Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Wednesday, 4 Nov 1992

Vol. 424 No. 9

Private Members' Business. - General Medical Service: Motion (Resumed).

The following motion was moved by Deputy Owen on Tuesday, 3 November 1992:
That Dáil Éireann, conscious of the enormous worry being caused to 1.2 million people in the General Medical Service Scheme particularly to the elderly and the very young, by the possible withdrawal of a majority of general practitioners from the Scheme:—
—condemns the Minister for Health for his unwillingness to enter into meaningful discussions with the Irish Medical Organisation on a review of the Scheme;
—calls on the Minister to take steps to remove the threat of the collapse of the Scheme; and
—calls on the Minister to recognise the need for major investment in the Scheme, so that the quality of the service delivered is kept up to the highest standard.
Debate resumed on amendment No. 1:
To delete all words after "That" and substitute the following:
"Dáil Éireann
—notes the recent arbitration award to doctors in the General Medical Service involving a significant increase of 17.5 per cent, implementation to be negotiated in the context of negotiations for the renewal of the 1989 Agreement;
—notes that the review of the GMS Contract has been under way for some time and that, in that context, the Minister for Health has brought forward innovative proposals for the development of general practice which take account of the realities of the budgetary situation and the constraints of the pay provisions of theProgramme for Economic and Social Progress;
—regrets the decision by the Irish Medical Organisation to withdraw from the scheme while the review is continuing; and
—calls on the Irish Medical Organisation to withdraw its threatened action and to continue negotiations in good faith in a normal atmosphere free from the threat of withdrawal from the existing Contract.
—(Minister for Health).

I said last evening that this important debate on the future of the general medical service scheme takes place in a totally unreal atmosphere, characteristic of the atmosphere that has prevailed in this House over the past two or three days. Since last evening the position has progressed from being unreal into being quite bizarre. Again today we have had the unedifying spectacle of Government Ministers and party spokespersons for the two parties in Government squabbling on the national airwaves. At least this disgraceful position will end tomorrow. The people will have an opportunity in about three or four weeks' time of passing judgment on this Government, on all their performances and policies.

In relation to their stewardship of the health services — the focus of our debate this evening — I have no doubt that both parties in this Government share equal responsibility and that they can expect no comfort whatsoever from the people. I dealt last evening at some length with the overall state of the health services and the indebtedness of the health boards nationwide. I put that level of indebtedness on the record for all to see. That is simply an indication of the neglect of the health services in general. The motion this evening focuses on the threat to the general medical service scheme by the possible withdrawal of a majority of general practitioners from its operation. We have a very fine general practitioner service in this country, a scheme and service that has developed over the years and enjoys the trust of the people, particularly the most vulnerable sections of our community totally dependent on the system, the elderly, the unemployed and the poor. It is a service which has performed well, giving frontline, basic and comprehensive health cover to people at home and within their local communities.

I said it is a service in which the people of Ireland trust, but that trust has now been fundamentally damaged. In the course of this debate I do not want to spread alarm or anxiety among the many thousands of people dependent on this service. I have no doubt that, even if it comes to pass that the majority of general practitioners are forced to withdraw, there will at the end of the day be very few doctors who will turn away patients in need of their help or assistance. If that were to happen it would be flying in the face of everything for which the medical profession stands. I do not believe it will happen, but what I am afraid will happen is that there are people out there — the poor, the old and the sick — who will be reluctant to call a doctor. These people are proud and independent and would be extremely reluctant to, as they would see it, throw themselves on anybody's charity. That is what will happen, as happened when one of the Minister's predecessors introduced charges for outpatient visits, when the elderly in particular simply stayed away and suffered at home. The statistics will not be visible but the hardship will be real.

We are now coming into the time of year when elderly people in particular are at their most vulnerable. Some years ago this Government took a policy decision, euphemistically described at the time — I thought it was a good line — as the shortening of the heating season, as if a Government by decree could decide that they could shorten the period of time when the weather was cold. Of course, in reality that decision simply meant that the number of weeks every year when free fuel would be available to pensioners would be dramatically reduced. Already this year we have seen the coldest start to a winter for many years. I dread to think what will happen to hundreds of people who feel they cannot call out their doctor as the winter progressively worsens.

The Minister has told the Dáil, in answers to questions I put to him on 21 October, that he will make alternative arrangements to ensure that medical card patients continue to receive general practitioner services even if the dispute goes ahead. The Minister must know that the answer he gave is simply fooling the people since the health services are already staggering under the weight of the financial debt I outlined last evening and the cutbacks imposed by himself and his predecessors. It is inconceivable that any effective alternative arrangements could be put in place on the timescale available.

When this Minister has left office it may well be that the only thing for which he will be remembered will be the glossy charter of rights for hospital patients he produced. I predict that will turn out to be seen as the public relations stunt of the year, as meaningless as any of the other Government policies simply because it was unresourced in any way. That charter is the only place one can read something about Ireland's health services, but one does not see the reality of patients on trolleys, beds in corridors or nurses and paramedical staff being laid off. That is the reality of Ireland's health service today. The crisis facing the general medical service system can only add to the sense of injustice surrounding the operation of our health services in 1992.

The Minister spoke last night about the high cost of high-tech medicine. I share his view that there is probably no developed country in the world which can afford an open-ended budget for health expenditure. It is a system that can absorb all the money that can be made available to it. It affects even the very rich countries. We have seen America fight a presidential election with the quality of health cover and health insurance as a major issue for both main presidential candidates. Therefore, it is clear that every country is faced with a challenge and a crisis in relation to proper, adequate and comprehensive medical cover for all its citizens. Surely in the light of that fact the general medical service, which is the front line service, should have priority.

The total expenditure on the GMS as a percentage of all health expenditure was outlined in detail last night. It is clear that if we properly resourced primary front line care, which is the GMS, there would not be the need for many of the more expensive hospital based procedures that are currently embarked upon. It is false economy for the Minister not to recognise that reality. It was also a false economy for his predecessor to close down geriatric hospitals, county nursing homes and other small hospitals up and down the country which cared for geriatrics and people who were convalescent. What happens now when those elderly people become sick and simply require a couple of days rest as opposed to intensive medical care? They enter acute hospitals where the cost of taking care of them is three or four times greater and force out people who need more acute care. That is a false economy, a wrong policy. I hope the Minister will recognise that and set about rectifying the situation.

The Minister spoke also last night about re-organising the GMS. He referred to multi-centred group practices, co-operative centres, shared facilities and other matters. I wish to state in relation to those suggestions that the patient must be the focus of any new arrangements and, in particular, any new arrangement that is put into place must have as its centre the right of the patient to select the doctor of his or her choice, and not the one that is convenient to any new re-organisation. The Minister also spoke last night about indicative prescribing targets. He emphasised that any such targets should be realistic but I am concerned that there would be a widening disparity, if that sort of objective was pursued, between the level and quality of service available to private as against public patients. I would ask the Minister or the Minister of State when responding to the debate tonight to explain in greater detail exactly what is meant in the script by the sentence that the Minister was seeking a greater contribution from other sources. What exactly are "other sources" in relation to the GMS?

It is clear to me that this is probably the last time I will speak on a health issue in the 26th Dáil. The current Minister is not very long in office. He came to office amid great expectations from all sides of the House and, indeed, from the broader public. Sadly, he has neither halted nor reversed the damaging health policies of his Fianna Fáil predecessors.

I am surprised that the Deputy should say that.

The last Government fell because they ignored one aspect of the health services during the crisis of 1989. It is perhaps appropriate that this Government will also fall in a week when they ignored another.

Acting Chairman

I now call Deputy Cullimore but I must remind the Deputy that the Minister exceeded his time by four minutes last night, therefore, the Government speakers will be penalised by four minutes.

Four faults.

The last hurdle.

With the permission of the House I wish to share my time with Deputy Michael Kitt.

Acting Chairman

Is that agreed? Agreed.

I would like to congratulate the Minister on his appointment and the excellent work he has done in the area of health since his appointment. I find it difficult to understand Deputy Howlin's argument. We must address this problem on a constituency basis. Prior to 1987, when Deputy Howlin was a member of one of the Coalition Government parties, in my own town we had no new hospital or no new paediatric unit, but under the present Government we now have——

What about the GMS?

It is important to put on the record of this House the hypocrisy of the Deputy——

You will have three weeks to do that.

Acting Chairman

Deputy Howlin was given time without interruption. Please allow Deputy Cullimore to continue.

He should speak to the Chair.

Acting Chairman

I agree that the Deputy should address the Chair.

Deputy Howlin has been critical of the Minister but he has not taken into account his own situation and that of his party while in Government. If this is my last occasion to address this House, it is important that I put on record the work of this Government and of the previous Fianna Fáil Government. All of the Fianna Fáil Ministers helped to ensure that we now have a new hospital and a new paediatric unit in Wexford town. When the Deputy criticises this Government and this Minister for Health, it must be put in the context that the Deputy and his party while in Government failed to provide those services for the people whom the Deputy and I will be canvassing next week.

I take this opportunity to pay tribute to the efforts being made by the Minister to bring the current GMS review discussions to a successful conclusion. We are fortunate that the Minister has had many years experience in general practice and has, therefore, a unique insight into the operation of this service. I know that the Minister has a particular interest in developing our primary care services and, in so doing, involving general practitioners to a much greater extent in primary health care delivery. I could not agree more with the Minister in his view that there is too much emphasis on expensive, high-tech, hospital based medicine. This is not to say that we should tolerate an inferior quality hospital service. However, we need to keep a sense of proportion in our approach to the development of our health service to ensure that our primary care services, which are the first point of contact with the health services for most people, are adequately developed.

We are very fortunate in this country to have a high quality health service, including general practitioner services. I support the Minister's view that there are certain structural flaws within general practice which, if overcome, would go a long way to solving the concerns of doctors. The current review has paid considerable attention to this very important issue.

Health care is a major issue and a major problem in most of the developed world. Indeed, as Deputy Howlin said, it was one of the key elements in the recent US presidential election. Why? Because health care affects every individual and every family. It affects working people and people who are out of work. Health care affects the young, the middle aged and old, literally everyone from the cradle to the grave. Good health is a marvellous thing that one does not appreciate when one has it. Increasingly, we become more aware that health is an asset. We have to invest in it as individuals and as a nation. We must do this in a way that makes the most of our assets. One of our best assets is local, family based health care. Other countries envy Ireland's GP service. If one is not feeling well, a doctor that you know and who knows you, is available at affordable cost or at no cost at all. Our GPs are, quite literally, family doctors. They provide a service when one of the family is sick, but they do much more than that. Our family doctors provide health education, helping people to change the kind of lifestyle that leads to ill health, and they provide counselling.

If one looks at problems such as domestic violence against women or the effect of alcoholism on a family, in the majority of cases the crucial intervention which helps the victims cope is the intervention of the family doctor. In addition, it is often the family doctor who helps people to come to terms with the unplanned challenges of life, perhaps an unplanned pregnancy or the hurt of redundancy. General practitioners often provide a thoughtful, sensitive and non-judgmental resource to help people sort out such challenges. Our GPs are of pivotal importance to our overall health. We must continue to acknowledge their importance. At a time when so-called professionals are downing tools and walking away from their responsibilities because of perceived dents in their honour, it is important to recognise the real heroes of this country who include the men and women who look after our health. Sometimes we forget that or are misled so that we begin to think that machines are the heroes — the CAT scans and the high-tech gadgets. We should be wary of that.

Our health services should not revolve around big institutions, computerised machines or magic bullets. Our health services should set out to empower the patient. Sometimes we start with the money that is available, with the systems and technology or with the expertise, but not with the patient. Our GPs are the caring face of an otherwise faceless uncaring and at times inhuman system. Efficiency and sophistication can sometimes be delivered in a way that diminishes the individual. In the search for cures we can often lose sight of the importance of caring. Tonight, I have a great sense of freedom in saying this. It comes from the fact that tonight we are seeing the end of the Coalition. That is relevant because I have been afraid over the last while that Fianna Fáil were getting sucked into a hard right wing way of thinking that is the Progressive Democrats way of thinking. The Progressive Democrats way of thinking is all about lowering income tax. It is a harsh yuppy self-satisfied way of thinking.

No Progressive Democrats bashing, please.


Acting Chairman

Order, please.

Such unfaithfulness.

Acting Chairman

Deputy Cullimore to make his contribution, without interruption.

Deputy O'Connell is a doctor, a man with a personal history of care and commitment and a Fianna Fáil Minister who is concentrating on his job and I wish him continued success.

Even though the Minister took three minutes of my time I sincerely compliment him on his efforts to resolve the GMS dispute. I would like to share the remainder of my time with Deputy Callely.

It is sometimes said that a teacher would not be a suitable Minister for Education or a solicitor a suitable Minister for Justice but the Minister for Health because he is a medical doctor who knows the health services inside out, particularly the GMS, has been doing a very good job in the negotiations so far. I was glad that when speaking last night the Minister mentioned that the patient should always be the primary concern.

In rural Ireland the capitation system which was introduced has been by and large successful. Family doctors would like to see an increase in capitation. GPs in rural Ireland and their patients have told me that for a full year's treatment, irrespective of the number of visits the doctor makes, the doctor is paid £45 per patient and he is expected to fully equip his surgery and provide secretarial services on that. The doctors say that they receive about £21 per annum per patient after tax. Capitation and taxation have been discussed in these negotiations. Independent surveys suggest that GPs should be paid £92 per patient annually. There should be more investment in the GMS. If there was we could provide a wider range of services and facilities for the GPs leading to shorter queues in hospital casualty departments.

If we had an increase in capitation with the benefits about which the Minister spoke we would have a very good service. The improved benefits the Minister mentioned were in relation to the 1989 contract under which a superannuation scheme was introduced with a State contribution of 10 per cent as well as payments for out of hours consultation and visits, a contribution towards the cost of employing practice nurses and secretaries and specific payments for a range of special services such as the ECGs and the nebuliser treatment. There would also be a contribution towards the cost of employing locums for doctors on annual leave, sick leave, maternity leave or study leave, a doubling of the rural practice allowance to over £5,000 per annum, payment of a fee for a second medical opinion, payment for out of hours special services within groups of partnerships on a rota arrangement and the introduction of earlier retirement arrangements. I understand that almost all doctors providing GMS services opted for this new style of contract on the basis that it would be reviewed after one year and again in March 1992.

Both the Minister and Deputy Howlin referred to the question of group practices. I was glad that the Minister spoke about setting up a central medical centre which will be equipped to provide facilities for all members of the group. I was amazed recently to find that doctors have to incur a great deal of expense in renting health centres from the health boards. One doctor told me that he was paying £3,000 a year rent to the health board for a health centre. This rent had trebled over two years. The idea of a group practice facility, putting the patient at the centre of the practice would be a worthwhile move. I hope the Minister will follow up on that.

One of the interesting features of the 1989 contract is that it provides for two reviews, the first after one year and the second after three years. The first review was carried out in late 1990 under the chairmanship of Mr. John Horgan, former chairman of the Labour Court, and its findings were published in February 1991. The recommendations which covered both the payment and service issues were implemented in 1992 at an additional cost of £4 million. The second review began early this year under Professor Tom Murphy's chairmanship and it has involved an extensive and detailed examination of the widest possible range of issues of interest to general practitioners as well as to health services management. It would be a great pity if that process were not allowed to continue as it appears to offer the possibility of breaking new ground in the organisation and management of general practice.

I should like to make a few comments on the statement made last night by Deputy Howlin. The Deputy suggested that we were nearing a stage at which general practice services may be available only to those who can afford them. I think I heard the Deputy right in that regard.

The Deputy also suggested that the gap between the quality of private and public general practitioner services was widening. Statements of that kind are not helpful. They serve only to create unnecessary fear and anxiety in the most vulnerable sections of the population who are dependent on the general medical services.

Ireland has an excellent general medical service that provides the fullest range of care for medical card holders on the same basis as for private patients. The general medical service represents very good value for taxpayers' money.

I hope the discussions in the House last night and tonight will lead to a better health service. The Minister is certainly approaching the matter in the right way. I completely disagree with Deputy Howlin in his statement that the Minister has failed in his role as Minister. The Minister is doing an excellent job, and I make that statement also as a member of a health board. The Minister has been very forthcoming in his meetings with health boards, particularly the Western Health Board, of which I am a member.

I appeal to the IMO to withdraw their threatened resignations and to continue the negotiating process within the review. In that way it may be possible to resolve present difficulties.

It is not just because Deputy Owen placed a Private Members' motion before the House that I rise to express my concern. I have previously communicated the concern of patients in Dublin North Central. I have before me a three-page letter from the Minister for Health dated 13 October which is in response to the letter I sent him. I wish to begin by quoting a couple of lines from it:

I fully recognise the major role played by general practitioners in the overall provision of health care and I have been anxious in the review to identify areas where their contribution could be enhanced in a cost-effective way.

The general medical services scheme is very highly regarded by patients. It is therefore most unfortunate that doctors are threatening to withdraw from the scheme, particularly while discussions reviewing their contract are taking place. The Minister's proposal, which were outlined in the House last night, represent a major step forward in the resolution of the fundamental issues that need to be examined in a review of general practice. The Minister has accepted the need for investment in the capital development of general practice in order to bring about the organisational changes required. For example, he proposes to provide incentives for the development of more group practices and for a better cross-cover between existing practices. That initiative will provide greater continuity of care and a more comprehensive range of services by general practitioners. Such improvements will be important factors in implementing the policy of refocusing health care delivery on primary care.

When discussing the question of investment in general practice we need to examine expenditure trends in the GMS scheme in recent years. Last night reference was made to the need for the Minister to do something about the price of drugs. Before being elected to this House I had personal experience in the pharmaceutical industry and in the sale and marketing of drugs. I know of the concern about drug costs and of the public perception of the pharmaceutical industry. It is important to recognise that the Minister indicated in his contribution that drug prices have been stabilised in the past two years. That results from a pricing agreement between the pharmaceutical industry, FICI, and the Department of Health. That agreement has served the State well, outside of all the other benefits of the pharmaceutical industry in terms of employment and so on.

The problem with expenditure on drugs in the GMS scheme is not caused only by the pricing structure but also by the larger volumes and the more expensive drugs being prescribed. Notwithstanding the price stability, there has been a constant increase of 11 per cent in GMS drug expenditure in past years. By the end of this year the GMS drug bill is expected to be more than £130 million. It is obvious that the continuing increase in GMS drugs expenditure uses up resources that could be more effectively utilised in meeting other health services needs, including the development of general practice.

The main point I wish to make is that meeting doctors' demands for State investment in general practice is to a large extent in the hands of the medical profession themselves and that it is in their own interests that workable arrangements are agreed as part of the current review process for implementing safe and cost-effective prescribing.

I am aware that the IMO accepted some time ago that the level of prescribing in the scheme could be reduced without any adverse effect on the quality of patient care. I welcome the Minister's proposal for the introduction of realistic drug targets for individual general practitioners and the fact that a proportion of any savings generated from the operation of those targets will be applied towards general practice development. Such an approach, based on consultation and incentives, has a much better chance of success than other more drastic measures. The administration of those targets by local general practice development units will greatly improve the chances of success.

In a discussion on the question of prescribing costs one would have to accept that there are factors that influence prescribing over which individual doctors have limited control. Many doctors are faced with pressure from patients to prescribe, pressure resulting from receiving hospital prescriptions and pressure resulting from public education programmes, because of which patients now demand a drug of their own choosing.

The Minister made a valid point in his contribution last night that if general practice was reorganised along the lines set out in the proposal that has been put before the review it would be possible to reallocate resources for the development of this service. That is particularly true in the case of expenditure on drugs and medicines in the GMS.

I sincerely hope that both management and general practitioners grasp this nettle once and for all and work out a satisfactory way of bringing the problems of prescribing under control. I wish to pay tribute to family doctors in the GMS. We all know that when a doctor operating within the GMS is telephoned it may not be the doctor who will answer but his wife or his children.

What about the husband.

I pay tribute to the doctor, their spouse and children.

That is better.

I want to pay tribute to them for their great dedication. I know they will be reluctant to disrupt this excellent service and I am confident that with goodwill on both sides agreement will be reached in the best interests of the patient.

Acting Chairman

I now call on Deputy Lee. I am informed that Deputy Lee wishes to share his time with Deputies McGrath, Cotter and Browne (Carlow-Kilkenny). Is that agreed? Agreed.

It is indeed truly apt, right, fitting and significant that the only medical practitioner on the Opposition benches is addressing the House in the last Private Members' Business in the lifetime of this Dáil. What Members will hear is the truth, the whole truth and nothing but the truth concerning the primary care medicine here; not the truth, the whole truth and anything but the truth that this country have been hearing in the last two weeks from the Government parties. Shame on them; their day has now thankfully finally come. Earlier this year the Taoiseach appointed one of his cronies to be chief executive——

Acting Chairman

The Deputy should withdraw that word.

I withdraw that word. The Taoiseach appointed one of his friends to be chief executive of the VHI and in a glorious publicity stunt he refused any salary but what the public does not know is that the VHI had to hire a top of the range Mercedes and a chauffeur to drive his car. In addition, this close friend of the Taoiseach has the personal use of all gold credit cards.

The Minister, and he alone, is entirely responsible for the crisis with the general practitioners. As the old saw states, "doctors differ and patients die". In fact, most patients do not die because most suffer from non-fatal illnesses which are of themselves limiting in nature. Although death must come to us all, it is far from clear what effect either medical care or health services have on longevity and life expectation; not least when they occupy the post of the Minister for Health in an Irish Government.

The Minister has a reputation of talking before he thinks — an unfortunate practice for one in charge of such a sensitive area as the health services. His careless and callous remarks on the efficacy of bypass surgery gave rise to public anxiety among the families of those patients who were awaiting for and have had bypass surgery. His performance is shaped by that element of medical education which seeks to forge change in society which creates the high profile campaigners in pursuit of Dr. O'Connell. His track record in office to date is largely one of impetuous commitment and erratic delivery on promises made. Bluff and bluster, sanctimonious sham, pious hypocrisy are his hallmarks.

Earlier this year I was present, as were 300 other general practitioners, in Jury's Hotel at a crisis meeting, which the Minister addressed, of doctors threatening to resign from the General Medical Service. In front of the television cameras and concerned doctors he said he would award the 17.5 per cent increase to general practitioners to be effective from March 1992 and paid in December 1992. He said that if the doctors agreed to set up an independent review committee, to be chaired by his nominee, Professor Tom Murphy, a card-carrying member of his party, this award would be independent of any finding of the review committee. Those were his exact words.

Approximately one month later, in the time honoured manner of the dirty tricks department of the Department of Health, the Minister said this award would not be paid unless the GMS review was successfully completed. This GMS review is a completely independent issue and has nothing to do with the 17.5 per cent award.

The Minister broke his word given to his peers, given to his equals, people whom he trained and worked with and who trusted him. He, and nobody else, is totally responsible for the current situation. Is he now going to verbally assault, intimidate and threaten me outside this Chamber as he did before on the Temple Street Hospital debate?

Health cuts are like a death in the family — until they hit you you know nothing about them and nowhere is this more true than in the present primary care health service which the Minister boasts about. The truth is that general practitioners, family doctors, are expected to care for a patient's entire medical needs for £45 per year. General practitioners' costs are 55 per cent of their gross take.

If one has to call out a plumber, a vacuum repairer or a washing machine service man or if his drains are blocked over the weekend nobody will not show up unless one pays £50 up front. The contrast is simple. The Department pay highly trained expert general practitioners to look after the most precious of all concepts, life, £45 gross for the year.

Two weeks ago I submitted a written Dáil Question to the Department concerning occupational therapy facilities for the city of Dublin. The Minister glibly replied to my question that the information was not readily available. One of those questions asked the number of patients on the waiting list to be assessed for occupational therapy. The answer is, 500. There is a one year assessment delay on whether a patient requires a handrail on stairs, a bath seat in a shower and special door knobs and tap knobs if a person has arthritis. It takes a further year for this assessment to be implemented — two years in total which at that stage of one's life is equivalent to five years. There are two occupational therapists, people who have expert knowledge in assessing the needs in the care of the elderly, job-sharing in community care area. That means there is only one occupational therapist for assessing and implementing the needs of 15,000 elderly people.

In addition we now have a new illness in the Irish medical lexicon specific only to Dublin and it is called the Fianna Fáil-PD toenail. It needs to be clipped or manicured only three times per year. The Minister has introduced cutbacks even in the chiropody service. Medical card patients over 65 years are now entitled to three treatments per year. They must pay handsomely for any further treatments. Many of these people have poor sight by virtue of their age. Many are obese and suffer from arthritis and they are unable to clip their toenails never mind see them.

Hundreds of people require domiciliary physiotherapy services in Dublin, for example people with post-operative hip replacements, people with extensive osteo-arthritis of the feet, knees, hips, hands or shoulders. I repeat, we have no community physiotherapist in community care area 7 in Dublin to do domiciliary visits. We general practitioners have no access to primary referral nutritionists for treatment of our patients. There must be something wrong. The recent emphasis of transferring care from the hospital sector to primary care without the appropriate funding has finally forced the overstretched general practitioners to withdraw from the General Medical Service contract.

When will the Department awaken to the fact that they get better value per pound from the general practitioner service than from any other branch of the health services? It is essential that a national council for general practitioners, preferably a statutory body, be set up in order that the needs of general practice in the future in Ireland are properly assessed and adequately resourced.

I welcome the opportunity to contribute to this debate and I commend Deputy Owen for putting down this motion. It is very important on what is perhaps the last night of regular business for the 27th Dáil that we should discuss the service given to 1.2 million medical cardholders.

People of my generation will recall the structured medical service which existed during the fifties, usually a doctor based in a dispensary serving a defined geographical area. This rural dispensary usually duplicated as the local pharmacy. This building was provided, owned and maintained by the local authority of the day. Usually a nurse was available in the locality and a caretaker repaired and maintained the building. Over the years the State failed to maintain this service and allowed these dispensaries to fall into disrepair; in many cases it disposed of them altogether.

In 1970 the choice of doctor scheme was introduced to replace the dispensary system. Under this scheme patients could attend a general practitioner of their choice. This involved an important shift in responsibility for providing and maintaining premises from the local authority to the local practitioner. Under this scheme the GP was to receive a composite all-in-one fee described as a fee per item. As this scheme was developed over the years GPs were subsequently accused of abusing it. For example, allegations were made that they were overprescribing drugs, encouraging patients to make unnecessary calls to surgeries and making many unnecessary housecalls themselves.

Accordingly, in 1989 the now infamous new contract was introduced. This gave GPs a fixed fee per patient, ranging from £15 per annum for a child up to 15 years to £74 per annum for an old age pensioner residing ten miles from the doctor's surgery. This contract dictates, among other things, that doctors work for 365 days a year, and for 98 hours per week. During the same years the hospital service, which is complementary to the medical service provided by general practitioners, has developed at a magnificent rate and we can now rightly boast of having a very high standard of hospital care. However, there are long waiting lists for some procedures. These waiting lists are topics for another debate; I will not go into them tonight.

GPs cannot now afford to invest in the infrastructure or equipment needed to provide an adequate service. Young highly qualified and highly motivated GPs, full of new ideas and armed with new techniques and procedures, are cash starved and cannot afford to provide certain procedures which they are qualified to supply. Some who endeavour to provide certain procedures and invest in the necessary technology and equipment quickly run into debt and have to abandon their efforts. This results in the stunting of the potential of our medical service which, as I have already said, they are well qualified to supply.

This remarkable situation provides an incentive to GPs not to invest in infrastructure or new technology. As a result some of our surgeries and medical centres are, I respectfully suggest, of a third world standard — hard benches in cold draughty waiting rooms, no wash-hand basins or toilets, etc. I understand that half of the GPs in Dublin and 40 per cent of doctors in rural areas have no secretarial back-up. One and a half million Irish citizens avail of this service. They are mainly the elderly, sick and young; in other words, the vulnerable in our society.

I ask the Minister what these people will do after 8 December? They cannot afford to pay for their treatment; otherwise they would not have a medical card in the first place. Are they to be forced to beg for free treatment from their GP, the person who has treated them so loyally and conscientiously over the years? Are they to risk going without their repeated prescriptions and necessary regular check-ups and not call out a doctor when they are sick during the night? Are they to clog up the outpatients' departments of general hospitals still further? Of course, we have to remember that at the same time the Department are telling GPs they are sending too many patients to hospital, that they are responsible for much of the overcrowding in our hospitals.

What about the anxiety of these medical cardholders who are faced with the prospect of receiving no medical treatment after 8 December. What assurance can I give to medical cardholders in County Westmeath that the Minister will live up to his responsibility and provide a general practitioner service for them after that date? Will the Minister allow the strike to go ahead? He seems to be standing idly by at present. Will he continue to allow the general practitioner service to decline? Will he continue to preside over a service which, because of a lack of capital funding for recruitment and equipment, is going to overload the hospital service?

Similar public services, for example, the Garda, FÁS, employment exchanges, etc., have been improved over the years. Yet nothing has been done for general practitioners. We are returning to the two-tier system which existed during the fifties, a system starved of cash which backs the basic facilities to enable GPs to carry out basic procedures in local surgeries and help to reduce the present overcrowding of the hospital service. I ask the Minister if it is reasonable to expect a GP to treat a medical card patient for one year at a net average gain to him of £11? I understand that GPs claim this is the amount they receive for this service. Is this the value of the service provided by GPs? Is it not a derisory sum for the quality of the service which they so loyally provide? I call for support for this motion?

I wish to share my time with Deputy John Browne.

Is that agreed? Agreed.

At the outset I urge the Minister, together with the IMO, to immediately negotiate a settlement to this dispute before a strike takes place. In view of the events of the past week, I wonder how much time the Minister has been able to devote to thinking about how this problem can be solved in the near future. I wonder if he had to devote some time over the past week trying to find a cure for the Taoiseach's mania at the Beef Tribunal which led to the destruction of the Government? I do not know how one could describe the Taoiseach's mania. Perhaps it could be described as "coalitionitis", or "anti-Progressive Democrats hysteria". I wonder if the Minister, who is a doctor, has been able to find a cure for this ailment? If he has found a cure he is too late; the cure should have been found earlier in the week. There is no doubt that the major problems facing us at present are not receiving the attention they deserve from Ministers or the Government who are looking at their neighbours and wondering where they will be in three weeks' time. I am sure they are getting good indications that they will be relieved of their duties fairly soon. I believe the public at large will make that decision when they get a chance.

So far as I am aware, it is unprecedented for doctors providing this service to take this kind of action. In general, doctors are a very caring group; that is the nature of their business. My experience has been that doctors take their work very seriously. The doctors in my constituency with whom I have discussed this issue feel they are being forced to take this action. They are extremely worried about the effects it will have on their clients, medical cardholders, within the GMS. It would be easy to think that doctors will pursue a policy of brinkmanship where they decide on 8 December not to go ahead with this action. It would be very foolish to adopt that sort of attitude. I hope the Minister does not think this is what will happen. It would put the whole service into chaos and put at risk the lives and the health of many people. The doctors are seriously aggrieved. If they did not have very serious grievances they would not be contemplating such action. Doctors in my constituency are very concerned about what will happen and about the Government becoming involved in brinkmanship. The effects of the proposed action would be enormous. Many people will not go to the doctor because they will not have the cash. This applies particularly to those trying to rear families, as well as many of the elderly. They would be ashamed to ask for services for which they cannot pay. Unless the problem is resolved, they will have to pay after 8 December. This is a great worry for many people because they know they will not be able to get assistance unless the Minister takes his responsibilities seriously and enters into negotiations to resolve the matter in good time.

Last night I attended a meeting in Monaghan town called by the Hospital Retention Committee. I was late arriving at the meeting but it transpired that two local Deputies had received a letter from the Minister during the past week. The contents of the letter were to the effect that the services at Monaghan General Hospital would be maintained at the current level. In a week such as this one would not expect people to believe the contents of such a letter. That was exactly the reaction last night. Who could believe anything emanating from this Government? There is a huge credibility problem which was evident at that meeting in Monaghan. Many supporters of the Government who attended the meeting cast doubt on the relevance of the letter and queried its dispatch to two local Deputies, particularly when we are facing into a general election. The whole exercise was regarded as quite cynical. I am asking the Minister to state that the letter was not a farce and that he intends in the future, in so far as he will be in control, that the services at Monaghan General Hospital will be maintained. I would also ask him to state that Comhairle na nOspidéal do not have his authority to put a plan into operation which will remove services from Monaghan General Hospital.

I am speaking for the people of north Monaghan in particular, the people of Monaghan town, Carrickroe, Emyvale, Glasslough, Scotstown and Tydavnet who tell me they are extremely worried that the facilities of Monaghan General Hospital will not be available to them in the near future. Without that hospital they would have to travel long distances along very bad roads to Cavan or Drogheda. Their lives would be put at risk if their health was in danger. I am asking the Minister to state clearly his position with regard to Monaghan General Hospital and to do so tonight rather than during the week when he might send out another letter under pressure. It is intended to run a hospital candidate because of the cynicism they feel regarding the Minister's actions.

I will give the rest of my time to Deputy Browne.

(Carlow-Kilkenny): Confidence in one's GP is as important as the medicine he or she prescribes. Anything that affects that confidence is to be avoided like the plague. The Minister followed that line in his speech yesterday when he stated:

Therefore, let me assure Deputies, at the outset, that while I am confident of a successful outcome to these discussions, in the event of this not happening the health boards will ensure that free general practitioner services and free drugs and medicines will continue to be available to persons covered by medical cards.

I wish to consider the possible effects in Carlow. All the GPs in Carlow are members of their organisation and they have all tendered their resignation from the GMS. There is no county hospital in Carlow. We have a district hospital which is looked after by the GPs and an excellent nursing staff. The hospital services in Kilkenny are in such difficulty that patients are often accommodated in corridors. Our hospital services are quite inadequate.

How does the Minister intend to look after medical card patients in Carlow when the GPs have withdrawn from the system and there is no major hospital in Carlow? The prospects frighten patients. Elderly people are worried about who will look after them if they become ill. I do not see any solution for them in Carlow.

The Minister concluded his speech last night as follows:

Finally, I would again take the opportunity to allay any fears that might exist among medical card patients and to assure them that free general medical services will continue to be available to them after December.

Who will provide the service if there are no doctors participating in the scheme? The farmer, the teacher and the general handyman can hardly step in. There is an onus on the Minister to negotiate with the medical profession. I accept that he is doing things his way. He stated that his objective was to reach agreement with the IMO and that he was confident of having the goodwill of the doctors in reaching that objective. I am quite sure he will have the goodwill of the doctors, who do not want to withdraw services from their patients. There is a marvellous relationship between GPs and their patients. One could not pay great enough tribute to general practitioners who without the use of X-rays and modern apparatus can diagnose what is wrong with a patient. The Minister said he was planning to expand services provided by GPs, thereby saving hospital beds. That is marvellous, provided that the money and the necessary facilities are provided. Doctors cannot be expected to provide all those services and not be financially rewarded. I ask the Minister: who will take care of the patients when the doctors have gone?

I shall explain the matter of time to the House. The excess of four minutes taken by the Minister last night was compensated for earlier and, accordingly, the provision that anticipated that not happening had to be altered. Therefore, it is preferably in order for the Minister of State to take five minutes.

First, I want to take this opportunity of congratulating Deputy Owen on her appointment and to express the hope that it will be one of long duration.

It will finish tomorrow for one month.

At the outset I would like to place on the record of this House my complete rejection of the assertion implicit in Deputy Owen's motion that my colleague, the Minister for Health, has been "unwilling to enter into meaningful discussions" with the representatives of the doctors involved in the provision of services in the GMS scheme. Nothing could be further from the truth. On assuming office as Minister for Health, Deputy O'Connell identified as one of his highest priorities the enhancement of the role played by the general practitioner in the overall provision of health care and he undertook to work to restore the general practitioner to what he described as his righful place as a pivotal player in an integrated health delivery system.

The review of the general medical service which commenced earlier this year offered the ideal opportunity to give effect to these aspirations and, seizing that opportunity, the Minister tabled a blueprint for the future development of general practice at an early stage in the review discussions. This document involved a complete root and branch examination of the current role of the general practitioner and identifies the current deficiencies in the system which mitigate against the general practitioner discharging the enlarged role envisaged for him by the Minister. This blueprint goes on to outline radical proposals for structural change at local and national level. It is indeed heartening to note that agreement has been reached in principle with the doctors' representatives on the broad policy content of this document.

I am acutely aware, from contact with the Tallaght-Clondalkin GPs in my own constituency, of the particular problems facing general practice in large suburban areas. The inclusion in this document therefore of the proposed establishment of general practice development units at regional level, with a remit to develop services tailored to meet local needs in consultation with general practitioners on the ground, is a particularly welcome initiative and will benefit the patient.

It is important to point out that the review process is ongoing. I understand that there have been to date 11 plenary meetings, with another one scheduled for later this week, and over 25 subcommittee meetings covering the widest possible range of subjects identified by both sides as being of importance. In the light of all of this, therefore, I think Deputies will agree that the Minister's approach to the review can scarcely be characterised as an "unwillingness to enter into meaningful discussions".

In response to Deputy Owen's call for a recognition of the need for major investment in the scheme, it is worth reflecting for a few moments on the current levels of expenditure on general medical services. The total cost of the GMS for 1991 was £176 million. The cost for 1992 is expected to rise to almost £194 million. The total amount of fees and allowances paid to the 1,600 doctors involved in 1991 was £56 million, or an average of £35,345 each. This is before account is taken of the 17.5 per cent arbitration award already referred to by the Minister which would increase the average to £41,530. Implementation of this award would cost £20 million in 1993 and would increase the average payment per doctor by £7,000 per year or £135 per week.

While it is recognised, of course, that there is a need for a continuous programme of investment in the development of general practice, I think Deputies will agree that in the current financial climate these figures indicate that this Government's response to the needs of general practice cannot be faulted.

In relation to the threatened withdrawal of services, it is regrettable that, despite the arbitrator's recommendation and the fact that the GMS review is currently underway, GPs have now decided to withdraw their services from the medical card population.

(Carlow-Kilkenny): They are forced to do it.

Notwithstanding this, I feel confident that Deputy O'Connell will use every means at his disposal consistent with Government budgetary and public pay policy to avert the threatened dispute. It is against this background that I appeal to the doctors' representatives to continue to act responsibly and in the best interests of their patients and to seek solutions to their problems in the context of the ongoing review negotiations.

(Carlow-Kilkenny): The Minister should act responsibly.

Deputy Howlin inferred in his contribution that the Minister's organisation proposals did not take account of the patient. The fact is that the proposals have been put forward for the purposes of providing a more comprehensive service for patients. Deputy Howlin also asked if I would clarify what the Minister meant in his speech last night when he referred to a greater contribution being made by other sources towards the development of the public health services. The position is that my colleague, the Minister for Health, is exploring a number of options in relation to this matter. As these options have yet to be fully explored and finalised, it would be foolish to elaborate any further.

Deputy Lee referred to the question of access of GPs to other primary and secondary care services as being one of the important issues. That is precisely what the Minister has put forward in his proposals to improve the situation in the current review. I will conclude by strongly recommending the Minister's amendment to the motion.

The Chair appreciates Deputy Owen's consideration in not crying stop.

I will concluding the debate but I am giving the first five minutes of my time to Deputy Creed.

Is that agreed? Agreed.

I thank Deputy Owen for allowing me some of her time to contribute to this debate and, as time is scarce, I have only a few salient points to put to the Minister. I would first like to ask him a question. Where does this crisis, involving 1.25 million patients dependent on medical cards for access to the services, leave the patients charter? That charter was hailed as the saviour for the health services but it has turned out to be a smokescreen behind which the Minister can hide. It has no credibility whatever. The last thing we need in the Department of Health is administration through public relations. We need resources, commitment, tolerance and understanding. As we are on the brink of a break-up of the Coalition Government, it is ironic that the coalition which should exist between the Minister for Health and the IMO is also teetering on the brink. That illustrates the lack of tolerance and understanding in the Minister for Health's comprehension of negotiation and consensus. The only consensus that appears to emanate from the Government benches, not just from the Department of Health, is that people must accept their view or reject it. We need serious negotiation on this issue, not public relations. As I said, one-third of our population is dependent on medical cards and in my constituency that involves approximately 10,000 people. I would advise the Minister that if he has any respect for his colleagues or indeed his colleague in my constituency, Deputy Kelly, he should make every effort to resolve this impasse sooner rather than later.

That is what is happening.

What will happen on 8 December when 10,000 patients queue up at the Gouldshill health office to have their prescriptions renewed? There will be total chaos. What will happen in regard to the anxiety which will exist between now and then when patients fear they will not have access to their GPs? People will become ill and there will be chaos on the doorsteps of our general hospitals. The buck stops with the Minister for Health.

It is ironic that the last Government under Deputy Haughey fell on a health issue and this Government, in the last debate in Private Members' Time will be defeated on a health issue. Crass incompetence and public relations are all we have had from the Minister for Health. Community care has been the Cinderella of the health services for too long. It does not come cheaply. We have a two-tier system in our hospitals and it appears to be the Minister's intention to create a two-tier system in the area of general practice. The Minister should not underestimate the resolve of the GPs on this issue. They are as convinced of the righteousness of their cause as any pressure group I have ever seen and they should be heeded. The bottom line is that patients will die if this issue is not resolved and the blame will rest fairly and squarely on the shoulders of the Minister and the Minister of State.

That is ridiculous. The Deputy is causing people unnecessary concern.

I want to start by thanking all my colleagues on the Fine Gael benches and my colleague, Deputy Howlin, on the Labour bench for their contributions to this debate. We on the Opposition benches have listened and learned about the nature of the dispute now threatening the GMS. I condemn the members on the Government benches who have clearly been receiving the same message but who have not listened to it and have not accepted it. Somehow or other the blindness and the deafness of this Government has led to the situation we are in now where we are facing an election. In this eleventh hour of this Dáil they still cannot accept that there is a crisis looming on 8 December.

I want to run through some points made by the Minister last night. The Minister litters his speech with words like "an atmosphere free from threat", "goodwill", etc. Where is the Minister's goodwill when he sits down to negotiate and review but does not negotiate, does not actually say to the doctors that there is anything on the table to implement any of the improvements he says are being agreed? No resources have been committed. Therefore the doctors do not accept that the Minister is sitting down in good faith.

There is no attempt to allay the anxieties and fears of people about how the Government can deliver a health service if this threatened dispute goes ahead. Who will prescribe the ethical drugs if it cannot be the doctors who have withdrawn their services from the general medical service? They will have to return the GMS prescription pads which it will no longer be legal for them to use if they are forced to go ahead with their action. Patients cannot be expected to go down to a health clinic. Nurses, chiropodists and other health care service workers in those clinics will not be allowed to write the prescriptions for ethical drugs. The Minister seems to have some magic formula to implement this scheme. I do not know where he will get the doctors to implement the scheme, where he will get the personnel. Perhaps he will tell us after this debate how he is going to do that. I do not know; the doctors in the scheme do not know and the patients do not know. I know they will expect their doctors not to turn them away in an emergency, and the doctors have said they will not, but who is going to write the prescriptions, who is going to pay for the prescriptions? On all these issues there was not a single word from the Minister to allay the anxieties and the fears of patients who are of paramount concern in this debate.

Only once did the Minister correctly refer to the 1989 agreement with doctors. It was not a contract. That was one of the issues that caused a great deal of anger at the time. The doctors did not get a contract; they got a new agreement. The Minister, instead of calling it the 1989 contract might correct that and call it an agreement.

The Minister implied that the scheme that was brought in in 1989 was the be all and the end all of the health service, and there were certainly great improvements in it, but in outlining the improvements the Minister neglected to fill in the gaps. For example, he spoke about the payments for out of hours consultations. That sounds fine and people looking at that will say that it is fine that a doctor will be paid if he works outside the normal working day which for most people is from 9 a.m. to 5 p.m. or 6 p.m. However, the average working week of a general practitioner, as shown by a survey by the ICGP, is 89 hours a week. They are paid for the normal working day which, for a doctor, has been assessed as being from 8 a.m. to 10 p.m. There are no special payments for calls between 6 p.m. and 10 p.m. and no special payments at the weekend. There are special payments for calls between 10 p.m. and 8 a.m. Another thing that the Minister neglected to say, and which adds greatly to the burden of those calls, is that there are 17 questions to be filled in on any night-time call form. Not only that, but the doctor has to ask the sick person who has called him out — if there is nobody else in the house — to sit up in their bed to sign that form. The mechanics, the complexities and the bureaucracy attached to some of this system absolutely befuddles the doctors at times and creates an antagonism to the whole scheme.

There are other issues like the early retirement arrangements. The Minister neglected to say that as doctors come towards retirement age they tend to let their lists get smaller and smaller and, of course, the payment at retirement is based on the size of the list when the doctor retires.

The delays in paying for most of the services that are now eligible for payment are just unsustainable. The Minister knows full well the manner in which the health boards are cutting back on their budgets because they have not received sufficient resources from central Government. They are holding back on payments. I am quite sure there is somebody in each health board area working out how long they can hold back on writing a cheque, making a payment, so it can go into the next year's budget. However, there is somebody on the receiving end and I hope the Minister realises this. They have had to borrow and make commitments for that spending. It is not good enough that the health boards are forced into holding back payments. That is what is happening.

I want to make one thing quite clear. My information from the IMO and doctors involved in negotiations is that whereas it was agreed that the 17.5 per cent arbitration award was to be considered in the context of the review it was not dependent on the successful outcome of the review. I hope the Minister will remember that. If on 8 December the review is not completed successfully, he is still obliged to fulfil the commitment on the 17.5 per cent arbitration award.

I want to move on to the question of prescriptions and the prescribing of expensive drugs. I do not believe that the thrust of the Minister's efforts should necessarily be on the general practitioners' running of the general medical service. The vast bulk of repeat prescriptions commence in hospitals. The hospital doctors write the prescriptions and when a patient comes out of hospital with a prescription he or she goes straight to the GMS doctor, the prescription is transcribed onto a GMS pad and the prescription becomes the doctor's. However, it is the general practitioners who are blamed for the high cost of the drugs they are prescribing. Perhaps the Minister could look towards the prescribing that is done in the hospitals and he might achieve his targets in reducing the cost.

The Minister refers to the fact that the review is about the organisation and funding of general practice rather than simply payments to doctors. I feel that is an underhand way of implying that that is why the doctors are in there, that they are in the review to up their payments. That is not why the doctors are in the review; they are in the review to improve the services of the GMS. A recent survey shows that health care delivery is over-reliant on the hospital sector. That is just one statistic. Sixteen million consulatations take place through the GP service and only two million through the hospital service so we can see that we are getting tremendous value out of the GMS system and that is where the emphasis of investment should be. The Minister spoke about increasing the scope and depth of general practitioners' contributions to primary care. Where, in the name of God, can the doctor find more time out of 89 hours a week?

The "lack of epidemiology data relating to the disease process" did not seem to worry the Minister when he put onto the shoulders of the doctors the responsibility for the HIV vaccinations.

Let me finish now by impressing upon the Minister that unless he is prepared to recognise the reality and the genuineness of the doctors' case — and I found nothing in what the Minister said last night or in what the Minister of State said this evening to make me feel confident that they recognise the genuineness of the case — the dispute will go ahead and patients will suffer. I agree with Deputy Creed that there may well be deaths because of fear and anxiety and people not going to the doctor on time.

I appeal to the Minister and the Minister of State to let the people know how they propose to solve this problem. They should not present information in such a way that the impression is given that doctors are making absolute fortunes under the scheme. Needless to say, to read that a doctor is in receipt of £41,530 leads to that impression. It sounds like a great salary but it should be remembered that that is a gross figure; secretaries have to be paid, equipment, overheads and withholding tax payments must be provided for. The impression is being given that somehow general practitioners are well off and living off the backs of the taxpayer but this is not true.

I say loud and clear to the members of the Progresive Democrats Party who I am sure are sitting in an office in the vicinity of the House that I hope they will come into the House tonight to vote in favour of this Private Members' motion as their last act of this Dáil to show what they think of the Government.

The Minister could be described as Dr. Doolittle.

I welcome the Deputy to the debate.

Amendment put.
The Dáil divided: Tá, 67; Níl, 61.

  • Ahern, Dermot.
  • Ahern, Michael.
  • Andrews, David.
  • Barrett, Michael.
  • Brady, Gerard.
  • Brady, Vincent.
  • Brennan, Mattie.
  • Brennan, Séamus.
  • Briscoe, Ben.
  • Callely, Ivor.
  • Collins, Gerard.
  • Connolly, Ger.
  • Coughlan, Mary Theresa.
  • Cowen, Brian.
  • Cullimore, Séamus.
  • Daly, Brendan.
  • Davern, Noel.
  • Dempsey, Noel.
  • Dennehy, John.
  • de Valera, Síle.
  • Ellis, John.
  • Fahey, Frank.
  • Fahey, Jackie.
  • Fitzgerald, Liam Joseph.
  • Fitzpatrick, Dermot.
  • Flood, Chris.
  • Flynn, Pádraig.
  • Gallagher, Pat the Cope.
  • Geoghegan-Quinn, Máire.
  • Hillery, Brian.
  • Hilliard, Colm.
  • Hyland, Liam.
  • Jacob, Joe.
  • Kelly, Laurence.
  • Kenneally, Brendan.
  • Kitt, Michael P.
  • Kitt, Tom.
  • Lawlor, Liam.
  • Lenihan, Brian.
  • Leonard, Jimmy.
  • Leyden, Terry.
  • Lyons, Denis.
  • McCreevy, Charlie.
  • McDaid, Jim.
  • McEllistrim, Tom.
  • Morley, P.J.
  • Nolan, M.J.
  • Noonan, Michael J. (Limerick West).
  • O'Connell, John.
  • O'Dea, Willie.
  • O'Donoghue, John.
  • O'Hanlon, Rory.
  • O'Keeffe, Ned.
  • O'Kennedy, Michael.
  • O'Leary, John.
  • O'Toole, Martin Joe.
  • Power, Seán.
  • Roche, Dick.
  • Smith, Michael.
  • Stafford, John.
  • Treacy, Noel.
  • Tunney, Jim.
  • Wallace, Dan.
  • Wallace, Mary.
  • Walsh, Joe.
  • Wilson, John P.
  • Woods, Michael.


  • Allen, Bernard.
  • Boylan, Andrew.
  • Bradford, Paul.
  • Browne, John (Carlow-Kilkenny).
  • Bruton, John.
  • Bruton, Richard.
  • Byrne, Eric.
  • Carey, Donal.
  • Connaughton, Paul.
  • Connor, John.
  • Cotter, Bill.
  • Creed, Michael.
  • Currie, Austin.
  • D'Arcy, Michael.
  • Deenihan, Jimmy.
  • De Rossa, Proinsias.
  • Doyle, Joe.
  • Dukes, Alan.
  • Durkan, Bernard.
  • Enright, Thomas W.
  • Fennell, Nuala.
  • Ferris, Michael.
  • Finucane, Michael.
  • FitzGerald, Garret.
  • Flaherty, Mary.
  • Flanagan, Charles.
  • Foxe, Tom.
  • Gilmore, Eamon.
  • Gregory, Tony.
  • Harte, Paddy.
  • Higgins, Jim.
  • Higgins, Michael D.
  • Hogan, Philip.
  • Howlin, Brendan.
  • Kavanagh, Liam.
  • Kemmy, Jim.
  • Kenny, Enda.
  • Lee, Pat.
  • McCartan, Pat.
  • McGahon, Brendan.
  • McGinley, Dinny.
  • McGrath, Paul.
  • Mitchell, Jim.
  • Moynihan, Michael.
  • Nealon, Ted.
  • O'Keeffe, Jim.
  • O'Shea, Brian.
  • O'Sullivan, Gerry.
  • O'Sullivan, Toddy.
  • Owen, Nora.
  • Pattison, Séamus.
  • Rabbitte, Pat.
  • Reynolds, Gerry.
  • Ryan, Seán.
  • Sheehan, Patrick J.
  • Spring, Dick.
  • Stagg, Emmet.
  • Taylor, Mervyn.
  • Taylor-Quinn, Madeleine.
  • Timmins, Godfrey.
  • Yates, Ivan.
Tellers: Tá, Deputies Dempsey and Dennehy; Níl, Deputies Kenny and Howlin.
Amendment declared carried.
Motion, as amended, agreed to.