allow us to monitor accountability in the health services.

In her ten point plan, the Tanáiste referred to a second MRI scanner for Beaumont Hospital. What progress has she made with regard to CAT scanners in other hospitals and why are they still being switched off at 4 p.m.? On bank holidays and outside regular hours in many hospitals, these scanners are not available to carry out simple CAT scans for people who may have suffered strokes or other head injuries.

The Tanáiste made some points about why attendances are high at accident and emergency departments and cited factors such as out-of-hours services and the availability of doctors. Are these points true because she will be making investments in accident and emergency services in the coming months which might not be related to the reasons she is using? A proper and well structured out-of-hours GP service is vital but I do not believe it will make an enormous difference in terms of attendances at accident and emergency departments. However, it is vital that everyone has access to out-of-hours GP services.

Even though the Tanáiste has focused again on the GP co-operative, which is being established by GPs in north Dublin and is awaiting funding from the Department of Health and Children, there are other parts of the country, for example, east Cork, which have been more or less told they will not receive funding for their out-of-hours co-operatives this year. In other parts of the country, co-operatives do not exist and certain parts of the country are struggling to provide any form of out-of-hours GP service, a matter to which the Government does not pay much attention. The Tanáiste did not talk about these issues but merely focused on one or two specific areas.

Who will receive home care packages and how much will each package cost? If I made such a proposal in the national media, I would expect to give far more specific information than a mere announcement that I was giving out 500 home care packages. Will anyone coming out of hospital who requests a home care package receive one? Will consultants decide who can apply for the packages or will it be the usual rigmarole when one applies to the health boards for any form of subvention, whether it involves having a new shower or stair lift installed or a new bedroom built? It can take between four and five months to get such a subvention from the health boards. The Tanáiste should be far more specific about who will qualify for home care packages because hospital discharges approach something like 1.2 million per year, with at least 400,000 of those being elderly patients. The 500 home care packages will not go very far, particularly if many of those patients — in the event that they cannot obtain access to a step-down facility or are not eligible for two weeks convalescence — feel they are entitled to such a package.

I welcome the Tanáiste's announcement about the BreastCheck programme. I hope it is genuine on this occasion because I have approximately five or six announcements stacked up in my office stating that BreastCheck is in place for all parts of the country. The reality is that BreastCheck is not available in all parts of the country and it does not look like it will be available for at least another two or three years.

One matter I have consistently raised with the Tanáiste — in respect of which I have yet to receive a clear answer — is why the national treatment purchase fund carries out relatively simple surgery on behalf of the Irish health care system when the major problem with regard to waiting times exists for more complex procedures such as neurosurgery, orthopaedics and ENT. Waiting times for surgery in these areas can be up to four to five years from the time the GP writes the letter to the date on which the patient receives surgery. However, much of what the national treatment purchase fund covers——

Chairman

There is a vote in the Dáil on Private Members' Business. We will suspend our proceedings until the vote is over.

Sitting suspended 12.40 p.m. and resumed at 12.55 p.m.

Chairman

Deputy Twomey has approximately four minutes remaining.

Dr. Twomey

I was speaking on the national treatment purchase fund in terms of a question I have asked frequently. Why does the fund not focus more on complex surgery? Its current focus is often on basic surgery, for which there is not a large waiting list. Currently, a husband and wife or partners will be flown to the UK, one person will stay in a hotel while the other goes to hospital and they are then flown home again. For the 17,000 people who have had their procedures carried out, this is fantastic but it contrasts with the many others who must wait years for the more complex surgery that the national treatment purchase fund should focus on. As the Tánaiste is aware, access to Irish neurosurgical services and complex spinal surgery is poor at present. Even private patients must wait as long as a year to be dealt with. In some respects, public patients do not have a hope of being treated surgically.

The Tánaiste said that 200 extra hospital beds were announced in 2004. Where are they? Does this number include the 19 beds in Wexford and 70 beds in Letterkenny that were announced in 2004 by the then Minister, Deputy Martin, beds the Tánaiste may announce again in the coming weeks? Many hospitals have not received an increase in their complement of beds over the past 12 months.

What are the background problems in the care of the elderly which have delayed for a long time the policy concerning care in the community and in nursing homes? The Tánaiste referred to the Mercer and other reports. I hope she does not follow the example of her predecessor by merely issuing reports. Why is there no policy relating to how the Government will take care of the elderly in the future? I find it strange that we must wait four years for the Government to come up with a policy when it has reports to hand for that period. I had not noticed costs for general practitioner services had increased to such an extent in the period 1998 and 2004. A breakdown of where that extra and significant amount of money has gone would be interesting.

The radiotherapy service for Waterford has disappeared from the radar in the Department of Health and Children. There is no mention of the emergency helicopter service discussed at this committee some months ago. We were given the impression that something was going to be done. Nothing has been discussed. I do not know if Mr. Pat McLoughlin is involved in the reform of the Health Service Executive but the Tánaiste should take on board the reforms programme announced.

Ms McManus

I welcome the Tánaiste. This is a new form of Estimate, divided into two parts, with the lion's share going to the HSE. The part relating to Department of Health and Children appears to have shrunk. I have questions regarding the Department's future. The Tánaiste has made much of her desire to bring efficiency to the public service. This Estimate will be a test for her.

It seems extraordinary that although the Department of Health and Children has had major powers and resources taken away, the figure for consultancy spending shows an increase of 135%. I thought it was moving away from reports and consultants. There is something not quite right if there are huge increases in a Department that has been emasculated.

I have great regard for the people present at this meeting but the image presented is that, rather than there being efficiency, the work of the Department and the HSE is being duplicated. It is difficult to see where the reform promoted by the Tánaiste is going to deliver major initiatives or improvements in the coming year. Some grants for which the Department is responsible should be transferred to the HSE. Some bodies were to be abolished under the reform programme. There seems to be an uneasy relationship between the Department and the executive.

Why has a full-time CEO not been appointed to the HSE? The Tánaiste has been in office since November and has already lost one CEO. It appeared that she had gained another but, extraordinarily, there has been no firm indication that the man in question is in place and prepared to take up his burden. The acting CEO made an interesting statement to the Public Accounts Committee, that the HSE is €180 million short of funding. All it is obliged to do this year is maintain the current level of service. It is not as if it needs to spend a great deal of money in new areas. If it is €180 million short and, as the Minister of Finance has stated, there will be no Supplementary Estimate, it appears that there will be a need for cutbacks. We need to know where those cutbacks will be imposed. It is disturbing that such a statement needs to be made, so clearly and with justification, at this stage.

The capital projects that would normally be under way have not been announced. Repeated announcements have been made about BreastCheck and Wexford Hospital but nothing has been brought to a conclusion. I understand that the Minister for Finance is blocking progress in respect of capital projects. We need to know now why these projects are not under way. The health service is under major pressure and this kind of delay serves no one, particularly in light of rising building costs.

How does the Tánaiste intend to address the issues of inequity highlighted by Mr. Kevin Kelly? How will the inequity to which he refers be dealt with?

Is the Tánaiste satisfied with what I would term her nine point plan? Including the MRI scanner in the ten point plan is merely a way of making it sound better. As the scanner in question was a replacement for a mobile unit taken away from the hospital, it is hardly a major initiative in terms of dealing with the accident and emergency crisis. Even though 1,000 people were to be provided for under the Tánaiste's plan, by the end of this week only 90 will have been taken out of hospitals as a result of the initiative to which I refer. That can hardly be considered progress, particularly in light of the promises the Tánaiste made when she announced this initiative and stated that she would be judged on results relating to it. She received support at the time but now there is much disappointment.

We are coming into the summer months, when there is always a downturn in accident and emergency admissions. Nevertheless, people are still on trolleys. My colleague, Deputy Howlin, informed me there were 20 people on trolleys in Wexford Hospital yesterday. In a small regional hospital, that situation is unbearable.

Nobody expects the AMUs to be built overnight but we do expect to have answers on the cost. It will cost €17 million to provide what is required at Beaumont Hospital. Nothing like that amount has been allocated. What will happen to meet the shortfall in terms of what has been promised and what can be delivered?

I would like to know more about the famous vested interests to which the former Ministers, Deputies Cowen and Martin, and the Tánaiste have referred. Who are these vested interests and how will they be punished for the terrible things they are doing? In my view, there is much industrial unrest and many difficulties that need to be resolved by way of good management. The megaphone approach relating to vested interests does not seem to be delivering the change the Tánaiste seems so keen to deliver.

The Tánaiste stated that she did not need to meet GPs in respect of doctor-only medical cards, that there was no need for consultation and that she would deliver. Now, however, negotiations with the GPs are about to commenced. Whenever one negotiates with GPs or doctors, there are costs involved. Nowhere is that more obvious than in the example of the disastrous over 70s scheme. The Government introduced this scheme as a political stunt and it cost taxpayers huge amounts of money. It was not the fault of the then Minister for Health and Children, Deputy Martin, or his Department. It was driven from the very top of the Government of which the Tánaiste is a member. She must take responsibility. A scheme that was to cost €19 million eventually cost €51 million. That was a disaster. There are going to be costs involved in other initiatives that have not been properly thought out. There are no guarantees that discussions on the GP-only scheme will not lead to additional costs.

Hospital consultants seem to have outstanding difficulties with the indemnity scheme. This matter is again a source of dispute. In my opinion, the Tánaiste is following bad advice in terms of taking this matter before the courts. However, that is her decision. Compromise with the MDU should have been possible and would have been a better way to proceed.

The INO is currently threatening an all-out strike and regardless of whether this materialises, it shows a level of poor morale in the nursing profession. Nurses have protested on the streets not to improve pay or working conditions but on behalf of their patients. I stood on many protest lines and spoke with them and can say that the only reason they are doing this is out of concern for their patients. I wish the Tánaiste understood that.

We must increase primary care but we are not producing the doctors that we need. What is the Minister doing, in terms of the provision of graduate and training places, to ensure that we will have a sufficient number of qualified medical practitioners? Shortages are already building up and I ask the Minister to deal with this issue swiftly.

The nursing graduates will not be on-stream this year and there are concerns about nursing shortages. What is being done to deal with that? The tobacco control section does not need extra money. We are inundated with information on tobacco control. The message has got through and people are compliant. We should focus now on areas such as the epidemic of sexual diseases, the money for which has been reduced. We should move away from tobacco and deal with other matters were problems are increasing.

Dr. Cowley

I welcome the Tánaiste and her officials. She wanted a health system that is the envy of the world and that would provide equality. She is now long enough in the job to know how essential and necessary this is.

The existing two-tier system, with access dependent on the ability to pay rather than on needs, has not changed. What is the net increase in the number of beds? A number of announcements have been made on increasing the number of beds, such as an increase of 200 beds announced in 2004 and 730 additional beds announced in March 2005. What, however, has been the net increase? The Tánaiste referred to a ten point plan to address overcrowding but she should realise the number of beds is the main factor in the lack of the system's capacity. How much progress has been made in restoring the 3,000 beds removed in the past?

The Tánaiste compared the amount of money being invested in the system currently with that in the UK. However, we have come from a low base and our infrastructure is also low and must be built up. Ennis Hospital is still in dire straits and is awaiting investment in facilities. A situation such as that in Monaghan and Cavan, whereby a hospital is downgraded and essential funding is not provided to allow facilities to be of a standard that can be vouched for by training bodies and insurance companies, is likely to occur in Ennis.

The stealth campaign towards Hanly centralisation continues. When will the Tánaiste invest the necessary funding in Ennis? I visited Ennis Hospital and was struck by the fact that it has a dedicated staff doing an essential job but is crying out for investment. Will the Tánaiste continue implementing the Hanly regime? I am aware that there are now doctors in Ennis Hospital to cover nights but that is no substitute for a proper 24-hour service.

Promises were made that €130 million per annum would be invested into general practice over ten years under the primary care strategy. However, only €15 million has been invested over a three-year period.

The Dáil discussed the issue of suicide this week and I stated that the essential needs of people suffering from depression are not met. A GP must go through the hospital system to get a psychiatrist to refer a patient to a consultant psychologist or a counsellor. This should not need to happen but the lack of funding means that it does. Will the Tánaiste make this investment of €130 million per year?

With regard to Ennis Hospital, Mayo General Hospital in Castlebar and other hospitals, does the Tánaiste believe the national treatment purchase fund——

Ms Harney

The Deputy is being parochial now.

Dr. Cowley

In that event, I will discuss Ennis.

Ms Harney

The Deputy is going national. He will replace Dana in the next election.

Dr. Cowley

We all have a national dimension and think of more than ourselves. I have worked at the coalface in my constituency.

The national treatment purchase fund is laudable because it has removed people from waiting lists. I understand that a new pilot programme might mean people can be seen directly by consultants. Individuals wait for years to get on the official waiting list and this pilot programme will mean that instead they can be seen by a consultant and referred directly for an operation. Does the Tánaiste agree that the bottom line is that hospitals should be capable of dealing with these situations?

The national treatment purchase fund is a sticking plaster solution and is an admission that the public system has failed miserably to deal with people's needs. Denying Ennis Hospital or Mayo General Hospital the consultants they need to provide a proper service to the people is a stop-gap solution that does not address existing needs. People wait for five years for an urological appointment and those with cancer have had to wait months to receive essential treatment. Where consultants are in place, there are no long waiting lists.

Promises have been made regarding BreastCheck on many occasions but we are still awaiting the advertisement in the EU Journal. I understand it will happen in the next few days and I welcome this because 65 people die each year in the south and west in the absence of BreastCheck and hundreds more will do so before 2007. Why was an offer made by the Galway clinic to carry out examinations on behalf of BreastCheck until static units were provided there not accepted?

Rheumatologists came before the committee over a year and a half ago and will do so again at the end of this month. We have 0.3 rheumatologists per 1,000 members of the population, which is the lowest level in Europe. I include countries such as Croatia in this. The position has not improved. The Taoiseach does not know when a national programme for cervical screening will be in place.

Three areas in the western health board region — namely, Tuam, Roscommon and the Mulraney-Achill-Ballycroy area — have been pinpointed for ambulance stations. As these locations are outside the internationally recognised limits on the maximum distance between an ambulance station and patients, there is not a hope in hell of people being treated within a reasonable timeframe. A case that was not so serious when a telephone call was made has often become an emergency by the time the ambulance arrives. People are dying as a result. This is a priority of the HSE in the western region but nothing is happening and people are dying because there is no proper ambulance service. Putting trolleys——

Chairman

The Deputy's time has expired.

Dr. Cowley

General practitioner services are important. However, the corporatisation of these services is not in the interest of GPs who want to be involved in developing primary care centres and who should be listened to.

Chairman

There are many questions to be answered and several other members wish to contribute. I ask the Tánaiste if she is willing to take note of all questions now and answer them together?

Ms Harney

Yes.

Mr. O’Connor

I am interested in the future plans for Loughlinstown Hospital.

As several colleagues have been parochial, I will take this opportunity to mention Tallaght. Deputy Neville pointed out that some of our colleagues are GPs. I am proud to say that I was a patient in Tallaght Hospital and the staff there were very good to me when I was sick.

Chairman

The patient is the most important person.

Mr. O’Connor

I am proud of what is being done at Tallaght Hospital. The Tánaiste will have the support of all of her colleagues and the public if she deals with the accident and emergency situation.

When I go to Tallaght Hospital to visit neighbours or friends, the message I hear is that when a patient gets beyond the accident and emergency department, he or she receives tremendous services. Mr. Pat McLoughlin knows that I will be contacting him about the development of Tallaght Hospital and the delivery of services. The hospital plays an important role, not only for the people of Tallaght but also for those in the wider catchment area which stretches as far as Carnew. Tallaght Hospital provides a great service and it is important that its continued development is given adequate funding and attention.

Mr. Neville

I am conscious of the fact that there are three GPs and the spouse of a GP sitting to my left.

This committee has expressed its concern that only €15 million in additional funding will be invested in the development of the mental health services this year. This represents one third of what will be spent by the Government on the special savings scheme and is much less than what was spent last year on the Punchestown development. When one puts the figure into context, it represents a quarter of what was spent on electronic voting. When one bears in mind that one in four people will need mental health services at some stage in their lives, the additional funding is clearly inadequate.

I ask the Tánaiste to outline the cost of providing an additional 14 beds at the Central Mental Hospital and to put that in the context of the announcements made last year on the closing of that hospital and its relocation to the site of a new prison in north Dublin. This hospital is due to close at some time in the future but I am not in a position to judge the need for that closure.

The Tánaiste spoke about further developing child and adolescent treatment services. I ask her to outline the planned development of the psychoanalytical service, which is an area requiring urgent attention. I also ask her to give details on the development of a dedicated psychiatric service for those aged between 16 and 18. There are no services for this age group at present.

Will the Tánaiste outline the number of additional community residential places for the mental health sector and where new mental health facilities will be located?

Ms F. O’Malley

I also welcome the Tánaiste and her officials. I wish to congratulate Deputy O'Connor on his enthusiasm for and interest in Loughlinstown Hospital.

The amount of investment in the health service is phenomenal but at least we can see some results. People are living longer, receiving treatment faster and seeing more specialists. However, I have concerns around efficiency. The cap on recruitment within the health sector means that the method of employing nurses is incredibly expensive and inefficient. It also means that we cannot plan properly or make the best use of the nursing resource. Is there an imaginative way to tackle this problem?

There is scope to save a large amount of money by using generic medicines. I am aware that here have already been some initiatives in this area but I would welcome further information on progress to date.

Ms Harney

Every hospital will be used to its most appropriate effect. I do not accept phrases such as "downgrading" or "upgrading". Many members of this committee are medical practitioners and are aware that when people are ill, they need to see the appropriate medical personnel in the appropriate setting.

In a country of four million, some services, such as complex surgery, can only be provided at a national level. Many other procedures can only be provided at a regional level. The mid-west region, which is the subject of the Hanly report, has one dermatologist and no plastic surgeon. A region with only one specialist consultant is not in a position to provide the kind of service that is required, no matter how committed or competent that consultant may be.

We want to provide a range of services, led by consultants, at regional level to ensure that patients will not have to travel long distances to Dublin for treatment. It will take some time to achieve this. The analysis suggests that we need to increase the number of consultants from the current level of 1,940 to 3,600. This increase must take place against the background of the working time directive and in the context of new consultant contracts. Most people, except those directly involved, would accept that the current consultant contract is inappropriate. We need new categories of more flexible contracts. We need to provide for a greater role for research and for those consultants who have only a public commitment as opposed to those who have mixed practices. Many changes are required.

People have asked me to whom I am referring when I mention vested interests. Everybody — the Minister for Health and Children, members of this committee and those who work in the health services sector — has a vested interest in the health service. The message for everyone is that we must be prepared to embrace change. Experience has shown that it is only when we embrace major change that we achieve outstanding results. We did not achieve our economic success in one or two years, it took a decade. To achieve a world class health service will take at least that amount of time, if not longer. We have to begin the process of achieving this. We will get the best results if we put patients' interests first in all that we do. The majority of those who pursue careers in health care, are primarily interested in caring for patients. Sometimes our work practices and environment are not conducive to bringing out the best in individuals. Many people have told me over the past six months that the system's innovators, who make changes behind the scenes, are ignored but those who shout loudest and prevent change are rewarded. This situation is not sustainable.

In terms of individual hospitals, Deputy Cowley mentioned Ennis hospital and Deputy O'Connor mentioned Tallaght hospital, which despite being in my constituency does not receive preferential treatment. Preferential treatment is not in the interest of patients. It is necessary to be fair in setting priorities and to ensure that appropriate change is implemented.

It is the intention of the national hospitals office to carry out a major audit beginning with at least ten hospitals. We want to learn how money is being spent, whether best practices are followed and if better results for patients may be achieved. We do not yet have this data but will soon begin the process of collecting it. We will be unable to channel money to the greatest benefit of patients until we can measure performance in terms of inputs and outcomes. This audit on practices and procedures is additional to the hygiene audit I mentioned earlier. Ireland is unusual in having many voluntary hospitals which are tax funded and of whose approach I am a fan. This year, €380 million more taxpayer resources than last year will be invested in hospitals and the ambulance service. We have to determine whether value is being provided for that money. This is not a matter of economics but of patients. We shall ask whether more patients may be treated, if better discharge policies may be put in place and the possibility of consultants implementing on a daily basis their holiday practice of discharging each other's patients.

Deputy Twomey raised the matter of equipment. Increased use of the expensive equipment already in place will allow the treatment of larger numbers of patients. However, as work practice issues remain, we have to include flexibility in reviews of contracts of employment. In the outside world, flexibility is essential to the delivery of good service. Health services must operate 24 by seven because people do not get sick between 9 a.m. and 5 p.m. While diagnostic facilities are available on an emergency basis, it is frustrating that these expensive and high technology facilities are often used for only a few hours. Procurement in the private sector allows greater flexibility, particularly for general practitioners, in accessing these facilities. All equipment cannot be used constantly, but it should be borne in mind that increased utilisation will result in better consequences for patients.

I support nursing as a serious career. Last year, the Central Admissions Office received 8,600 applications, of which 4,600 were first preference and 1,600 were from mature applicants, for 1,640 places on nursing courses. As nurses move up the career ladder, I favour that they perform duties which traditionally were the remit of doctors. This will be a feature of the new nursing Bill. People with different skill sets may carry out certain nursing functions. We cannot have a situation where people continue to perform the same functions while doing more at the top. This is clearly expensive and inappropriate. If others may do the job, let them have a career path as health care assistants. In the UK, the ratio of nurses to health care assistants is 70:30. Ireland is a long way off that ratio. A comparison of per capita statistics between a small and a large country is not completely fair because of economies of scale. Notwithstanding this, Ireland should emulate the more flexible model in the UK.

Ms McManus

What will the Minister do this year in terms of nursing staff?

Ms Harney

Due to the replacement of three year apprenticeships with a four year degree course, there will be no new entrants to the profession for one year. For this reason we allocated €2 million for an international recruitment campaign. Unless we persuade nurses to re-enter the workforce, much of our recruitment will be overseas and mainly in the Phillipines. Directors of nursing have travelled on major recruitment campaigns.

Ms F. O’Malley

Will the recruits be on agency or permanent rates?

Ms Harney

It depends whether they replace people in permanent jobs or whether they are additional to requirements. Many nurses are on an agency contract basis because of employment ceilings. The health services directly employ 98,000. As this represents a considerable figure that has increased substantially in recent years, we have not been prepared to lift the ceiling. As we carry out certain reforms, surrounding issues may be re-examined.

I would have found it preferable to have reached agreement with the MDU on the indemnity scheme. Nobody wants to litigate if it can be avoided because it is expensive and time consuming. As it was not possible to avoid litigation in this case our duty to tax payers and consultants was to ensure that the MDU was not allowed to walk off the pitch. It would be preferable if, as has been suggested, the MDU re-entered negotiations.

Ms McManus

The MDU has made that clear.

Ms Harney

I will not comment on that. They would not allow the kind of audit we wanted to establish. This difficulty was ongoing before I became Minister for Health and Children. I support all the efforts of my predecessor, Deputy Martin, and his officials to resolve this matter, which has continued for years. The Department's approach was correct. We cannot reach agreement with the company unless we know its state of affairs. We cannot accept a certain sum of money if we are entitled to more.

Ms McManus

I do not disagree with the Minister but I do not believe negotiations to resolve the problem have been sufficient.

Ms Harney

I accept Deputy McManus' comments in good faith. The negotiations broke down over the issue of auditors examining the books and affairs of the company. Disagreement arose over the extent to which the auditors could investigate matters. If the auditors were unable to see the whole picture, there was no point in going to the expense of having them investigate.

My predecessor, Deputy Martin, and the former Minister for Education and Science, Deputy Dempsey, established the Fottrell report on graduate entry into medical school and medical numbers generally. I share the view of Deputy McManus that serious issues are arising. GPs are being increased from 80 to 150 per year on a phased basis.

I am unsure whether Deputy McManus is suggesting that the medical card be taken from the over 70s. The doctor only card is issued to those at the bottom on the basis of means and income. It has always been the view of the Irish Medical Organisation, in any agreement they reached with the Department of Health and Children, that when the card is extended on the basis of means, as opposed to class of individual, the same arrangement applies. That has to be the case in this respect. There is no question of general practitioners being paid more money to deal with this category of citizen. We are willing to pay this money. We have allocated €50 million this year, which is an average of €25,000 per general practitioner in the GMS. I would plead with the Irish Medical Organisation not to have the people who are at the bottom in terms of income levels in our society pay when the Government is prepared to pay for them. The advertising campaign will begin shortly. Applications will be submitted and I hope that in the meantime agreement can be reached on that issue. There are other issues in dispute between the IMO and the Minister and the Department of Health and Children, including industrial relations issues concerning Sustaining Progress, benchmarking and so on but those issues should not stand in the way of agreement to operate the card. They are separate issues that I want to see dealt with.

Deputy Twomey asked me what happened to all the extra money. I was talking about the money allocated to the general practitioners, which has increased from €158 million in 1998 to €300 million in 2004. I realise the Deputy's colleagues will say all that money is not going to them. That is true but it has been allocated to the doctor piece of the GMS, so to speak, as opposed to the drugs area, which has greatly increased also. I am simply making the point that if they are doubling their costs and reducing their numbers by 100,000, as we go forward we want to get better results than that.

In the context of new negotiations, and I am conscious that I am speaking to two people who may be affected by this, there are more procedures that general practitioners can do, one of which is cervical screening. The immunisation programme, in which we have very poor participation rates here, should be examined also. There are many issues that we need to discuss with each other with a view to having a greater role for the general practitioner, who is the most important player in the health care system in terms of interfacing with patients on a much more frequent basis. Follow-up care and managing chronic illness in the community and so on is very much a role for general practice.

I did not hear the comments of the acting CEO of the Health Service Executive. He comes from a banking background and he will admit that if we increase spending by 10.8%, it is not a cutback. Everybody would like more funding but we want to achieve greater efficiencies and value for money, and there is a good deal of scope for that.

Ms McManus

Where is the scope?

Ms Harney

Right across the system.

Ms McManus

That is not a very helpful answer. Is the Minister including the front line services in that?

Ms Harney

One of the conditions laid down to the HSE was that there could not be a reduction in services to patients; it had to come from efficiencies in the way business is done. I believe there is enormous scope to do that but we will monitor that throughout the year.

On the CEO, if we had taken the CEO off the dole list he may have been able to start work the next day but this man is a senior clinician and academic, a global leader——

(Interruptions).

Ms Harney

That is an unfortunate comment, Deputy. He has to disengage from his clinical practice and somebody with his expertise is not easily replaced. The issue of the start-up date is to do with that. He is engaging already with the HSE and he intends to do more of that over the next few weeks. We are talking about a start date between July and 1 September. I would like to think it will be July but it may be 1 September. That is the type of timeframe we are talking about.

Ms McManus

What experience does he have in macro-management?

Ms Harney

Macro and micro-management are big phrases. He does not have a management background. He is a clinician, as was Mr. Halligan. He is a highly impressive individual. I did not know him before he got this appointment but I met him and had a long discussion with him. Those who know him and have worked with him say he is a team leader, a player and a man with great vision but he is also a person who wants to find solutions that are practical. An intensive global search was conducted for a CEO for the HSE. The position was not lightly allocated to somebody. The HSE board recommended Professor Drumm to me and I was happy to accept that recommendation.

On the issue of radiotherapy, it is important that we provide a national radiotherapy service. As we are aware, many cancer patients are unable to avail currently of radiotherapy facilities. We have the Hollywood report. I will meet Dr. Hollywood this afternoon to discuss that report and we hope to come forward with a proposal. Accepting reports is one thing, and as a society we are always good at the report aspect, but behind every report is the need for resources and timeframes. The implementation of a national radiotherapy service must be put in the context of resources and time frames. We may be able to advance a proposal shortly. I hope that will be the case.

On the care of the elderly, the policies on the care for the elderly are patchy and unclear. We have the nursing home subvention, institutional care, home helps, home care packages — I will deal with the question raised by Deputy Twomey in a moment — welfare supports of various kinds and housing grants. The Minister for the Environment, Heritage and Local Government, Deputy Roche, said recently that to give somebody €8,000 by way of a grant cost €8,000 in bureaucracy and takes eight months to implement. That does not make sense. We are examining the various aspects to ensure we have a clear policy and that an elderly person and his or her family will know exactly what they are entitled to. We cannot move to a universal system where everybody is entitled to a nursing home place or institutional care because the country could not sustain that. The purpose of putting this group together to work on the recommendations in both the O'Shea and Mercer reports — one about services and policies and the other on funding issues — is to finalise the policy in this area. It is a priority and it will be done over the summer months of this year.

Deputy Twomey also asked about the policy regarding the payback. It is hoped that proposal will go to Government within the next fortnight. A number of issues arise in that regard, including timeframes for paying back money and so on, and we want to make it as easy as possible.

On the number of hospital beds and the location of the additional beds, we have approximately 2,500 private beds in public hospitals. The 25% increase this year, which I did not mention in my opening remarks but which is in my script, was provided with a view to moving us closer to a situation where the full cost of those beds is charged to the insurers. That is in the interests of ensuring fairness, equity and access. I hope to shortly publish and give the HSE proposals for the development of private hospital facilities on public hospital grounds. That makes a good deal of sense from a host of perspectives. As I have said previously, if private individuals with resources want to invest them in health care, I am happy to accept that. The role of the State is to ensure that everything operates to very high standards and that we police and enforce those standards but we do not have to own every facility providing health care.

Ms McManus

That is a costly way to solve a problem.

Ms Harney

I do not accept that. It is a cheaper way——

Ms McManus

I do not believe the Minister.

Ms Harney

——for a host of reasons.

On the question of out of hours GP services, the HSE is making good progress regarding the north Dublin proposal. It is currently discussing the location of the communications hub with the north Dublin GPs. The executive is also making good progress in the Cork area, which Deputy Twomey mentioned, and in the south east.

Dr. Twomey

Work on the one in east Cork has stopped.

Ms Harney

I believe that is not the case. My note from Mr. Browne indicates that the executive hopes to make good progress on that matter towards the end of this year.

Dr. Twomey

Is it not the case that work on the facility in east Cork has stopped for 2005? I understand that is the case.

Ms Harney

Unfortunately, the officials are not allowed speak to this committee. I am relying on the note I got from——

Dr. Twomey

It appears the people in Cork have a different view to that of the Tánaiste.

Ms Harney

The national treatment purchase fund was referred to as a sticking plaster measure. It was an initiative. All of us must think outside the box and I believe the fund is working extremely well. It has dealt with almost 28,000 patients by the end of March this year and the vast majority of those patients have been dealt with in Ireland. I can give Deputies a breakdown of that figure. Of the 27,268 patients treated by the end of March, 1,698 were treated outside the State — 1,069 in Northern Ireland, 611 in the UK and 18 in the US. Nothing is excluded from the remit of the fund. Anybody waiting for six months is entitled to the resource available under the fund. However, for example, the State only has one neurological centre.

Mr. Neville

Does it cover psychiatric illnesses?

Ms Harney

No, it covers surgical procedures. I have asked the administrators of the fund to examine waiting lists and other pressure points but nothing has been finalised in this regard. We have only one neurological centre.

Dr. Cowley

The difficulty is one must wait years to get on the waiting list for the fund. That is why pilot projects were mentioned. One must be seen by a consultant to get on the list.

Ms Harney

I accept that and the list for some specialties is long. Neurological illness is one example. There are only 13 or 14 neurologists in the State and there are only 20 specialists in the field of dermatology.

Dr. Cowley

One could wait five years to see a neurologist.

Ms Harney

That is why I mentioned increasing the number of consultant posts nationwide. In the meantime, I have asked the chairman of the national treatment purchase fund to examine possibilities for outpatient appointments. It is slightly removed from the fund's focus to date but I await a response from her in this regard.

With regard to neurosurgery, there are centres in Beaumount Hospital, Dublin, and Cork. Discussion is taking place about whether a centre is needed in the west but the jury is out on that. I know the Deputy's view but a third centre may well be needed. The difficulty in providing neurosurgery domestically is the lack of facilities. Patients are treated on the basis of urgency. I do not know if patients have been taken overseas for neurosurgery but I can check that. If they are suitable, there is nothing to prevent the fund from catering for such patients.

Deputies O'Connor and O'Malley asked about Loughlinstown hospital. Every hospital will be used to its full potential. We will not close hospitals but we will not open new ones. Every hospital in the State cannot have the range of services everybody in the immediate area might like.

Ms McManus

What about the accident and emergency department at Loughlinstown hospital, which is busy but which, under the Hanly report, will be closed and replaced by a nursing unit?

Ms Harney

It was never intended that it would be closed under Hanly.

Ms McManus

Yes, it was.

Ms Harney

No, it might not have accident and emergency consultants. I am advised serious trauma cases will go to St. Vincent's Hospital.

Ms McManus

They do currently. It is an extremely busy accident and emergency department, allowing for——

Ms Harney

There is no plan on my agenda to close any accident and emergency facility.

Dr. Twomey

Just to downgrade them.

Ms Harney

We want people treated at the appropriate level. In some cases, a nurse can administer this treatment. When I met representatives of the Neurological Alliance yesterday, they said the most important thing we could do for them in the short term was give them access to clinical nurse specialists. That would greatly help the range of services that could be provided. For example, new minor injury clinics will be opened by the VHI and the Beacon Clinic will be staffed by general practitioners. The appropriate service must be provided.

Deputy Neville mentioned mental health issues and the number of beds in the Central Mental Hospital. When that proposal was made to me, I asked my officials whether we needed to do this if the hospital was moved. There will be a long gap between now and the provision of a new hospital. The provision of 14 beds is urgent and €1 million has been allocated for that purpose.

The Minister for Finance has not blocked the capital programme. It is agreed the Department will have €584 million for capital expenditure in 2005. The issue in many of the projects is the revenue and staffing implications of that expenditure. We must make sure appropriate staffing is provided. If, for example, a hospital will have the same number of beds, we must question why it needs 300 additional staff and we would be wrong not to do so. I do not want a scenario where state-of-the-art facilities are put in place but cannot be opened because staff are not available or grossly inflated staff numbers have been agreed. We want appropriate staffing for the new facilities. If a new school is opened with the same number of classrooms and pupils, 300 more teachers are not needed. However, when a new hospital is opened with the same number of beds, it needs more staff. I acknowledge more procedures are provided, which must be taken into account. However, a sustainable capital programme will be announced with the revenue implications built in and accounted for.

The announcement will not be made with great fanfare and there will not be a major press conference. The relevant people will be told about progress regarding their capital projects. The priority is services for the elderly and more beds, particularly in regional locations. However, there are significant pressure points such as accident and emergency facilities and so on. Reference has been made to Rolls Royce and Morris Minor in the context of accident and emergency units for Beaumont, Tallaght and St. Vincent's Hospitals. Resources are limited and they must be scaled to the appropriate level. Mr. McLoughlin is in serious negotiations with the three hospitals on their plans for accident and emergency units. It is not a question of them having the accident and emergency unit they would like just because we announced they would get such units. Sometimes, when we make plans, we ask each beneficiary what it would like, put it all together and pass it on. We must have accident and emergency units, which are affordable and appropriate to the needs of the moment.

An additional €50 million will be invested in mental health services this year. The budget has increased from €716 million to €766 million. The increase is for new services and the establishment of the new tribunals under the Mental Health Commission, which are urgently required to examine the 600 patients involuntarily detained.

Another member asked about the other new hospital beds and whether they were announced previously. I did not announce new beds earlier but I outlined the state of play for this year. A total of 29 beds will be provided in St. James's Hospital; 30 in Naas General Hospital; 21 in James Connolly Hospital; six in Mullingar hospital; ten in Monaghan hospital; 35 in the South Infirmary Hospital, Cork; 44 in Galway University Hospital; two in Portiuncula Hospital; nine in Roscommon hospital; and one in St. Joseph's, Raheny. That makes up the balance of the 900 beds.

I refer to the helicopter service. The Air Corps has acquired new helicopter facilities for this purpose and discussions are under way between the HSE and the Department of Defence on this matter.

Dr. Cowley

That is for a dedicated service, which is the problem.

Ms Harney

It is a hospital to hospital service.

Dr. Cowley

The Air Corps has many other jobs to do and it spends more time on them than on mercy missions. The difficulty is its helicopters are not available when they are needed. Recently, there was a terrible tragedy on Clare Island when a girl died of hypothermia because of the delay in getting a service. Shannon search and rescue arrived at the scene but it was unable to do the job because it is not a flying intensive care unit, which was recommended in the 2004 North-South emergency care bodies feasibility study between the Department and the Northern Ireland Department of Health. A joint study was carried out——

Ms Harney

That study recommended the inter-hospital service.

Dr. Cowley

Yes. An inter-hospital service is needed but instead what is being proposed is a multipurpose service, the same as before. The multipurpose role of the Air Corps is reflected in the equipment they carry and in their availability. They are more often carrying Ministers from A to B than undertaking mercy missions. This will be a problem until helicopters for medical mercy missions are provided.

Ms Harney

The difficulty in the past was the Air Corps had a shortage of helicopters but it now has substantially more helicopters.

Dr. Cowley

Helicopters are always available for other things but not for health.

Ms Harney

The ambulance service, which includes this service, is being reviewed by the Health Service Executive.

Dr. Cowley

The ground service needs to be addressed.

Ms Harney

I will ask the HSE to look at the issue being raised by the Deputy.

Dr. Cowley

The Tánaiste referred to availability of money, the Hollywood report and the lack of funds. There is a crying need in the north west and the south east. The consultants in Waterford recently proposed a public-private partnership facility to provide a radiotherapy facility and private beds. Has the Tánaiste considered this proposal?

Ms Harney

I met the group which has connections with major providers in the United States. As Minister for Health and Children I cannot promote any single project.

Dr. Cowley

This is not a new project because it will be built in the grounds of the hospital.

Ms Harney

It is a private initiative on behalf of a developer. It would not be proper for me to promote any single proposal. I have also met another group of consultants.

Ms McManus

Charlie McCreevy did.

Ms Harney

I do not think that is a fair comment. He promoted investment perhaps in issues that the Deputy——

Ms McManus

He wrote to Dr. Sachs.

Chairman

There is a time constraint.

Ms Harney

He promoted a scheme of which Dr. Sachs may be one of the beneficiaries.

I met a group of consultants last week from Waterford Regional Hospital who have a proposal for a private facility on their own grounds.

Dr. Cowley

That is the proposal to which I referred, a public-private partnership.

Ms Harney

I am anxious to have a national service. I am having discussions this afternoon with Dr. Hollywood. Some innovative thinking will then be required about how to provide resources for the service. The amount of resources and staff required to provide a national service is not inconsiderable. We may be required to think outside the box. Proposals must be subject to a tendering process. We cannot just endorse someone who has come along, no matter how good the proposal is judged to be. I do not wish to play down the proposal but I reiterate I cannot endorse any particular individual proposal and the Deputy will understand my position.

Dr. Cowley

This is already happening in the mid west in Limerick.

Chairman

Deputy Cowley has made his point.

Ms Harney

The Mater Hospital is involved in the facility in the mid-west which will be linked into the Mater Private Hospital facility in Dublin. I believe the service will begin in the autumn with one linear machine.

Dr. Cowley

That would work for the north west also which has a crying need.

Ms Harney

I would love to think that a facility in the north west could be provided in conjunction with Northern Ireland.

Dr. Cowley

I do not think it will happen.

Ms Harney

We may well enter into discussions with the authorities in Northern Ireland post the election and the new regime, along the lines suggested.

Dr. Twomey

I am sure the Tánaiste is aware, as I am following my visit to Letterkenny hospital, that Northern Ireland has no interest in providing radiotherapy services to Donegal. They can barely supply the capacity for their own patients.

Ms Harney

That is true. They may be at full capacity in Belfast. There are two issues, the issue around breast surgery in Altnagelvin Hospital and the issue of radiotherapy. As politicians we should never give up trying to make things happen on a cross-Border basis. Health is one area where a lot of progress could be made.

On the smoking ban and the points made by Deputy McManus, the ban has been a great success but we cannot become complacent. I am mindful of the comments made by the Deputy. We did not want to take the foot off the lever in year one into the smoking ban because it is not just about the ban but also about promoting an anti-tobacco culture and trying to reduce the incidence of smoking, particularly among young people. We have serious challenges as far as young girls are concerned because there are very high levels of smoking in that population group in particular. It is a question of effectively targeting this group.

Dr. Twomey

The Minister does not have to answer these questions today. What would she like to see in a new consultants' contract?

Ms Harney

I will answer in two words, "greater flexibility".

Dr. Twomey

My other question relates to the inspection process to measure improved cleanliness in acute hospitals. Why is this needed? Our hospitals were cleaner 25 years ago than they are today. It should be a simple process of putting somebody in charge of the matter and making it the responsibility of an individual. This is the reason our hospitals have a problem with cleanliness.

Ms Harney

I do not know what the reason is. They are paying a high price to outside contractors to do the job.

Ms McManus

That is an example of the private sector.

Ms Harney

It is not the private sector because many places are spotless. If one visits Intel, Hewlett-Packard, IBM, in the morning, their premises will be spotless.

Ms McManus

They do not have 20 people on trolleys.

Ms Harney

I visited Abbott last week. Some 4,000 people work in Intel and as many again in Hewlett-Packard. It is a question of enforcement of standards and the Deputy makes a valid point. Mr. McLoughlin is head of the national hospitals office. He wants to audit in order to measure performance in respect of very simple tasks. This should not be necessary. As someone said to me recently, hospitals were spotless when the nuns were running them.That is a fact.

Chairman

The time has expired.

Mr. Gormley

Unlike other Deputies, I have not had a chance to ask a question.

Chairman

Deputy Gormley had five minutes allocated to him earlier.

Mr. Gormley

I was delayed in the Chamber because I was speaking.

Chairman

I thank the Tánaiste and her officials for attending the committee and for staying long over their time.