Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 4 Dec 2001

Vol. 545 No. 4

Private Members' Business. - Medical Cards: Motion.

I move:

That Dáil Éireann:

–concerned at the fact that many people on low incomes are denied access to adequate primary care for financial reasons;

–further concerned that a failure to increase the eligibility limits will result in people who receive a small increase in their incomes losing their medical cards;

–conscious that the value for money audit commissioned by the Government described medical cards as "real value for money";

–deplores the decision of the Government and the Minister for Health and Children not to proceed with the planned extension of eligibility limits to bring in an additional 200,000 people;

calls on the Government to immediately reverse its decision.

I wish to share my time with Deputies Quinn, Gilmore, Moynihan-Cronin and Wall.

On a point of order, the House might want to know that there is speculation that Deputy Healy-Rae has got some sort of medical card—

That is not a point of order.

The House might want to know that.

The Deputy is taking time out of the 40 minutes allotted to the Labour Party.

If there is any change, it will clearly be the result of the pressure being put on the Government by the Labour Party and others in the House. We are united in highlighting this essential matter.

In the last four years Ireland has become an increasingly wealthy and, at the same time, increasingly unequal society. We have one of the highest levels of income inequality in the European Union. The gap has widened dramatically in the last four years. The top 10% of the population now have disposable income 13 times greater than the poorest 10%. This has not happened by accident, rather it is the legacy of an ideologically-driven Government which continues, even to this day, to deepen the divide. Nowhere is this divide more evident than in our health service.

We have great health professionals working to deliver care to their patients, but they work in a uniquely dysfunctional system which discriminates against the poor in favour of the rich. We have a two tier health system based on a kind of Irish apartheid which would not be tolerated in any other EU state and which is rapidly becoming unacceptable to the broad majority here. The public is ahead of the Government in its desire for change. People are genuinely appalled at the discrimination which ensures, at hospital level, private patients can access the quality care they need when they need it while public patients often end up on long waiting lists. Even a visit to the family doctor is not exempt from injustice. Those on very low incomes who do not have medical cards are forced to pay the full price to see their family doctor or do without the care they need and suffer the consequences. Such people include the single person living alone whose income exceeds £100 per week or the married couple with two children living on an income of just over £9,000 per year. These are people who are already struggling to pay their household bills and for whom a medical bill constitutes a crippling burden. If other European citizens do not tolerate such inequality, why should we?

Last week the Minister for Health and Children, Deputy Martin, launched his health strategy. It was the occasion of lavish PR, clever media management and a benign, if bewildered, public response. It was also four years overdue. Starting out in government with a strategic policy makes good sense. Waiting until the dying months of an Administration leaves the Minister vulnerable to the criticism that this was a political stunt. Be that as it may, there are some good elements in the health strategy, though it is still a failure. It fails to address the central challenge of health care reform. It does not deliver equality. Despite its title, Quality and Fairness, it is a ten year plan designed to perpetuate unfairness in health care. That was a disappointment in itself, but worse was to come.

Two days later the Government's primary care strategy was launched and the result can only be described as a disaster. An overly ambitious billion pound plan was reduced to tatters when the Minister admitted that, far from delivering equality at primary care level, the Government had decided to freeze any increase in income limits to qualify for a medical card for the duration of its lifetime. It is a decision that has been described as deeply disappointing, callous and cruel and even as obscene. It is also a decision that can be reversed, which is the reason the Labour Party has tabled this motion and it is seeking majority support across the House.

The first line of the Government document states, "Primary care is the first point of contact that people have with the health and personal social services." The harsh reality is that for thousands this is simply untrue. They cannot access primary care because it costs too much. They end up in accident and emergency departments because their health has deteriorated or it is their only route to treatment. The Government is on record as stating that an additional 200,000 or so people should have medical cards. We, in the Labour Party, go further by asserting that primary care should be free at the point of delivery. Even if the Government was simply to live up to its own commitment, it would make a significant difference to the lives and health of up to 250,000 people on low incomes. The Minister justified his decision to exclude them on the grounds that their unmet needs would put pressure on the service. This is a terrible admission. Is he really saying the unmet need is so great that he cannot set about meeting it now?

It is clear that general practitioners – they should know since they deliver primary care – do not agree with the Minister and they are so keen for this improvement to be made now that the Irish Medical Organisation has issued a strong warning to him by stating that failure in the forthcoming budget to commit to the extension of the medical card would be a failure to meet the health care needs of the 250,000 who need it most. This, the IMO stated, would only lend currency to those who say the health strategy is no more than an expensive election ploy. A leading GP, Professor Tom O'Dowd, revealed that a recent survey in his practice showed that a quarter of his patients were put off going to the doctor because of the cost. I hope the Minister does not try to convince us that we cannot afford to extend medical cards to the people concerned. The recently leaked value-for-money audit carried out in the health service found that the current medical card scheme is excellent value for money. Nevertheless, the Minister is ignoring that expert opinion as well as the opinion of medical practitioners.

When the Minister extended medical cards to the highest income group among the over 70s he got it wrong. He introduced inequity into the GMS system for the first time. General practitioners are rewarded three or four times as much to care for this group of medical card holders as they are for caring for the poorest in our society. The Minister has thereby introduced, for the first time, incentives to attract GPs out of areas of deprivation and to set up practices in high income areas instead. Already we know that in areas of deprivation there are up to three times fewer GPs per capita, yet the only significant legacy of a Minister who has talked about fairness in the health service has been to make that service more iniquitous. When the Government took the decision to extend medical cards to the over 70s, it did not get its sums right. It estimated 30,000 would apply according to a reply to a parliamentary question I tabled some time ago. Already, 52,500 have applied.

The Minister says his decision results from setting priorities, but does not explain the reason he ignored the advice of doctors, value for money experts and even his own officials. The chief medical officer in the Department of Health and Children in his annual report on the health of children stated:

Specific policy measures, which redistribute resources and provide opportunities and services for families with children, especially poor children, will do most to create better health provision. For this reason basic universal health provision, such as free access to primary care for all children, should be considered.

Despite the good advice and promises made by the Government, the Minister has turned a deaf ear. On Monday he launched a health strategy which promised that "significant improvements will be made in the income guidelines in order to increase the number of persons on low incomes who are eligible for a medical card." By Wednesday the truth emerged that this commitment was not worth the paper on which it was written. It seems the Minister was so bedazzled by his ten year primary care plan that he could not see the real needs to be met.

The Labour Party recognises the central role of primary care in good health care delivery, but we warn the Minister against trying to import into our system the clapped-out British ideas from the 1970s upon which his strategy relies so heavily. He ignores the strengths of the Irish system at his peril. It is vital to maintain and enhance the personal relationship between patients and their doctors. We oppose any proposal which puts barriers between patient and doctor. The proposed triage system could end up with a patient having to get approval from another health professional before he or she can access his or her doctor. No member of the public seeks such a change. It is not good practice and unnecessary. It is also not within the Irish tradition of personal health care. In Ireland people who can afford it or are on medical cards have direct access to the general practitioner of their choice. What is being sought is that such access be guaranteed to 200,000 people on low incomes in order that they can have the security and access for themselves and their children which is denied to them.

If the Minister is serious about primary care reform, he should also commit himself to a free GP service at the point of delivery as the Labour Party has done. He should be less grandiose in his plans to reform primary care and concentrate on the needs of patients. There is nothing to stop him from extending the medical card scheme as the first step towards a free GP service, encouraging the growth of group practices, integrating community nursing with practice nursing, providing incentives for GPs working in areas of high deprivation, guaranteeing patient registration by way of a comprehensive GP scheme, ensuring the regulation and standard-setting concerning out-of-hours emergency services, whether by co-op, rota or commercial deputising, or building the capacity of primary care to deal with prevention, rehabilitation and the management of chronic long-term illnesses. These measures would significantly improve Irish primary care while retaining its strengths and making it more accessible. We, in the Labour Party, propose real reform of primary care rather than the overblown proposals from abroad upon which the Minister sets such store.

The motion is of great importance to people throughout the country. I have no doubt as the debate continues that clear evidence will be given about the suffering and hardship caused as a result of people being unable to access their family doctor. I urge the Minister to accept the motion. He has a chance to put right a terrible wrong being done to families and children who are denied a basic right to medical care. Surely the time has come when the Government and the House can make a simple guarantee of quality and fairness to those who need it most.

An Irish singer named Johnny Logan won the Eurovision Song Contest with a memorable song called "What's Another Year." The Minister for Health and Children, Deputy Martin, is giving his swansong to a whole category of people by saying to them "what's another year" and that they can simply wait. By deciding not to increase the income eligibility limits for access to the medical card system, the Minister has inexplicably penalised upwards of 200,000 people. Will he, if he can, justify the reason he has made this ideological choice? He said last week in the House that he had decided to give people over the age of 70 years the medical card without reference to income. As Deputy McManus said, in making that decision he interfered fundamentally with the basis on which the general medical service system works and introduced structured inequality into the application of the GMS in its current form.

The Minister will not have seen earlier this evening on the "Six-One" news the report from the Society of St. Vincent de Paul condemning outrightly the failure of the Government to do what could be done and what the country could afford to do, which is to give, for the sum of approximately £80 million a year, the medical card to upwards of 200,000 people. That is more than the entire population of the city of Cork.

This Administration has been in government for four and a half years and is the most favoured in the history of the State. It inherited an economic framework unrivalled by that of any previous incoming Administration, a framework which was further underpinned by the stability introduced by Ireland's membership of the euro zone, which meant lower interest rates and exchange rate stability, and ensured the economy grew at an unprecedented rate creating levels of wealth and growth undreamed of by any forecaster or economist. Looking back on that four and a half years, on what was achieved and where the key choices were made by the Government, we begin to see a pattern which reveals an ideological choice which is undeniably right of centre. The choice of the Minister for Finance, Deputy McCreevy, between rich and poor in terms of reducing taxes, whether it be capital gains tax, the top rate of income tax, changes in the thresholds, capital acquisitions tax or a range of other areas, has always been to opt for the smaller group who least need the type of support given to them. This is reflected in the decision of the Minister for Health and Children to give people over 70 the medical card and enhance the operation of the terms and conditions of the GMS to ensure doctors complied with its operation. Many over 70 do not need the support of the medical card system, which is the argument made by general practitioners.

I do not like the GMS system. It is a Third World type of operation for a country which developed it and the concept of the medical card, or the blue card as it was originally called, at a time when this was a very poor country. While we are no longer a poor economy, we are still an impoverished society. As Deputy McDowell said outside the House, now that we have achieved the average per capita income of the rest of the European Union, we need to achieve a similar level of public service. One of the key areas where the quality of that service can be measured is in access to health services in general and primary care, in particular.

The reason the Labour Party has proposed and will implement, if we are in a position to do so, a system of free access to primary care is because two out of three people must pay to go and see a doctor. That is the reality. Our measure, small as it is, would at least extend that facility to another 200,000 people. If the child of a young parent on the average industrial income and without a medical card becomes sick for the third time in a month – they tend to become sick at night and other inconvenient times as anyone who is a parent knows – the one thing that parent should be able to do, especially where he or she is detached from family supports because of where he or she lives and where he or she is trying to discern whether the cough is a bad cold or possibly symptoms of meningitis, is access primary care without fear, certainly without the fear of wondering if he or she can afford to pay. Going to see or asking a doctor to make a house call will cost £30 of a person's wages after tax. In effect, it represents a sum closer to £40 of somebody's gross wages. That barrier of fear and denial should no longer be in place.

Access to a properly resourced and established primary care system should have been provided by this Administration. It cannot plead what previous Administrations could legitimately claim, that the resources were not available. Neither are we saying that it can be done overnight. Some of us in opposition have experience of working in a Government that, over 15 months, published the most comprehensive health policy document ever produced by a political party. We know just how complex the task is. We do not claim to have all the detail of such a policy 100% correct, or that the policy cannot be improved, or that aspects of it will not require the input of medical health providers. That is one of the reasons we have proposed that a medical forum should be an integral part of health policy.

At the start of the 21st century the frightening reality is that we know more about the health profile of animals on this island than we do about our fellow citizens. The failure to establish a proper comprehensive primary care system with the necessary support for GPs has left us in a state of chaos and anarchy that prevents the system from delivering the sort of health care to which our citizens are entitled.

We are not asking the Minister to do much. For the past four and a half years he has been a member of the Government whose budget allocation tomorrow will run to £19.5 billion. The Minister has undoubted political skills and influence in the Cabinet. All we are asking him to do is to obtain the extra money needed to increase eligibility income limits, thus enabling 200,000 more people to have medical cards. They have been left behind as a result of the failure to increase the limits in recent years. It was not an arbitrary decision, an accident or an imposed criterion over which the Minister had no control. That deliberate choice was made in recent years at a time when average income was increasing, through the PPF and other social partnership programmes, by the order of at least 8% per annum and in some cases by far more. The Government clearly recognised that a group of people would be consistently left behind as their incomes grew.

In reply to a query from me the Secretary General of the Department of Health and Children informed the Secretary General of the Department of Finance, Mr. John Hurley, that to restore the GMS system to the 40% of the population which, under the current agreement, should be entitled to access it would cost £116 million, based on March 2001 figures. These choices have been made, they have not happened by chance. We are asking the Minister to reverse these choices, and to change the direction of social policy in a manner that will have an immediate and direct impact on 200,000 people. He is in a position to do this. He can make changes elsewhere in his overall budget allocation and negotiate with the Taoiseach and the Minister for Finance. We are asking him to do so by accepting our motion.

Tomorrow, mercifully, we will hear the last of the five budgets from the Government. It is a useful point at which to look back at its period in office. No Government has ever had it so good. No Government has ever had so much of the people's money to redistribute and invest. At the end of that four and a half year period it is shameful that the Government has decided that a couple with two children, earning £180 per week, cannot be given a medical card. Such people are effectively being told that if they need to see a doctor, they must pay for it.

The decision not to extend medical card eligibility limits is one that affects all low-income families who must make daily decisions about their health, based on income rather than medical necessity. A parent with a sick child must decide whether to visit the doctor, a decision with which every parent can identify. For the 30% of parents who have medical cards, or those fortunate enough to be able to afford to visit a doctor, that decision is made solely on the basis of whether an ailment is sufficiently serious. For someone on low income, however, the decision on whether to visit the doctor is a financial one. Going to the doctor is not just about the £20 or £25 fee, it also concerns the cost of any prescription the doctor may write. A visit to the doctor with a sick child may end up costing £40 or £50. Many parents on low incomes will have to weigh up that cost against the price of school books, an electricity bill or other household costs. It is a major decision.

People caught in this situation are on low incomes, saddled with big mortgages or paying high rents. The decision not to extend medical card eligibility levels is one of the cruellest that any Government has made. In its recent annual report, the Society of St. Vincent de Paul estimated that for the sum of £80 million the medical card scheme could be extended to another 200,000 people. The Minister, however, says, "Sorry, we can't afford it." The Government takes that stand in the very week when £80 million was found by his colleague, the Minister for the Environment and Local Government, to provide additional compensation for farmers and landowners who have spent the last year obstructing the building of new national roads, but, of course, the IFA is a powerful lobby, unlike a mother with a sick child. That is the reason the Government has turned its back on the sick and the poor. It has done so, however, against the advise of the Minister's own chief medical officer who stated in a report earlier this year that no child should be prevented from having access to a doctor simply on the basis that its parents cannot afford the doctor's fee or the prescription costs involved.

The Minister took office on the strength of the slogan, "Health cuts hurt the old, the sick and the handicapped." I agree with that slogan because the hurt caused by health cuts is never justified. Given the resources the Government has had available to it for the past four and a half years, there is no justification now for it to turn its back on those who cannot afford to go to the doctor.

I support my party's motion. The issue of medical cards has been one on which I have campaigned passionately all my political life. I know intimately the hardship thousands of families experience in my constituency by being denied a medical card which should be available as an entitlement rather than constituents having to go cap in hand to politicians when in difficulty. Every Member constantly makes representations to health boards on behalf of persons in dire need. My constituency of Kerry South is no different. I was interested to read in this morning's edition of The Kingdom that my constituency colleague, Deputy Healy-Rae, said:

We don't have to be shouting in the Dáil. We make our own representations about medical problems to the Health and Finance Ministers in the Chief Whip's office.

If this is the way the Government dishes out medical cards to Independent Deputies, it is an absolute disgrace.

It is shameful.

I ask the Minister if this is the health policy over which he presides.

It is shameful.

It should not be the case that an application for a medical card brought to the Chief Whip by one of the Government's Independents should receive more preferential treatment than any other. Will the Government Chief Whip treat those who have made representations to me or any other Deputy in the same way as those who have made representations to the Independents who support the Government?

During the past four and a half years the Government's Independents have had ample opportunity to assert their so-called independence in which task they have failed miserably. They have proven that they are just so-called "Independents." The vote at the end of this debate offers them another chance to carry out the mandate their constituents gave them at the last election which was to act, legislate and vote as Independents. I earnestly appeal to the Independents, particularly those who support the Government, to vote in favour of the Labour Party motion and exercise real independence for the sake of the 200,000 people up and down the country in dire need of medial cards. I had a woman in my office yesterday who has two children. Last week she took them to the doctor at a cost of £60. One night during the same week she had to call the doctor to the house at a cost of £45. This means she had to pay out £105 in one week. Is the Minister telling me she is not in dire need? She is self-employed and is a few bob over the limit.

That is right.

Perhaps I should go to the Chief Whip who would be able to help her. I will be making many trips to the Chief Whip between now and next June because there are many in my constituency who ask me to do so given that they cannot get them from the health board. I presume the Chief Whip has a bag of them upstairs. I might go up to him after I conclude my speech and ask for some of them.

A Deputy

They are only for Jackie.

I agree with the National Association of the Mentally Handicapped in Ireland that children with intellectual disabilities should be entitled to a medical card in their own right. Thousands of children up and down the country continue to live in poverty because they do not have access to primary medical care. Will the Minister see the Minister for Finance, Deputy McCreevy, tonight and ask him to see sense, to think about the woman who spent £105 in one week and ask him to ask the Chief Whip what his medical card costs?

This is the time when the four Independents should either shut up or put up. It is a real opportunity for them and their colleagues on the Fianna Fáil back benches to prove to their constituents that they are committed to quality and fairness in the health service. I sincerely hope they rise to the challenge.

The ink is hardly dry on the Government's much hyped health strategy and at the first hurdle it has failed. It has failed to tackle inequality. It has failed to rebalance our health resources in favour of those who need them most. The conscious deliberate decision to freeze eligibility limits for medical cards in 2002 is cruel and heartless. It will cause anger and hardship among low paid workers and families across the country. The decision clearly demonstrates how much out of touch the Government has become. It is a clear signal that the sooner an election is called the better.

Hear, hear.

The people being penalised are among the most hard pressed workers. Manual workers earn little more than the minimum wage and struggle to make ends meet on a tight budget. The Minister for Health and Children and his colleagues in Cabinet have decided these are the people who must pay the price for the health strategy. They will get in the way of its delivery and, therefore, will be written out of the equation. It is as simple and as straightforward as that. It is a disgrace. Clearly, the Minister does not understand the enormity of what he is proposing. In answer to a Private Notice Question in the House on Thursday last he singularly failed to address the core issue – why, with the advent of the Government health strategy, are the most needy families about to lose out. It is a simple question and the Minister did not even try to answer it.

Let us face the facts. A citizen with an income of over £5,200 must pay every time they visit their general practitioner. A working parent earning £324 gross per week would need to have ten children to qualify for a medical card. Low paid workers are denied free access to a GP. Under the Government this will continue to be the case. The Minister talks continually of ten year plans and establishing priorities. Much of this is arrogant waffle. The Minister has no power, jurisdiction or mandate to speak of Government health plans for the next ten years. At most the Government has six months to run. There is no Government health strategy for the next ten years. That matter will be decided by the people at the next general election. It is they, through their choice at the ballot box, who will determine health strategy for the duration of the next Government. This point appears to have escaped the Minister. However, it will be brought home to him time and again in the next few months.

Having made such an appalling mess of health strategy since 1997 I can understand the reason the Government wants to sweep that failure under the carpet and fast forward to 2011. It will not wash. The Government has a disastrous record in the health service. At a time of unprecedented wealth it has failed to give the people the health service they deserve by right. It has stood over a two tier health system and watched hospital waiting lists grow. Popular frustration with the health service has never been worse. Is this the outfit people want to chart health care reform in the next ten years? One must be joking.

The final act in the health area by the Government is the decision to freeze medical card income limits. The Minister may deny it, but his backbench colleagues, who have retained some degree of reality in the past five years, know this only too well. The Government has targeted some of the poorest families in the State. Some families will lose their entitlement to a medical card while others will be denied free access to primary health care. I know the effect of this on the ground: parents will go without to get their children to the doctor, single parents will put off visiting a doctor because they cannot afford it while accident and emergency units in acute hospitals will be busier than ever. It is a disastrous mean-minded stupid decision, but then what can we expect from a Government which forced the nurses onto the picket line?

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"commends this Government on its achievements in developing the health service, and:

–acknowledges that, during the life of this Government:

–funding for public health services has more than doubled;

–hospital activity is now increasing faster than ever before;

–the resources available to deal with hospital waiting lists have quadrupled for all the benefit of public patients, resulting in a 16% reduction in waiting lists in the year to the end of June 2001;

–the funding for capital development has virtually tripled over that of the previous Government;

–funding for disability services has increased massively; and

–child care services have seen unprecedented and strategically targeted growth;

–commends the Government on the publication of the new health strategy which is firmly grounded in the principles of equity, accountability, fairness and people-centredness;

–notes the Government's commitment in the strategy to:

–extending medical card coverage to cover more people on low income, including targeted increases to ensure more children, in particular, are covered in order that over 200,000 more people are covered by way of these measures;

–increasing hospital bed numbers by 3,000 by 2011, the largest bed capacity expansion in the history of the health service, with 650 of these beds coming on stream in 2002;


–commends, in particular, the new primary care model, which is an innovative response to the needs of a modern health service."

Is that the Healy-Rae version?

I wish to share time with the Minister of State, Deputy Moffatt.

Is that agreed? Agreed.

Last week saw the launch of the mot comprehensive and ambitious strategy in the history of the health service. The strategy addresses every element of the service and points the way forward to a permanent end to many long-entrenched problems. The public and professional response has been extremely positive with patients' representatives calling it "welcome, and well thought out." One of the big departures in the strategy is the fact that specific commitments are given and direct responsibility is allocated for implementation. In this context it might have been expected that the Opposition would be interested in a serious debate about the strategy. Most reasonable people would have assumed that our time could be best used by talking about the programme of development and reform set out. Of course, when one is dealing with the Opposition the expectations of reasonable people will always be disappointed and once again we are confronted with the desperate attempt of an Opposition overwhelmed by the indifference of the public to claw its way into contention. It has decided that the health strategy will provide it with the electoral magic bullet that will achieve what two new leaders and a merger have not achieved.

The basic premise of the posturing of the Opposition parties on this issue is that everything can be done at once. As far as it is concerned, every element of the health strategy that is not implemented within the next few months will represent a betrayal. Under the Opposition we would have a perfect world where everything would move at once. It did not mention this evening that the policy it is condemning was one it pursued throughout its term of office during the rainbow coalition Government.

On a point of order, will we get a copy of the Minister's speech?

I will arrange for a copy to be sent to the Deputy. I have been here since 4.15 p.m.

Deputy Healy-Rae has not completed the last page.

I have been here since 4.15 p.m., but I take it arrangements are being made for copies to be made available.

Does that mean we will get a copy of the speech before the Minister finishes reading it?

I hope so.

Is there a doubt about it?

I have been here since 4.15 p.m. The Deputies probably will get a copy of it.

I presume somebody other than the Minister is working in the Department.

Deputy Healy-Rae is putting the finishing touches to it.

The Opposition parties sat down together to decide income guidelines for medical cards and decided against implementing any real term increase during its term of office. There were no increases at any stage during Deputy Quinn's term as Minister for Finance or Deputy Noonan's term as Minister for Health. They agreed that indexation was an appropriate response. It seems once again the Opposition believes we are to be condemned while it is to be allowed to ignore its record. In contrast we have now proposed to move beyond indexation and to do so as part of the stepped implementation of actions, but the Opposition roars as if we have reversed a policy, as if we are cutting back. It is the same sort of approach it has had to many Government policies.

What I find most curious about the Opposition's position is that it continues to make it up as it goes along. Last week Labour tabled this motion and Fine Gael agreed to support it. It would entail significant additional expenditure next year. Yet on Sunday Labour launched its pre-budget statement, but failed to mention medical cards or health. It recommended major borrowing and spending relating to a range of projects, but no provision whatsoever for medical cards.

In this fact is laid bare the motivation and tactics of the Labour Party. It is to refuse to engage with the detail of the strategy because one cannot beat the best researched and best received strategy of its type ever launched, concentrate on one point and hype it up. Some members of the Labour Party have enjoyed talking about the need for joined-up policies. Where is the join between its budgetary policy and this new decision where medical cards are the number one issue? Welfare, tax, roads, carers, child benefit and housing are mentioned, but there is not one word about health, not one word on the issue about which it is seeking to condemn the Government tonight.

The high rhetoric of empathy is once again revealed to be without substance or credibility. One year after it began an orgy of self-praise, the Labour Party has honoured us with a redraft of its quick fix answer to everything. After one year it contained less substance than the first draft. Last year it admitted that a whole new layer of administration would lead to more administrative costs. This year apparently there will be none, even though every similar system across the globe has significantly higher administrative costs than ours.

Fine Gael, however, has had even more difficulty keeping its line together. In February last year its spokesperson said:

Our health service requires radical reform. Whether the necessary reform can be brought about by the introduction of a universal health insurance system is questionable. What is needed is less, not more, bureaucracy.

Its new leader said on 28 May this year, "If you go in first and announce a universal insurance system, the whole service would just end up like the present accident and emergency chaos." Yet Deputy Mitchell told us on 11 November that they were committed to prioritising an insurance-based system.

One can talk all one wants about equity, but the bottom line is that this is the first Government ever to set out a comprehensive programme for delivering high class and accessible health care for all.

What happened in 1993? Fianna Fáil did the same then.

Equity in health care is not only about the income guidelines for medical cards. It is about a full range of services and supports. Equity is a core principle on which the strategy is based and one which the Government is committed to addressing in the implementation of the strategy and through service development across the board. The overriding necessity in relation to equity, as was well recognised in the submissions to the national anti-poverty strategy review, is the need for access to services.

Services have to be built up, waiting lists reduced, activity increased and specific groups such as children and those with disabilities require targeted service developments if equity is to be served in a meaningful way. A broad strategic focus is essential to deal with these sorts of problems and no single narrow approach will address the real need for better and more equitable health care services for all.

Before we let the Opposition away with its repeated accusation that the strategy is a last ditch attempt to gain support or that we have been doing nothing for four and a half years, once again the truth is its enemy. More and better paid professionals are delivering significantly more care and services to significantly more people. Waiting lists are down. There have been unprecedented increases in hospital activity. There have been very significant increases in places for the intellectually disabled whose service needs had been all but ignored previously. There is a much enhanced framework for mental health services coupled with much increased targeted investment. Some £41 million has been committed to the implementation of the cardiovascular strategy with the first progress report of the health heart task force completed and launched, and there have been many more advances in cancer treatment services and other services.

Real advances in health and personal social services over the past few years have come as a result of our new and strategic approach to the health services coupled with the most significant programme of investment in health care ever undertaken. Spending has more than doubled since 1997. The overall budget for 2002 is 7.75 billion, or £6.1 billion, representing an increase of 135% since 1997. That is not an illustration of some ideological right wing orientation, as alleged by the Labour Party and its leader. This shows a much greater commitment to health than any previous administration. A year ago the Opposition's big attack was that we were refusing to allocate extra funds to health, today it has abandoned that argument in face of the weight of increases we have put in place. Its only consistent approach is attack.

If one is interested in equity, one must be concerned with the often prohibitive cost of prescription drugs. That is why we introduced the drug payment scheme to replace the schemes where patients reclaimed drug expenditure from health boards. Under the DPS no individual or family need pay more than £42 per month for approved prescribed drugs and non-medicine items from their community pharmacist.

The scheme has been extremely successful. It provides an effective and streamlined point of contact service for more than 950,000 people. Patients no longer need to seek reimbursement from their local health board for prescription expenditure above the threshold, with obvious financial benefits for thousands of families. The total of 950,000 DPS cardholders represents a 36% increase, or 342,000 people, in only one year. The total possible registration is 2.4 million people. All these people can benefit from this scheme which is so much easier to access than previous schemes and which removes the fear of excessive large drug bills. It is not surprising the Opposition has chosen tonight to ignore this major advance.

If one is interested in equity, one must be concerned with the fact that poorer people have to wait longer for necessary treatment. That is why we have been working hard to reduce, and have shown how we will permanently eliminate, waiting lists.

No, the Government will not do that.

The Opposition is aware of the figures but chooses to ignore them. The number of people on public hospital waiting lists in June 2001, the latest date for which figures are available, was down 13% on the comparable figure for the day we took office. During last year there were significant reductions in the waiting lists for target specialties, with the number waiting for cardiac surgery down by 52%, the number waiting for gynaecology procedures down by 35% and the number waiting for ENT procedures down by 30%.

Considerable progress has also been made in reducing waiting times. During the period June 2000 to June 2001 the number of adults waiting more than 12 months for cardiac surgery had decreased by 68%, the number waiting for ophthalmology services had decreased by 38% and the number waiting for orthopaedic services had decreased by 16%. During the same period the number of children waiting for more than six months for cardiac surgery had decreased by 85%, the number waiting for ophthalmology services had decreased by 31% and the number waiting for ENT services had decreased by 25%.

These figures are continuing evidence that the level of targeted funding provided by the Government is achieving results. In spite of this, we saw Fine Gael last week publish a directly misleading leaflet in which it stated that "waiting lists are still rising dramatically". The facts show a decline, but the Opposition does not like the facts so it makes up its own. Perhaps Fine Gael has adopted Labour's most creative attack, where the baseline figure used is January 1997 rather than June 1997. By doing this we become responsible for the unprecedented increase of 4,500 that took place as a direct result of a Labour Minister for Finance and a Fine Gael Minister for Health getting together and deciding to cut back dedicated waiting list funding.

We have no problem justifying our record, but we have no intention of trying to justify the legacies of Deputies Quinn and Noonan.

Shame on the Opposition.

We now have the arrival of the great Minister for Defence.

Please allow the Minister to continue.

If the Deputy goes back in time to the beginning of the rainbow coalition, he will see that waiting lists increased by a huge 28% during the Quinn-Noonan golden era of the health service.

The key to reducing and ending waiting lists is capacity and effective management of treatment lists. The strategy on the way forward is clear. Next year will see the largest ever concentrated expansion in acute hospital capacity. That will end over 12 months of waiting for adults and over six month waiting for children. This target will be delivered because of the major foundation already in place in recent years. This year alone will see a 6% – 52,000 in-patient numbers – increase over last year in the number of patients treated in our acute hospital system.

If one is really interested in equity, one must also be concerned with the significant differences in health status that occur between groups. This is the first time any health strategy has comprehensively addressed the issue of health inequalities. It sets out a range of actions specifically directed at disadvantaged groups and which are concerned with ensuring these groups do not continue to suffer most ill-health. The most important action we can take for disadvantaged groups is to ensure they do not get sick in the first instance or that they do not suffer the current disparities in health. Actions to reduce inequalities include implementing a programme of actions to achieve new national anti-poverty strategy and health targets for the reduction of health inequalities. In addition, there are provisions to eliminate the barriers for disadvantaged groups, in terms of making healthier choices easier for these groups, supporting them at community level to understand and access services, as well as specific programmes of action for groups such as Travellers, the homeless, drug misusers, prisoners and asylum seekers and refugees, all of whom have a real risk of poor health status.

If one is really interested in equity, one must be concerned with fair access for all. The strategy sets out a comprehensive plan to ensure equal access for equal need is a core value for the delivery of publicly funded health services. There are different strands to this goal. The first involves clarifying eligibility through legislation and communication with hard to reach groups.

The actions set out in the strategy will ensure all those eligible understand their entitlement, can easily access the services they need and can be sure that regardless of where they live there is a standard approach to their eligibility for services. It will also see a major extension in eligibility. The basic policy of indexation is one followed under Deputies Quinn and Noonan. The idea that we are taking services from people or that next year will see a major reduction in entitlement is a travesty of the truth. If indexation is to be condemned, then every member of the Opposition who voted for indexation is also subject to condemnation.

The strategy recognises that the issue of health services for disadvantaged groups is a complex one which needs to be tackled in a number of ways, both in terms of ensuring, first, that people are healthier and are less likely to need health and personal social services and, second, that when they do, barriers such as transport or opening times do not prevent them from accessing the services they require.

In addition to these measures, on which work will either begin straightaway or has already begun, the Government has set out a range of measures to make more people eligible for services. The commitment to their introduction is clearly stated in the strategy and we will deliver.

It is clear there are other barriers to equity in the system, and these have been prioritised to ensure that in the future the eligibility framework can readily support equal access for equal need. The Government is fully committed to extending medical card coverage to more people on low incomes, including targeted increases, to ensure more children are covered by way of these measures in the course of the strategy. Such actions always have to be considered in the light of the full range of priorities which arise in relation to health services.

The Opposition's only priority is whatever might grab a headline at a particular time. It steadfastly refuses to state which of its promises will have to wait.

We did not spend £10 million doing it.

In the real world one has to have priorities, and ours will deliver real improvements for people and help towards achieving sustainable progress.

The Minister's priorities are for the rich.

Panic stricken.

Please allow the Minister to continue without interruption.


We expect more from Ministers.

We expect all Members of the House to allow the Minister to continue without interruption.

I will put a ring of steel around Deputy Ring.

If one is really interested in equity, one has to be concerned with the historic under-provision of care services for people with disabilities and older people. As a society, we have accepted that they are vulnerable groups and that the services, particularly those for older people, need to be expanded hugely to meet current need and to anticipate the needs of the population as it ages.

People with disabilities will gain from the addition of a significant number of extra day places, respite care places and residential capacity. The Government's record in investing in this area is second to none. These people deserve to be and will continue to be a priority.

We have implemented a huge increase in funding. This has delivered over 4,000 new day, residential and respite care places for people with disabilities in the past few years. The Opposition Members should acknowledge once and for all—

The Minister should get off the stage.

—that this is the first Government which moved to end a major inequality in Irish life, namely, the lack of services for people with disabilities.

The Minister would make Goebbels ashamed. Shame on him.

Please, Deputy Mitchell.

Shame on Deputy Mitchell and all others who presided over that history of discrimination. We will go further, however, by ending waiting lists for services and making sure that people with disabilities are not inappropriately placed in psychiatric hospitals. Next year will see further major investments which will help deliver greater equity for some of our most vulnerable citizens.

Older people will also benefit substantially under the strategy. Our commitment is for a total of 1,370 extra assessment and rehabilitation places, 600 extra day places and 800 extra residential-community nursing places per annum each year in the next seven years. These improve ments will bring tangible benefits for older people.

The Government's record on improving services for older people is well recorded. Last July the medical card was extended to everybody over the age of 70 years. The extension of medical cards to the over 70s is wholly consistent with Government policy towards improving the position of the elderly and was a logical consequence of the three year phased doubling of income limits initiated in March 1999. Before the last election the one commitment we gave on medical cards was that we would double eligibility over three years for people aged over 70 years. We have delivered on that promise—

I will deal with that in a minute.

—despite the twisting and turning of the Opposition.

The Minister paid five times over the limit for that on the eve of a by-election.

Please, Deputy Mitchell.

When the Opposition was in government it presided over no increase for any group in society in medical card thresholds.

I will deal with that in a moment.

That is Deputy Mitchell's record.

Wait for the facts.

His party presided over a nil increase. In three budgets the Opposition, in government, presided over a freeze on medical card eligibility.

Dr. Jekyll and Mr. Hyde.

The Government has doubled eligibility for the over 70s, and in the last budget—

I will deal with that in the next few minutes.

Please allow the Minister to continue.

—we provided free medical cards for everybody over 70 years who need to see their doctor more than any other age cohort of society.

Bank managers need to see them more.

The Opposition continues to twist and turn on this issue, wanting to oppose, but ultimately satisfied with sniping. Despite all we have heard tonight, even from Deputy Quinn and Deputy McManus—

Look at the ground now.

—the bottom line is that they voted for this to cover their electoral backs.

The PR people will be annoyed.

Deputy Mitchell and Deputy Ring will have their opportunity shortly.

We are being provoked.

Throughout last year, one week we were being condemned for not concluding a deal with the Irish Medical Organisation for the over 70s, but when we concluded a deal the following week we were condemned for concluding it.

If one is really interested in equity, one has to be concerned also with our underdeveloped primary care system. Our new departure on primary care gives it a central role in the future development of our health services. It provides the policy framework to advance equity and recognises the need to address inequalities in accessing the services people need most.

Access to primary care services is of crucial concern to the Government as is shown in the new primary care model that was so well received last week. Many services are not as available as we would like throughout the country. This model seeks to address this problem by putting in place co-ordinated, integrated one-stop-shops for service that will be of particular benefit to older people and medical card holders.

The primary care strategy is a radical, long-term programme which needs to build up momentum as quickly as possible to achieve the targets we have set. The consultation process has demonstrated to us the great value the public places on community based services. The public has recognised what international research tells us, that we can do much more to keep people well and independent as well as to improve the quality of life of those who are ill or have a disability by working at a community level in broad based terms. A properly integrated primary care service can lead to better outcomes, better health status and better cost effectiveness.

We have prioritised as a first step the national development of 24 hour, seven day GP co-operatives. These will be supported by the immediate establishment of a primary care task force to help drive the roll-out of the new model. The emphasis will be on putting together primary care teams which can meet the needs of patients and clients effectively. Patients will have the option of enrolling with these teams and with an individual general practitioner. If they so wish, they will be able to self- refer to any member of the team. This model offers the way forward. It will change utterly the way in which we deliver primary care services and will be hugely important in helping to streamline the delivery of patients and clients to other more specialist services, both within and beyond the community setting.

Anyone really interested in equity and delivering quality care for all must support a move to end the days of the quick fix sloganeering which has so often dominated debates on health in this country.

Tell us about the Irish Blood Transfusion Board.

Unfortunately tonight's debate is part of the old way of doing business. It is an attempt by a desperate Opposition to get some attention and damage a more substantive and credible health strategy than they could ever produce. It will not work. Nobody believes that everything can be done at once. Deputy McDowell's statement does not even mention medical cards as a priority for tomorrow's budget. People will see that the Opposition is unwilling to say what it will do and when it will do it. Over the coming months they will see an Opposition becoming ever more negative and shrill, trying to pick short-term holes in a solid long-term strategy.

The Opposition keeps on arguing for quick fixes, refusing to prioritise, attacking us for implementing policies which it followed and producing leaflets based on misleading figures. We will get on with the substance of delivery and will face into the future. The public will recognise credible and sustainable policies over those with shelf lives as long as a sound bite.

Health cuts damage the old and the young. Does the Minister remember that?

Order, please.

We have produced a strategy built on equity which will deliver high quality care for all.

Produced by programme managers and consultants.

I am fully confident that the public will recognise and support our record of achievement and strategy for the future.

I am thankful to the Labour Party for providing this opportunity to address the issue of health service reform. The health strategy is now synonymous with health reform. It is plainly the way forward. Anyone familiar with my area of responsibility – food safety and older people – will understand how truly exciting the strategy is.

The partnership approach which, much to the ire of the people opposite, is the hallmark of this Government, is at the very core of the strategy. It incorporates the largest public consultation ever carried out in the health service. Members of the public were invited to describe their experiences of the health services and give their opinion on future policy. We received more than 1,500 submissions. We also commissioned market research involving a nationally representative group of over 2,000 adults. Added to this was partnership with the medical organisations and the medical personnel. When we talk about the health strategy we should not think of it as a Government document handed down from Hawkins House to be implemented below. It is a far more egalitarian strategy than has ever before been attempted in this area.

This poses serious questions for the Opposition which it has yet to answer. Should it find itself in Government, would it scrap the partnership and thus ignore the commission on nursing, the strategic assessment of hospital capacity, the national consultative forum and the medical manpower report or reports from the National Council on Ageing and Older People? Would it disregard the 121 specific targets contained in the strategy? What of the specific deadlines along the road to reform?

Labour has already asserted it would not water down its policies to enter Government. Having attacked the Government for taking too long in launching the strategy, would it return to the lengthy negotiations and research? Were it to adopt the sensible path and adopt the strategy, could we trust it to implement it?

There is no fear of that.

There is Devil a one. The record of the parties opposite in Government suggests we could not trust it. After all, in the last few months of the Rainbow Government Fine Gael and the Labour Party decided to cut funding to reduce waiting lists by 20% when these same waiting lists had actually risen by 27%.

How long are they now?

They have been reduced by 25% since we took office.

Does the Minister of State remember the biscuit factory—

Order, please.

In both Houses of the Oireachtas they have been challenged to explain this decision. Time and again they have failed to do so. It was the same rainbow coalition which refused to seriously increase the health spend and did not fund the necessary additional nurse training places.

Fortunately for the health service, the present partnership Government will return to office to build upon the reforms to date and complete the health strategy.

The Minister is wishing.

Considerable work has been done. We have not been sitting on our hands. As a direct result of our policies to date, there were 90,000 more treatments carried out in 2000 than in 1997 and 52,000 more treatments were carried out this year than in 2000. This is the largest ever increase in hospital activity. We have more than doubled the health spend to over £5 billion and it is plainly delivering. Staffing in the public health service is up from 68,000 in 1997 to about 86,000 today, which is 18,000 additional people working in the health system. One needs workers in the health system if one is to bring down waiting lists.

Now the Minister of State is talking.

Time has not stood still. While we prepared the health strategy, the job of reform was very much on hand and reform delivered. In the area of equity we have delivered medical cards to the over 70 age group and developed health targets as part of the national anti-poverty strategy. We have introduced the most significant improvements to services for people with a disability in the history of the State. All of this occurred prior to the introduction of the health strategy.

Contrast this with the legacy of inaction left by the rainbow Administration. Other speakers, I am sure, will examine the Opposition's health policies. They are shallow and ultimately unworkable in the context of a large and complex health system in need of reform.

Did the Minister of State write that or did Deputy Gildea do it for him?

Without the policies of future reform and a record of past reform, the Opposition parties come before the House once more to talk about equity in the health system. No one will buy it. Equity is a far broader issue than medical cards. Nevertheless we will increase income guidelines for the medical card – it is in the strategy. The provision of real and lasting equity in our health service involves a broader, more strategic approach which will ensure that services are built up and can be accessed by all those who need them.

It is cynical for those opposite, who failed to increase medical card eligibility in any significant manner while in Government and whose policies would not increase equity in the health system, to feign concern tonight.

Some 39% of the population has a medical card.

For the Opposition this debate is not about health reform or equity, but using the issue of health for purely political ends. The new health strategy represents the way forward in terms of health reform. In my area of responsibility, the health and well-being of older people, it will greatly improve the quality and degree of care provided. In terms of community services it involves the provision of 7,000 additional day centre places, increased funding for appliances and aids in the homes of older people and recruitment of additional staff to support a wide range of primary care services, such as domiciliary care and day and respite services. In terms of hospital services it involves 1,370 additional assessment and rehabilitation beds and 600 additional day places.

Contrast the new health strategy with the uncosted ambiguity of the Opposition. The strategy is specific, with concrete targets and concrete means of achieving them. It outlines what has to be done, how and when it will be done and who is responsible for getting it done. Reforming the health service and providing equity of access and treatment is a serious, complex business. Those parties which have little or no Government record of health reform and did not increase equity in terms of health or social welfare in Government now stand before us as would be champions of equity. The people whose policies would shut local hospitals and increase administration costs now tell us they have a better way. Nobody will buy that agenda.

I call Deputy Gay Mitchell.

Fetch the men in white coats.

I wish to share my time with Deputies Ring, Farrelly, Gerry Reynolds and Boylan.

Is that agreed? Agreed.

I am grateful to the Labour Party for giving us an opportunity to again discuss this important matter. The Minister and the Minister of State talked about what they call a specific health strategy. However, it is about as specific as the one they put forward in 1993. Action 38 on page 166 of that specific document refers to the scope of eligibility framework being broadened. It states that income guidelines for the medical card will be increased and it refers to this being deliverable. There is an asterisk after "target date" for the revised income guidelines which relates to the statement that the timing of the introduction of action 38 will be decided by the Government in the context of the prevailing budgetary situation.

When was that?

This is the health strategy.

We always took the matter seriously.

The Deputy's party was in office then. It was in Government between 1994 and 1997.

Deputy Healy-Rae was on a radio station earlier, announcing an increase of 200,000—

That was Deputy Howlin's strategy.

Order, please.

The Minister should take his medicine. Deputy Healy-Rae was on the radio earlier, announcing an extra 200,000 medical cards from tomorrow. The Ministers do not know about this yet because they were not told. The Minister said the Opposition wants everything at once, but that is not the case. We want the poor and not the rich put first. I will return to this point later.

A well meaning journalist, who is a decent person, wrote a column last weekend in which she appeared to suggest that Deputies would have a better time writing to their constituents, enclosing medical cards. We do not do that but some of my constituents sit at home alone in cold houses. They have an income of £101 a week, but they cannot get medical cards. I would not mind writing to tell them that an exception had been made and they will be granted medical cards. If anybody in this House had to pay 30% of their income every time he or she visited a doctor, how many of us would go? The Minister claims to be concerned about reform, fairness and quality but he kicked in the backside, those people with incomes of £101 a week. He gave medical cards to wealthy, retired businessmen who voted for him and he left out the very poor. Such people do not go to doctors and I will return to this point later.

The Deputy does not know the statistics in regard to the elderly.

In times of plenty, the Minister gave medical cards to retired chief executives and he left out the poor.

Neither of the marvellous Ministers referred to the Deloitte & Touche report during their contributions. The report stated that medical cards at £50 a head would be value for money. However, it did not refer to the activities of the devious Minister who, in the week of a by-election, caved in and gave £250 a head to the IMO to get it to abandon its argument with him about giving priority to the poor. The Minister gave the IMO five times the norm and he also gave it a deal on secretaries. It thought all its birthdays had come at once. The Minister squandered £17 million of taxpayers money to buy that deal in the week of a by-election and he ignored the poor. I can understand the Minister pulling that stroke, but I do not understand him leaving out the poor.

That is an outrageous statement.

I do not understand how the Minister could leave out the very poor.

The Minister did it.

That is outrageous.

A stroke Minister.

Order, please.

The Minister quoted his great policy document. The waiting list for orthodontic treatment in the Eastern Regional Heath Authority area increased by 1,300 last year. Some 11,500 people are now on the list, of whom 10,300 have been waiting up to six years for assessment before they go on to the list for treatment. They will not be covered by the Minister's 12 month guarantee because he has no interest in them.

The Minister packed the Blood Transfusion Board with his cronies from his bailiwick for his own advantage. This service needs to have confidence in it restored and it was an outrageous action by the Minister, as I told the House previously. It was outrageous that the Minister undermined the board and this ultimately led to the resignation of its chairman. The Minister leaked information about 1,000 extra consultants months ago, but the report still has not been published. He is at loggerheads with the Department of Finance—

On a point of order—

We listened to the Minister's blarney. He should take his medicine.

The Minister on a point of order.

The Deputy referred to people outside the House in a tone and using a term that is disrespectful and damaging to their reputation.

That is not a point of order.

So did Deputy Gildea but the Minister defended him.

These independent, professional people are not cronies of mine or anybody else.

The Minister should sit down.

Order, please.

That comment should be withdrawn.

I stand over it. I named them in the past. The Minister packed the board of the Blood Transfusion Service—

Withdraw the term.

—with his cronies and people from his bailiwick. These people inflated the Minister's ego in Cork but they did nothing for the national reputation of the service. When the chairman resigned, her letters were published and we saw the references to the Minister's political hacks. Those were her words, not mine.

At the Ballymascanlon discussions, the Minister wanted 5,000 extra beds. His plan now states that 3,000 extra beds will be provided over the next ten years. The Minister hid the Deloitte & Touche value for money report, which he did not commission. The Government commissioned it because it is fed up with him pouring money into a black hole and because he does not have the ability to take a decision and deal with the issues.

During a time of plenty, the Minister made a mess of public services. The country had unprecedented wealth and first class services could have been created. The Minister wants to appoint a board, in addition to Comhairle na nOspidéal, called the hospital authority or hospital board because he cannot take a decision on the role of Comhairle na nOspidéal. He cannot decide where cancer services should be located. He does not want to upset a few people so he proposes to establish another board. No other country the size of Ireland has two boards dealing with hospitals. The Minister makes this proposal in what he considers his marvellous document.

The Minister for Finance, Deputy McCreevy, told the Minister, Deputy Martin, to get lost. He also told the Minister, Deputy Martin, that he could not pour any more money into a black hole. The Minister will not be allowed to repeat the mess he made of the Department of Education and Science in the Department of Health and Children. He rode on the back of decisions made by other Ministers and he came out smelling of roses. However, when Mr. Seán Cromien was sent into the Department to examine the management systems after the Minister left, he said they were in chaos. The Minister wants to preside over the health services in the same way and he hopes nobody will find out about it until after the election. The Minister has established more than 70 reviews, committees, standing groups and quangos. Everything is sent to a review group and none of them ever wind up. He has more quangos and review groups than Heinz has products.

The Minister referred to the document I published last year. It is true that I made proposals in it and I said it was outrageous that the death rate of males over the age of 55 years is three times higher among lower income groups compared to higher income groups. I asked why the Minister for Health and Children recently extended the medical card entitlement at enormous expense to retired businessmen while leav ing persons on incomes of £100 a week without medical cards. Why did the Minister not quote that statement from my document published in November 2000?

Why did the Deputy vote for it?

It is outrageous.

The Deputy voted for it.

The Minister has presided over a system of apartheid in the secondary care area and he has deliberately and wilfully extended apartheid to the primary care area. In the document published 13 months ago, I proposed the doubling of income limits for medical cards to bring them up to a decent level and to fill the State's 40% agreement with the IMO, as the organisation has sought. I proposed a doubling of the limit from £5,200 to £10,400 for a single person. Would that be too much given that £10,400 in this day and age is nothing? Doubling the income limits should not be out of the question. The limit for a married couple with two children should increase from £8,760. As it stands, they are disqualified from having a medical card if their income is above that sum. Even keeping it within the 40% level, doubling the amount would increase it to £19,720. That is still nothing to write home about for a family of four, but the Minister, Deputy Martin, did not do that. He did not look at giving the free GP service to children, as the chief medical officer in his own Department recommended and as I recommend before the CMO did in my document last November which contains these proposals to which the Minister referred, or at giving it to those over 65 only, as I suggested, after doubling the income limits. The Minister did not quote those things in his contribution.

The Minister has missed a golden opportunity to do something decent. I do not mind him playing politics. I am used to his smiling face but when I grew up I was told, "Handsome is as handsome does". The Minister is not handsome. He has let down the poor and he has done it deliberately while smiling into the camera. That is unpardonable.

I look across the floor of the House and I see a wary, tired Government. They are tired Ministers in every sense. They have lost their ideas and certainly they have lost the run of themselves.

I have never had the pleasure of being a Minister. If one continually listens to the spin doctors, the Civil Service and the cameramen telling you "how great thou art", I suppose you get carried away. That is what happened with this Minister.

Tonight I listened carefully. I am told that £80 million will bring 200,000 into the medical card arena. In Opposition, we are accused of not providing answers. I can tell the Minister in two minutes where to find that £80 million. Since the Government came into office, it has spent £130 million on consultants and it has 75 spin doctors. If it gets rid of the consultants and the spin doctors on 1 January, there will be 2,000 more who can have medical cards next year.

What should I tell the woman who was at my constituency office on Saturday? She has four children and her husband brings home £321 a week. He pays £70 on the mortgage and he pays for his car which brings him to work. He, his wife and four children applied to the Western Health Board for the medical card and they did not qualify because his income is greater than that laid down in the guidelines. She said she did not ask the State for a house, for a car or for anything else and all she wants for her four children is a medical card.

A medical card is worth £1,000 per year to a family. It is fine if one can afford to go to the doctor. In some parts of Mayo doctors charge £20 per visit in other parts of Mayo they charge £25 or £30. On average, therefore, doctors in Mayo charge £25. The other day I went to the doctor with a sore throat and he charged £25 straightaway. I went down to the chemist and spent another £30. I can afford it, but what about the poor woman on £321 a week.

If the Deputy keeps shouting he will have another sore throat.

That "man's wife" said her child was sick last week. He had a sore throat – this complaint is prevalent at the moment, as the Minister of State, who is a doctor, will confirm. She said: "I could not send him to school but I certainly could not send him to the doctor because I could not afford it." Is it not shameful in this day and age that there are such young families in this situation?

Since this Government came into office there has been one attack after another on the family. It has no respect for the family. One needs a medical card most when one has young children. Fine Gael proposes to give every family the medical card to cover every child from the day of birth until he or she reaches the age of 18. Does that not make sense? Why is the Government always looking after the rich? Since they took office, the rich have got richer, the poor have got poorer and the middle class is being squeezed.

I listened to a colleague refer to Deputy Healy-Rae. I do not know whether he qualifies for the medical card. If he is over 70, he does but I do not know his age. If he got one from the Minister of State, Deputy Séamus Brennan, in the bag, it would not be the first bag which was brought into Fianna Fáil offices. In future, instead of writing to the health board and to the Minister, I will write to the Minister of State, Deputy Séamus Brennan. If Deputy Healy-Rae is right and if the Minister of State is handing out medical cards on a day-to-day basis, then the Minister of State can apply for the vacancy in the Western Health Board. The appeals officer is taking up a job in the legal profession, which is another lucrative profession. If the Minister of State wants to apply for that job, there is a vacancy and he has enough friends within the health board.

I am sick and tired of listening to the Minister of State, Deputy Moffatt, and the Minister, Deputy Martin, telling us about all the money which is going into the health service. What they do not tell us is—

The Opposition did not give medical cards or anything else.

—what has happened over the past number of years. Let us look at the Western Health Board, the Minister of State's, Deputy Moffatt, health board area. When I became a Member of this House in 1997 it had one press officer now there are three press officers. I would not mind if they were spinning out good news, but this morning the first ten letters I got from the health board revealed, for example, that a woman in need of a cataract operation must wait 18 months, a man waiting for hip operation must wait 18 months and another man must wait for a prostate operation. In the case of the man waiting for a prostate operation, who has gone to Galway Hospital twice, I hope on the third occasion I will be able to get him that operation. If I do not, I will raise it on the Order of Business every morning until he gets it.

The Minister has applied spin on the issue of money, but that is what is happening with the health boards and that is what is happening with the money. If he provided less money to consultants for reports and more money to medical consultants, there would not be half the problems.

What is happening in the health boards at present is that, again, they are introducing new structures and new programme managers. There are more managers in the health board than at Manchester United. Up to a couple of weeks ago Manchester United was delivering, but the health service is not delivering. Something must be done.

I put this challenge to the Government and to the Minister this evening. Let us put this health strategy before the people and let them decide whether they think it is a political gimmick. If the Minister thinks that he will send out the political masters from the health boards to sell this message, I have a message for the officials and for the health board. I will be there to meet them at every public meeting. I will bring people waiting for orthodontic services and I will bring people in wheelchairs who are waiting for hip operations to the meetings. When they have been through a meeting or two, they will tell the Minister that they will not go to any more public meetings. The Minister and the health boards should let the health board officials stay in their offices to administer the services. We are paying them to do that, not to go out to public halls telling the people how great is the service. The service provided is not a proper service.

I am sick and tired of people coming to me in tears because they must go to England to get their son to pay for their heart operation or hip operation. That is how the waiting lists are being reduced. The waiting lists are being reduced because people are getting the operations done privately and people are dying because they have not been provided with a service. The Government should be ashamed. As we approach Christmas, this is a disgrace.

I welcome the opportunity to say a few words about the total failure of the Government to deal with the problems of the ordinary people of Ireland. The IMO and the Government had an agreement in place for quite a long number of years that 39% of the people of Ireland would be covered by medical cards. Up until recently, the percentage covered was 29%, a reduction of 10%. That reduction took place because quite a substantial number of spouses or partners, who took up jobs which perhaps did not pay too well, ended up in a position where the income they received put them over the limit for the medical card.

Over the past four years the IMO should have told the Government about this. I am wondering was it discussed during the negotiations when they were getting the IMO to agree to the provision of services for those over 70 years of age. The majority of the people who lost their cards tell us they cannot afford to bring their children to the doctor. As a result many children are going without proper medical care. We waited for four and a half years for this Government to produce a health strategy. We read in the weekend newspapers that it took 36 to 48 hours for that strategy to unravel. I am not surprised there is such a large number of civil servants in the House helping to keep the rest of the strategy together until the Minister for Finance arrives here tomorrow to agree to the demands of some of the independents who know a little more than the Ministers of the problems out there.

The first phone call I had yesterday morning was from a man whose wife became very ill on Saturday and had to go into hospital in Dublin on Sunday. Up to yesterday morning at 10.30 a.m. she was still being treated on a trolley. That is the health service the Government says is working. There has not ever been so much money in the Department of Finance as there has been over the past four and a half years. The Department of Health and Children has not ever had so much money and yet people are still on trolleys in the same way they have been for years.

This Government has ignored the realities of what is happening in our hospitals. The Minister said he would provide 650 new beds next year. How nice to do so in the year of an election. All he will do is re-open the beds that have been closed for the past four and a half years. Where are the consultants and nurses in the strategy who will look after the patients when the beds are opened? They are not there at the moment.

We are training more.

The Minister of State knows they are not there at the moment—

There are 1,700 more.

He knows the wait of a year or two years about which my colleagues have spoken, is the reality in every constituency. It would befit the Minister and the Minister for Tourism, Sport and Recreation, Dr. McDaid who has joined us, if reality struck the Government before 2 May, which I believe is the date for the general election. They might put money into services to look after people who are afraid to bring their children to the doctor, because of the costs involved. This Government has left 200,000 people short of care, 10% of the accepted figure of the IMO and the agreement with the Department of Health and Children.

I compliment the Labour Party for putting down this motion. I read the amendment tabled by the Government and one line in it almost jumped out at me: "that the Government commends itself for the resources available to deal with hospital waiting lists". I find that an extraordinary statement. To put it down on paper is even more extraordinary. The reality is that all the Members of this House have people coming to them every day of the week seeking to try and jump queues and the waiting list to get into public hospitals.

A young man of 34 years who has a tumour on his brain has to wait eight weeks to get into St. Luke's Hospital. In that period he had to go to the general hospital in Sligo three times. He had severe difficulties and went into a coma on one occasion. Despite that, he still had to wait for service and had to come to a politician like me to get into hospital.

No politician should be put in that position but more particularly, no citizen should be. The Minister of State, Deputy Moffatt sat smugly and told Deputy Ring that Fine Gael did not do it when we were in Government. We did not, but we tried and we did not have the funding that has been available to this Government for the past four and a half years.

The Deputy's party had enough.

Where has the money gone? Where has the value for money been and why is the Minister for Finance asking the Minister and the Minister of State where the value for money is? They have put money into the health service but it has deteriorated. That is a fact.

What did the Deputy's party do?

The Minister of State is unable to answer the tough questions. The health strategy he introduced has taken four and a half years to produce and has been launched just six months before a general election. If he thinks the electorate will buy that, he is mistaken. It is sin and spin. It is a sin that this Government has allowed people to remain on waiting lists for health services that are not available. If people are on public health waiting lists they do not get the services to which they are entitled. That is an indictment of the Government. It has failed miserably in trying to provide a health service.

Each Deputy in this House is approached by many people trying to get into hospital for operations. The Minister did not have the courage of his convictions to put in place what is needed. Some 67% of all jobs last year in the health service were in administration. That is horrendous. What are they doing? Is it not more important to have hospital wards open and more nurses, doctors and consultants? That is where the money needs to be spent – at the coalface.

People are leaving the medical profession because they do not have development opportunity due to being over-worked, over-stretched and starved of resources. What this Government has done in the past four and a half years is a disgrace in the management of the health services. Even with this health strategy, the issue in the next general election will be the mis-handling of the health services by this incompetent Government. I am glad we have the opportunity every so often to raise these issues in the House because we, as an Opposition, have come up with policies that we are willing to put in place that will give proper health services to all the citizens which is what they are justly entitled to.

The motion we put down stated that we want to ensure that poor people would get medical cards. The Government has turned it into a motion praising itself for its action on waiting lists. There are two eminent doctors on the Government bench and it is a shame this Government has not dealt with the waiting lists. We have a health strategy policy because the Government has suddenly realised, in its fifth year in office and in the run up to a general election, that there is a health crisis.

A woman in my constituency had a relative who was called off a waiting list for a procedure. She had died seven years previously. This is documented fact in Galway. The longest period of time a person has been on a waiting list in Galway, acknowledged to me in a letter from the chief executive, is ten years. Is that any kind of health service? According to the strategy of the Government and the Department of Health and Children, adults must be on a waiting list no longer than 12 months and children no longer than six months. The figures for University College Hospital, Galway show that for ENT, there are 386 people on the list, that 262 of them, or 67%, have been waiting more than 12 months. Some 122 people, or 44%, have been waiting more than 12 months for ophthalmology, 103 or 80% have been waiting more than 12 months for plastic surgery and I could go on and on.

The Minister of State at the Department of Health and Children, Deputy Moffatt, spoke about appointing consultants. The Minister for Health, Deputy Martin, told me in reply to a Dáil question that a consultant neurologist was sanctioned for University College Hospital, Galway in January 2000. Because of the red tape involved that consultant has not yet been appointed and will not be appointed until well into next year, two years after sanctioning. Will the Government cop itself on about its health strategy, consultants and waiting lists?

I will share time with the Minister for Tourism, Sport and Recreation, Deputy McDaid.

The crucial feature of the new health strategy is that it proposes to extend medical card coverage to cover more people on low incomes. It will also have an increased target to ensure more children are covered and that over 200,000 additional persons will be covered by medical cards during the period of the strategy. That is a stated commitment. We can say to the people that we will do this if returned to Government next year.

What did the Government do when it had the chance?

It is not very clear what will happen if the Opposition is returned. Deputy Mitchell addressed the House this evening as the health spokesperson of the principal Opposition party and suggested that the decision of the Government to extend free medical card access to elderly persons was wrong. He instanced cases of persons who should not have obtained medical cards. Let us be realistic. There was a substantial increase in medical card provision last year which has to be accommodated by the medical profession and must be implemented through the health board system. That is being done. It is a cheap political gimmick for the Opposition parties, in an election year, to come out and promise the people medical cards they know they cannot give out. The people think all we are doing is engaging in cheap political games.

That is what Fianna Fáil is doing.

They think we are engaging in cheap political games instead of addressing the real problems of the health service. The key problems of the health service are ones of priorities. This year the Government has committed additional funding to provide 650 extra acute hospital beds and is addressing the waiting list problem through a new treatment purchase fund. I agree with Deputies Reynolds and McCormack that the waiting list problem is the greatest scan dal of our health service. That is the reason it is top of the list as far as Government priority is concerned in the coming year.

The treatment purchase team will be established in 2002. It can buy services from both public and private hospitals to meet the defined laid out targets in the health strategy, but what has the Labour Party said to this? It suggests a further increase in free hospital coverage for the entire population. That will not be implemented by the end of 2002. It is an ambitious strategy which may have some intellectual merit, but it has a considerable problem. It would result in a vast increase in public expenditure on health services when we have already seen a substantial increase since the last general election in 1997.

All Members of the House must recognise that management of the health service in an efficient cost effective way that provides a decent service for the patient should be our priority. There is no point coming in here week after week cherrypicking the health service and picking out one isolated issue and pretending that issue can be addressed through cheap abuse and point scoring off the Government. Let the Opposition face up to the fact that the Minister has produced a health strategy which has commanded and secured substantial public support.

The Government would not spend the money when it had it. It stashed it away.

There is no question of money being stashed away.

Order, please. Deputy Lenihan to continue without interruption.

The increase in expenditure on the health service has been substantial under the present Administration. In fact, the historic under-provision in the health service was not addressed the last time the Labour Party had the health portfolio in the years from 1995 to 1997. I do not want to have to refer to those years, but if provoked on the issue, I will because the Government has a sound, well thought out, common sense strategy. What is most interesting about it is the confidence expressed in it by those who work to provide the health and medical service in this country.

I thank the Opposition for providing the House with the opportunity to discuss the reform of the health system and, in particular, the medical card system. As Deputy Lenihan stated, this issue is being used as an exercise in political opportunism. I remind the House that the previous Minister for Health and Children is now the leader of the Fine Gael Party and the previous Minister for Finance is now the leader of the Labour Party.

We all know people who have been let down by a system that has been underfunded for decades and the frustration, hurt and anger which these failures have caused. For decades the system went underfunded, and crying out for reform, but in the two years prior to 1997, when Deputy Noonan was Minister for Health and Children and Deputy Quinn was Minister for Finance, when money was available—

There was more available in the Government's time.

—there was a notable absence of any Government commitment from those speaking on the issue tonight. I listened to Deputies Quinn, McManus, Gilmore and others tonight, but it is a fact that in the three budgets for which the Opposition was responsible during its period in government it never touched on the medical card issue. The Government, in the past four budgets, has consistently improved the medical card scheme, most notably last year when it extended it to include those over 70 years of age. The rhetoric of the Opposition is not matched by any workable policy now or any credible record of the past.

Again, I remind Members that when Deputy Noonan was Minister for Health and Children and Deputy Quinn was Minister for Finance they cut the waiting list budget in the winter of 1996 and 1997 from £12 million to £8 million. Are we now supposed to believe that they have had some form of Pauline conversion and that at last they are concerned about the health service? Their record does not stand up on this. Not once in three budgets did they touch on the medical card issue.

That is not true.

Reforming the health system is a complex and long-term project which requires a thorough and workable strategy and sustained investment. It also requires specific targets and specific means of achieving them. It takes a hard neck for the Opposition, particularly Deputies Quinn and Noonan, to table a motion on health care and, above all, on medical card eligibility. While I welcome the Opposition's late interest, the people will not be fooled by this latest Pauline conversion.

The Government had the money. It had billions.

I must ask the Opposition, taking its past record into consideration, if we can really trust it on the health issue. Instead of having the courage to stand up and support the Government's health strategy we have instead political opportunism at its worst.

The extension of the medical card to those over the age of 70 years has made a huge difference to many who in their later years tend to suffer more from poorer and deteriorating health. It is a fact of life that old people generally have more cause to visit their doctor than others. Medical cards are only one aspect of health reform. By extending eligibility at this time, a substantial amount of funding would be used in paying capitation fees to the general practitioners of cardholders. Figures of 200,000 to 250,000 people, to whom the scheme should be extended, were quoted tonight, but extension of eligibility will include many—

They are the Government's figures.

—who never – I will address the Deputy's point – or rarely need to avail of the benefits of a medical card, yet they will be taken into account because the capitation fee will be paid regardless of whether the cardholder seeks assistance.

The Minister is arguing against the Government's health strategy.

I estimate that up to 80% of the people that the Labour Party wants to include will not need a medical card. A small percentage of young married couples with children should be included, but 80% of the 250,000 people whom the Labour Party wants to include will never need a medical card. They will be in pubs, sports clubs and discos while £80 million is paid in capitation fees to GPs.

I am refusing a £20,000 annual income into my practice, just as Deputy McManus's husband would, because it is the GPs who will benefit from the scheme. All available funding for health services should be channelled into areas where it will directly affect those in need of treatment. The health strategy—

I ask the Minister to withdraw remarks made about someone outside the House. He should not impugn someone else's professionalism.

I have not done that.

The Minister has.

I said it is GPs who will benefit from the scheme and I would prefer that 80% of the £80 million be channelled to health boards for services or as capital.

I did not know that the Minister was still in practice. Is he still practising as a GP?

The health strategy contains major reforms of our health system. Everything cannot be done at once and change will not happen overnight, but we have started something that has the potential for change. No one disputes that there is a need to bring low income young couples with children into the medical card system, but I dispute the figure of 250,000 and know the people who would benefit.

They are the Government's figures.

The Government is committed to extending the scheme to those families and, unlike the previous Government, we have a strategy that will deliver on the commitment.

I am glad of the opportunity to make a short contribution. I welcome the publication of the excellent health strategy which provides a comprehensive programme to deal with our society's future health needs. It is the result of proper and full studies of the entire health service. We have the reports on medical manpower and junior hospital doctors' working practices, the commission on nursing, the strategic assessment of hospital capacity and the national consultative forum which facilitates the input of health stakeholders into the national health strategy. Through a progressive programme of research and negotiation, a quality, well founded strategy was developed, which will stand the test of time.

We should bear in mind that Government spending on the health service has more than doubled since 1997. The biggest ever increase in hospital activity will occur this year. The total staffing figure for the public health service has increased from about 68,000 in 1997 to 86,000 today. There are 1,700 extra nurses in the health service. A record number of nursing students are training this year while the number of nurse training places is at an all time high of 1,640. I welcome the fact that the report of the commission on nursing is being implemented fully with major improvements in conditions and support for nursing staff.

There is a major capital investment programme in my county, County Cavan. I am sure there are similar programmes in other counties. I thank the Ministers, Deputies Cowen and Martin, and the Minister of State, Deputy Moffatt, for their decision to allocate major funding to the North-Eastern Health Board to enable it to provide an operational 30 bed nursing unit and community health facility in Ballyconnell, a 50 bed nursing unit and health centre under construction in Virginia, a major health care unit under construction at Cootehill and major developments planned for Cavan General Hospital. These are the results of decisions made by the Ministers to provide a proper health infrastructure in rural Ireland. I am glad that these investment programmes are taking place because of the Government's good management of the economy and the provision of facilities for our health service.

Beneath the Labour Party's rhetoric is the infamous insurance company health plan which would shut local hospitals. It would place an insurance company between the patient and the hospital bed. It is a system which has been repeatedly shown to increase funding for administration at patients' expense. Its policy document clearly states that "public and voluntary hospitals will be required to cover their operating costs through income from health insurers and patient co-payments where applicable." This would mean, in effect, that smaller hospitals which could not win service contracts from private health insurers may have to close or, at least, cut their level of service. A year on the Labour Party relaunched the document and again conceded that smaller local hospitals, which could not provide cheap services could "find themselves excluded from insurers lists of approved facilities." The vociferous call for reform from the Labour Party benches does not rest easy with the policy of hospital closure.

Fine Gael initially dismissed entirely the Labour Party policy, but then changed its mind. In February 2000 its spokesperson, Deputy Shatter, stated, "Whether the necessary reform can be brought about by the introduction of a universal health insurance system is questionable. What is needed is less, not more bureaucracy." All of us agree that we do not need more bureaucracy in the health service, yet in November 2000 Fine Gael, in its health plan for the nation, announced a consultative process in which the insurance company policy would be discussed.

Beneath the Labour Party's rhetoric is a policy that would increase administration costs and shut local hospitals. Despite its opposition to the health strategy, in its pre-budget statement last Sunday, it makes no mention of health. Plainly, its focus is elsewhere.

I am glad that the Government, the Minister and Minister of State in particular, have devised a health strategy which is sound and will deliver the level of health service to which the people are entitled. It will deliver an additional 3,000 hospital beds – 650 next year. Rightly, by the end of 2002 no adult will wait more than 12 months for treatment and no child more than six. By the end of 2003 no adult will wait more than six months for treatment and no child more than three. By the end of 2004 no public patient will wait more than three months for treatment. These are achievable targets and a level of service to which people are entitled.

During the years my health board, the North-Eastern Health Board, has bought in services from the North, which was beneficial for those awaiting hip and cataract procedures. I endorse the establishment of the treatment purchase fund. Wherever services are available, in the North, Britain or elsewhere, every effort should be made to buy them to ensure our patients are treated as quickly as possible.

I congratulate the Minister and the Government on the publication of the health strategy, which is a new direction and states that medical cards will be extended to more families with children and people with disabilities being the priority. I welcome the emphasis on increasing bed numbers because we lost out on beds in the 1980s. In particular, I welcome progress in County Galway where, in recent weeks, the Mini ster announced an allocation of £3 million for the Western Health Board to purchase the Bons Secours hospital, which will ensure Tuam has a community hospital. He also announced an allocation of £11 million to purchase Portiuncula Hospital, Ballinasloe from the Sisters of the Franciscan Missionaries of the Divine Motherhood. Portiuncula Hospital has played a very important role in the provision of public hospital services in the region in the past 50 years under the stewardship of the order and it is important that it be retained as a provider of public hospital services, now that the order has decided to withdraw. The purchase of the hospital by the Western Health Board will ensure the acute hospital services will continue to be provided to the public at Portiuncula Hospital and it will facilitate the expansion and development of services in the future.

I pay tribute to the sisters at Portiuncula and the Bon Secours sisters in Tuam for their dedication to caring for people and all their work over the years to provide hospital services for the people of the area.

The Minister has said waiting lists are down substantially for the first half of 2001. There are also regional issues that the Minister should look at. There are a large number of people in the Western Health Board area who must travel outside the area to get medical treatment. The Government is committed to improvements in the west and I welcome the developments in University College Hospital in Galway concerning cancer and heart treatment. I have mentioned the new developments proposed for Tuam and Ballinasloe. I look forward to the day when patients from the west do not have to travel to the Mater Hospital, Beaumont or St. James's Hospital and can have treatment in their own region. I have often been told that patients from Galway cannot get treatment in Dublin because there is a shortage of beds and this must be addressed.

An additional neurological centre is needed in the west. People with head injuries need treatment as quickly as possible and at present, they must go to Dublin or Cork. I urge the Government to support the effort to put this unit in place.

I welcomed the statement by the Minister that a treatment purchase scheme will buy services from both public and private hospitals to meet targets for the years 2002, 2003 and 2004. I welcome the announcement that 800 adult community nursing beds per annum will be available over the next seven years. I urge the Government to support the many projects that involve the retirement villages planned throughout the country. In particular, I commend Dr. Cowley in County Mayo for his initiative. He has given a lead to other communities in rural areas and I thank him for his advice and help.

One of the achievements of this Government is the extra funding for persons with an intellectual disability and those with autism. There are now extra residential respite and day places available. The number of people with a disability in psychiatric hospitals has been reduced from 970 in 1996 to 571 now. I hope these new residential places will be as near to the people's homes as possible.

I hope the Western Health Board will continue to support the Brothers of Charity and the Galway County Association for Children with a Disability so that they can continue their good work. The Minister, Deputy Martin, and his predecessor, Deputy Cowen, have been very pro-active in giving priority to people with disability.

Death rates from coronary heart disease in Ireland are considerably higher than the EU average. I welcome the planned recruitment of 800 professionals throughout the community in the first two years of implementation. I congratulate the Minister on the measures he has introduced, both in prevention and rehabilitation. I wish the Government well with the new national health strategy.

I wish to share time with Deputy O'Flynn. I welcome the opportunity to speak on the debate on health tonight. I welcome the publication of the national health strategy by the Government. This motion was tabled by members of the Labour Party, despite the fact that during their time in the rainbow coalition the medical card eligibility was not increased significantly. Now they present themselves as the great advocates of the health service. They left it to us to give medical cards to all people over 70, to develop the health targets as part of the national anti-poverty strategy, to start the job of reform in the area of disability and they now speak about equality, access and reform as if they had ever done anything about these important areas.

Under the national development plan, annual capital health spending is almost three times that of the previous Government. Our hospitals are treating more people than ever before. The past year alone has seen an extra 52,000 people treated in our hospitals, the largest ever increase in hospital activity. In the area of disability, we have turned the tide on the shameful trend of neglect. By the end of this year, we will have invested additional revenue and capital funding amounting to £205 million in services for people with either an intellectual disability or autism. Since 1997, more than £107 million in additional funding has been allocated for services to people with physical and sensory disability.

I am not saying all is rosy in the health service it is plainly not. However, the investment is being put into the service for the first time and this will deliver results. The new health strategy is a continuation of that process. Built on years of research and negotiation, it represents the path forward in health reform. There will be 3,000 new beds in the system, 650 of these in the first year. By the end of the second year, no adult will wait more than 12 months for treatment. By the end of 2003, no adult will wait longer than six months and by the end of year four, no public patient will be on a waiting list for more than three months. Some people might say these are loose targets. However, when we went into Government we had four key tasks including restoring peace, and reducing tax and unemployment. We have delivered on these and we will deliver on the health strategy.

Enormous effort has been put in by the Minister, Deputy Martin, his predecessor, Deputy Cowen and the Cabinet. In a number of years time, those of us who will be privileged enough to still be Members of these Houses will be able to say that the national health strategy put in place in 2001 was the beginning of the great new health service that we have.

The rainbow Government in the mid 1990s was harsh on the poor and harshest on the health system.

It looks like it took a terrible toll on Deputy O'Flynn.

Thankfully, the then Minister for Finance, Deputy Quinn, continued the policies of the previous Government, which was one of our Governments, and for the first time in the history of the State, a considerable amount of money was available to him. The Minister for Health in that Government, Deputy Noonan, had for the first time in seven years the funds to effect real reform and improvement in the health service, but the wealth was not spread among the poor and needy. The opportunity to reform the health service was not availed of. The total health spend over the life of that Government was a meagre £400 million. It failed to put money into cutting waiting lists. It failed to provide new nurse training places. It simply failed to fund the health service. Deputy Quinn has admitted that concerns about the future of the medical profession, particularly about the nursing profession, were communicated to him and that he was disappointed he had not put systems in place and had not dwelt more on the health system when he was Minister for Finance.

Cork has done very well.

The Deputy should mention Knocknaheeny.

I commend the Minister, Deputy Martin and his predecessor, Deputy Cowen for what they have done for Cork. We were neglected from 1995 to 1997. A new maternity hospital costing £80 million has come on stream. There are new accident and emergency facilities and a new cardiac unit in Cork University Hospital. The South Infirmary and the Mercy Hospital have done well. I was there deputising for the lord mayor yesterday when the Minister for Health and Children opened a new oncology unit. This is the kind of investment which I and the constituents I represent want. This is the kind of investment Fianna Fáil in Government has delivered and will continue to deliver under the new health strategy. Through this strategy we offer our constituents definite reductions in waiting lists. We offer them a system whereby hospital appointments made for 9 a.m. will mean that and not 11 a.m. or noon as at present.

People are waiting three years not three hours.

We will improve the system. In one year we will have 650 additional acute hospital beds. We will tackle waiting lists through a new treatment purchase fund. We are very fortunate to have a Cork man, Deputy Micheál Martin, as our Minister for Health and Children doing a fantastic job. I hope the Opposition joins with us and votes for the amendment the Government has tabled.

The Deputy does not believe a word of it.

I wish to share my time with Deputies Bell, Rabbitte, O'Sullivan, Kenny, Deenihan and Ó Caoláin.

Is that agreed? Agreed.

I am glad to have the opportunity to contribute to this debate tonight. I am beginning to wonder if some people are living in cloud cuckooland. While the health strategy announced by the Minister for Health and Children last week promised some improvements in the funding and delivery of health care, it did little to address the fundamental inequalities that characterise our health service. The two-tier system which condemns public patients to months and sometimes years of suffering, while private patients are given priority, remains firmly in place. Even if the increased spending which has been promised by the Minister takes place, we will still have a system which is one of the most inequitable in the developed world. We have a system with a nominally free hospital service, but the fear of public hospital waiting lists has driven almost 45% of the population into private health care.

We still have a system which charges 70% of the population for GP visits and where people on low incomes pay a significant contribution to health spending in their payments to GPs and for medicines, while private health insurance contributes approximately 9% of all health spending. We still have a system whereby private care in public hospitals is heavily subsidised by the taxpayers, many of whom cannot afford to avail of such care.

The Minister for Health and Children must be aware that one in four voters puts health care at the top of the list of issues on which the next election should be fought. People throughout the country are asking why, at a time of extraordinary economic growth, many people are on waiting lists. These people are often in pain and many of them will suffer permanent impairment as a result of delayed treatment. They are also asking why, at a time of rapidly increasing incomes and medical costs, the income limit for eligibility for medical cards is below the average industrial wage. At a time when our economic growth is said to create two new millionaires a week, why must some parents reduce their spending on food to pay for essential medical care for their children? Is the Minister aware that free and equitable health care is taken for granted in many developed countries?

Despite being a long time in gestation, the health strategy is largely a series of ad hoc measures and quick fix solutions which the Government hopes will deflect the wrath of the electorate. There is no radical reappraisal of how our health care system can best be funded and organised to meet the needs of our increasing population. The strategy does not show any commitment to tackle the vested interests particularly of hospital consultants whose contacts give them an opportunity to use private beds in public hospitals. In Denmark, which has one of the best medical care systems in the EU, hospital consultants are paid less for their work in the public sector. Consultants in Denmark are remarkable because they oppose the extension of private medical care. It is hardly surprising that 90% of Danes are satisfied with their medical care system, which is the highest satisfaction rate in the EU.

My family depended on a medical card which gave them access to medical services. Without it my family, like many others, would have had to make choices. Parents who need to go to a doctor might stay at home to provide the necessary finance to allow their children to go to the doctor. I am perplexed that someone who is diagnosed with cancer is put through the ringer to get a medical card. As soon as someone gets that news, a medical card should be provided immediately. Some of my family were in that situation. As someone who has lost aunts and uncles from asthma and bronchitis, I cannot understand why a humane society cannot provide medical cards to people with such illnesses. The Minister for Tourism, Sport and Recreation, Deputy McDaid, knows more about this than I do. People can die from such diseases. This area should be examined.

An aspect of the health strategy which has not received much attention is health promotion. It appears from the Estimates that expenditure on health promotion might be reduced this year. The Minister is aware of the frightening level of consumption of alcohol, tobacco and narcotics by young people which will eventually lead to health problems. I am sure he is also aware that the fitness levels of school children are low compared to other EU countries. Many of us, including myself, eat unhealthy diets. More resources need to be devoted to health promotion to avoid huge increases in health care costs in the future. Finland, which once had a level of heart disease simi lar to Ireland, has reduced it dramatically through effective health promotion.

I remember reading about Aneurin Bevan and the opposition he encountered while setting up the NHS. In his memoirs he recalled getting a letter from an old woman in Lancashire who had worked in a cotton mill from the age of 12. She wrote to thank him for the spectacles she had received under the NHS which enabled her to write letters. She ended her letter with a prayer: "Dear God, reform thy world beginning with me." I doubt if the Minister for Health and Children will get many such letters, but he should ponder the old woman's wish.

I listened with great interest to the debate and it is interesting to hear some of the speakers on the Government side. I do not know what is happening in other health board areas, such as Donegal and Cork, but the contributions do not reflect what is happening in the north-east region. I was surprised at Deputy Brendan Smith's contribution. The situation is completely and utterly different from what Government speakers stated here tonight. There are empty wards and beds in every hospital in the north-east region. There is a lack of nurses and medical staff at every level. As a qualified GP, the Minister for Tourism, Sport and Recreation, Deputy McDaid, should know that better than anyone.

What are they doing with the resources we are giving them?

It is called politics.

It is not only happening in Drogheda and Dundalk, but in every town throughout the country. Beds are lying idle, while people are lying on trolleys in the corridors and in emergency beds in waiting areas for hours. If one was to take the non-EU staff out of the hospitals in my area, they would fold up overnight. Most of the staff are non-EU citizens and Asians who had to be brought in because people will not work in the health services as they have lost confidence in the Government and its health policy. One has only to look at the national newspapers every day, particularly at weekends, to see the hundreds and thousands of pounds being spent trying to get consultants and nursing staff. Various incentives are being thought up to entice them into the health service. It is not possible to get nurses to accept jobs in Dublin. I know nurses from my own town who gave up nursing and are now working in Dublin in other professions because they were not paid enough for the hours they worked.

Orthodontic treatment in the north-east region is non-existent. Perhaps the Minister for Tourism, Sport and Recreation, Deputy McDaid, will tell me how many are on the waiting list for orthodontic treatment in Donegal. I am sure the position is as bad there as it is in County Louth – if it is not, there is something wrong. I cannot get any positive response from the North-Eastern Health Board about orthodontic treatment. People must go from Drogheda, Dundalk and elsewhere in County Louth to Newry and other parts of Northern Ireland where they must pay more than £3,000 in some cases.

Why would someone work in the public service if he or she can get £3,000 for each case?

The Minister knows that because he lives in the Border area, like I do. People cannot get treatment because they cannot afford to pay for it. It is cheaper in Northern Ireland. People are borrowing money from the credit union on a never-never basis to have their children's teeth treated. The waiting list is miles long – it would stretch from Drogheda to Dundalk. I cannot understand people saying there is not a problem with waiting lists. Another area of concern is hip replacements. How long does it take for someone to get a hip replacement operation? There is one unit in Navan which does a good job, but it cannot cope with the waiting lists.

The man who made the biggest contribution to the health services in my area was Deputy Howlin. He saved the North-Eastern Health Board and other health boards from bankruptcy by giving them a substantial cash injection to wipe out the deficits. He put proper health policies in place in each of the health board areas. Instead of that position improving when we had the cash, it has got much worse. The biggest problem we had to deal with in our clinics used to be people having to wait two years to get a telephone. Thankfully that is no longer the case. Subsequently it was unemployment, but any Member of this House will tell the Government, quite openly, that the biggest issues we face in our clinics now are health related. They are in the North-Eastern Health Board area. The main issue relates to medical cards. The system is an absolute disgrace. People are coming into my clinics crying. There are women who cannot go to the doctor because they cannot afford to pay the fee or for the prescriptions. Some of these women are paying £5 a week on the "never never" so that they can get a prescription when one of the family gets sick. In my town people are paying £5 per week to the doctor and getting a receipt for it every week because they cannot afford to pay the bills. If we could only admit that there is a serious problem, we could do something about it. This is the most outrageous decision of all, because it hurts the most vulnerable in our community.

I have heard the Minister for Tourism, Sport and Recreation, Deputy McDaid, Deputy Brian Lenihan and other Members on the Fianna Fáil benches, throw at us on the other side of the House what happened when other Governments were in office. That is extraordinary, coming from Fianna Fáil, a party that has been in Government for 12 of the past 14 years. Its members seem to have forgotten that the man they lionised, former Deputy Ray MacSharry, is directly responsible for the gap that has to be made up in the health services. I do not know why they want to look to this side of the House for explanations when the fact is that we now have wealth which we did not have when Ray MacSharry was Minister. Is this the way to use that wealth?

I listened to Deputy O'Flynn talking about the bad years and he looks like a man who weathered them reasonably well. The health services in Cork are in fine fettle according to him, but that is unknown to us in the rest of the House. It is remarkable how quickly this Government has grown remote from the people as evidenced by the Minister for Health and Children slipping on a banana skin of this size. Even the Minister's most ardent and well-placed supporters – we have seen some in recent days – are taken aback by his blunder on medical card eligibility limits. This was the immediate acid test of his eleventh hour health strategy. Fine rhetoric for reform and promises of what will happen when the Minister is no longer in office are all very well, but what about the here and now? There is, after all, a general election around the corner and we all remember the surprise expressed by the Taoiseach's mentor, Mr. Haughey, when he went to meet the people in 1989.

The present health strategy is an attempt by this Government to retaliate first. The media – and thus the public – was generally well disposed, even if the end of a term of office is an unusual time to promulgate a health strategy. The test must be what actual reforms this Government implements in the time left to it. Enhanced eligibility for medical cards would have been a practical reform on the way to a free GP service. Given the extent to which our health services are characterised by inequality, extending the medical card scheme would at least acknowledge the core problem. The Minister purports to acknowledge that reform of the primary care system will help contain the pressure on acute hospitals, but he has blown it. He managed to persuade the Minister for Finance, Deputy McCreevy, to ignore the publication of a glossy document underpinned by notional billions for the future, but he could not manage to persuade Deputy McCreevy to approve a small step to tackle an inequality that causes so much hardship. This calculated rejection of poor people is perfectly consistent coming from this Government.

Everything this Government has touched in four and a half years has widened the gap between the very well off and those struggling to make ends meet. The IMO has said that the Minister's decision will "undermine the Minister's own health strategy's guiding principles". The Society of St. Vincent de Paul has pointed out that more families on the minimum wage are "turning to the Society for money for doctor's bills and for medication". Professor Tom O'Dowd, who has carried out studies in my constituency and is based in the Mary Mercer Health Centre in Jobstown, has noted that 25% of male patients in their fifties were "putting off going to see the doctor because of the cost". In his professional view this is a very vulnerable group with a high risk of cardiac failure. I do not say this Minister's failure with regard to medical cards sets his health strategy at nought. I, along with his party's backbenchers and many groups outside this House, say that the credibility to be attached to the health strategy is greatly diminished. For thousands of poor people it is more serious than that. People on low wages in indifferent health must continue to pay to visit their GPs or else go without and it is an intolerable disgrace if that is to be the legacy of this Government at the end of the boom. I note that if this motion is to be carried tonight it will depend on the votes of the likes of Deputy Healy-Rae, whom I notice is quoted in a south Kerry local newspaper to the effect that he does not need to come in here and vote and make loud speeches. All he has to do is go to the office of the Chief Whip where he will meet the Minister for Health and Children and get bags of medical cards. It would be much better if Deputy Healy-Rae came in here tonight and voted to support this motion and to share the bag of medical cards with the rest of the country.

We are spending three hours talking about something which is very simple. It is about the right of access to basic primary health care. It is extraordinary that this issue has not been prioritised by a Government that has so much money and that we are only getting its health strategy on the eve of a general election. The Government is totally out of step with the people. It does not recognise that the right to access primary care should be an absolute priority. If one does not have access to basic primary care, what rights does one have in health care? What would we say if somebody did not have a right to basic primary education?

The issue of health has been left to be dealt with later. What is being said is that a couple with two children and who are earning less than £200 per week do not have the right to go to their GP. They have to make a choice. When their child is sick they have to think about whether they can afford to go to a GP based on how sick the child is. They have to decide if they can wait to see if the child gets better or grows worse or if that is too great a risk to take.

The Deputy's party did nothing about medical cards in three budgets.

We are living in a wealthy economy and have the money to spend on this most basic of problems. This is something that will come back to haunt this Government. Given that billions of pounds have been discussed in regard to this health strategy and its complications over the past week, this is the simplest of issues. It is the one that should have been concentrated on. It is extraordinary to hear Deputy McDaid implying that the strenuous opposition of the IMO to the Government's proposal might be motivated by self interest. That seemed to be what he implied when he said the money would go into the pockets of the GPs. The IMO strenuously objected to the decision that was made. Is the Minister for Tourism, Sport and Recreation suggesting that the Society of St. Vincent de Paul might be motivated by self interest in its opposition to the Government's decision? I have sat and listened for approximately an hour to the bombast that has come from the Government side of the House. No attention has been paid to the issue that we have put on the table which is one of access and civil rights for every citizen. What is at issue is the right to have health care needs addressed when a person is sick. The Government will have to go back and look at the decision it has made.

I will make an economic argument which might reach the ears of the Minister for Finance, Deputy McCreevy. If I were a working person on such an income, I would ask the reason I was working and if I would not be much better off if I had my medical card and did not have my job. That is a genuine economic argument which might be of interest to the Minister because he does not appear to respond to the human stories behind the widespread opposition to this decision.

I will give one human story which I heard this morning. I spoke with an elderly person over 70 years who qualified for a medical card this year. She said she would have much preferred to see her grandchild receive the card because they did not have access to one. She had seen the mother of the child having to decide whether to balance the household budget or take the child to the doctor. That is how basic this issue is.

I believe the Minister for Health and Children, Deputy Martin, has the best interests of patients and the people at heart and that he would like to be the Minister who set down a landmark strategy which ensured a health culture was brought about where health bills were reduced and those in need of medical attention received it. This ten year strategy with a price tag of £10 billion was presented with a veneer of competence. The reality of its implementation is far removed from the slick public relations we witnessed.

In every one of past ten general elections in which I have participated there has been a major blunder by the Government in office before the election. I recall the former Taoiseach, Charles Haughey, admitting he did not know the position of haemophiliacs was as serious as it was, the late former Minister Boland saying prescriptions would not be issued from rural pharmacies, and the former Minister for Education and Science, Gemma Hussey, proposing to remove school transport from medical card holders. In each of these campaigns, despite overall figures being shown to be for the good of the country, the issue people understood became the one close to their hearts.

After presenting what is a worthwhile document in many respects and following with a worthwhile document in the context of a community network of care, to follow with a major blunder of excluding 200,000 people from the general medical service scheme who would be eligible next year, while not the Minister's fault, is an indication of how the Government feels about the people. The slogan in the previous election was "People before politics." It appears to be reversed now.

I have a letter from a woman in my town who must wait two years for a tonsillectomy. Her neighbour has a daughter who has blackouts and been assessed as not having epilepsy but who must wait six months for a brain scan in Beaumont Hospital. These are the issues with which these people must deal every day.

In respect of the Government's amendment, which states that funding for disability services increased massively, how does this relate to the young woman—

There are five minutes remaining and two further Members are sharing the time allotted.

The situation is terrible.

There has been misinformation on the guidelines for medical card holders. If one is a single person under 66 years, living alone and earning more than £100, one cannot get a medical card. If one is a single person living with one's family, the threshold is £89. It is £144.50 for married couples under 66 years of age. This rules out anyone who is working or on a low income. As a result, the people concerned cannot avail of the services of a doctor. Minor ailments can become serious and lead to death because people cannot go to a doctor because they do not have the money in their pockets. Doctors are not charitable organisations. The people concerned might go once or twice because the doctor might be kind to them, but they cannot afford to go generally. The health service is not coping with the needs of the underprivileged. Our health status is not what it would be if a proper health service was available and there was proper access to primary care services which the current system does not allow.

I heard a number of Members on the Government side defending the Minister's record on waiting lists. The chief executive of the Southern Health Board announced today that the out-patient waiting list in Tralee General Hospital had been reduced from 5,173 to 3,790. He said that was as a result of verification of the waiting list. Many of those on the waiting list for five years or more were dead. I know this because they were called for procedures and were found to be dead. Others on the list had made other arrangements for treatment. There was an attempt to deceive the people by saying this was a decrease in the numbers on the out-patient waiting list. It is misleading the public and the Minister should correct it.

It is patently obvious that the long delay in producing the Government health strategy had nothing to do with the extent of the work involved, rather it had everything to do with the fact that there was no clear leadership and no direction at Cabinet as to how to put right our grossly inequitable health system. The Taoiseach let the Ministers for Health and Children and Finance fight it out. We are on the side of the Minister for Health and Children.

The health strategy was unveiled with great fanfare and the Government then told us it would not take the one vital short-term action needed, namely, to extend medical card eligibility. Nothing is to be done on medical cards in the remaining term of the Government. We are told the planned extension will not begin until 2003, budgetary considerations permitting.

The Minister for Finance, Deputy McCreevy, won the argument. That is the reality, plain and simple. He has once again had his way. More significantly, the Taoiseach did not take the lead and ensure action was taken in tomorrow's budget to help those most in need in our health system. We have heard the initial extension of medical cards to 200,000 people would have cost £80 million. In 2001, the Minister for Finance reduced corporation tax at a cost of £214 million. That shows the priorities of the Government. The profit margins of big business come before the needs of families who cannot afford to bring their children to the doctor or buy essential medication because they are denied a medical card.

I call for the immediate extension of medical card eligibility to all under 18 years, to all on or below the minimum wage, and to all with disabilities or conditions such as asthma which necessitate expensive ongoing medication. My brother has Down's syndrome and long held a medical card, but I was shocked to learn recently at a meeting of the North-Eastern Health Board that there are many others with the same or similar intellectual disabilities who do not qualify. This is a disgrace and—

The Deputy's time is up.

—after four and a half years of huge budget surpluses, the Government should hang its head in shame.

I support the Labour Party motion and indicate that we in Sinn Féin will face the battle in the upcoming general election on our policy of ending the gross inequalities in the two tier system of health care delivery in this State and the introduction of free and comprehensive health care for all.

I ask Deputies to stay within their time, in fairness to other Members.

The Minister, Deputy Martin, has set out the health strategy, building on the investment and services that are already in place. The strategy was developed because the Government thought it appropriate to implement the strategy developed by Deputy Howlin when he was Minister for Health. The time is now opportune to spell out where we see the health service going for the next ten years.

Why did the Minister not do it four and half years ago instead of talking about it?

It did not come out of the blue because the strategy builds upon four and a half years of investment and development. The strategy is based on that.

As the saying goes, "Live horse and you'll get grass."

Please allow the Minister to continue without interruption.

They will be dead before the Minister gets around to them.

I would ask Deputy Stagg to allow the Minister to continue as she has only five minutes.

It was interesting to hear Government speakers dealing with real issues and acknowledging the progress that has been made in tackling disability, cardiovascular disease and cancer, as well as managing the drug payments and medical card schemes. How quickly we have forgotten that people on the lowest incomes, the most vulnerable, and those who deserve them most such as the elderly were given medical cards. There is a commitment in the strategy to extend medical card eligibility to people on low incomes and those with more children.

Tell that to the people who cannot afford to go to the doctor.

That will happen in the lifetime of this strategy. We have no problem on this side of the House in addressing the real issues relating to health.

The Minister should address the subject before her.

On the other hand, it took Deputy Gay Mitchell to launch a personal attack on the Minister, Deputy Martin. All he could focus on was an attack on the Minister's ability and achievements. I remind Deputy Mitchell that the Fine Gael Party spent all last week objecting to personalised comments, yet its Members did the very same in the House tonight. If Fine Gael Deputies have to resort to personalised attacks and cannot talk about the real issues, it shows that they do not realise what is happening as regards policy, planning and progress.

The Minister is hurting.

Deputy Ring, please allow the Minister to continue, she only has a few minutes.

Much has been achieved during this Government's term of office and it is clear where we intend to go.

What about the Minister's U-turn on medical cards?

Nowhere is that clearer than in my area of responsibility, which has not been mentioned in the debate, involving the welfare of the most vulnerable children. The Government has not only set out the philosophy and policy which guides its thinking, but has also backed it up through legislation, supported it with investment and is delivering it through new structures. Major policies and guidelines have been set down for the protection of our children, which were not there before. These include the national children's strategy, the homeless strategy, which aims to reduce and eliminate homelessness, and the children first guidelines for the identification and reporting of abuse.

No one, either inside or outside the House, can say that real progress has not been made in this area. Policies and philosophies which are backed up by legislation are changing the focus of how we deal with children in these circumstances. This is particularly the case with the Children Act, which we have started to implement. The focus has changed from locking up children to ensuring that detention is used only as a last resort. More importantly, this has been backed by investment in recent years, with over £90 million extra being spent on these children.

One thousand children are homeless on the streets of Dublin. Why did the Minister not reach them?

The numbers have doubled.

Deputy Stagg, please allow the Minister to continue.

This ensures that family support is there for them, that springboard projects are developed and that foster care is developed to the extent that the carer of every fostered child in the country now receives £210 per week.

What about those with no carers, the children on the streets?

It also provides residential care for the most vulnerable children because where formerly there were 17 special care places there are now 88. They can be staffed by child care workers who have received adequate salary increases backed up by a new career structure. The centres established by the Government have a social services inspectorate to ensure the highest standards.

What has this to do with the motion?

All these services can, thus, be delivered by the national children's office and the residential social services board. The philosophy, legislation, investment and structures are there, more particularly for children than for anybody else. That is what the Government has achieved, not only for children but for the entire health service which is properly funded and well focused. It will continue that way through the development of our health strategy.

Dr. Upton

I wish to share time with Deputies Michael D. Higgins and McManus.

Is that agreed? Agreed.

Dr. Upton

The promise that 200,000 extra people were to receive medical cards in 2002 was welcome news indeed. It was a great Christmas present for many low income families, or so it seemed. After last Wednesday's shocking announcement, however, Christmas now appears much bleaker for 200,000 people. The announcement has hit the most vulnerable in society at the most difficult time of year. How can the Minister defend his position to a single mother who wakes up to hear her child crying in pain at 3 o'clock in the morning, but who cannot afford to call out a doctor because it would cost £40 or £50 to do so? How will the Minister explain his decision to an old age pensioner couple who, with an income from the State of £185 per week, do not qualify for a medical card? The guidelines dictate that such a couple can only earn £162 per week to qualify for the medical card scheme. Medical costs for such an elderly couple can be considerable, yet they are a miserable £23 over the limit for medical card eligibility.

Another example of the people who will be penalised by this appalling decision is a married couple with one child and an income equivalent to the minimum wage. All that couple can earn to qualify for a medical card is £162 per week. If their income exceeds that amount by a mere £10 or £12 they will not qualify for a medical card. They can appeal the decision but will be forced to jump through a series of hoops to get what is a basic requirement.

I could cite numerous examples of those who will fall victim to the harsh decisions of the Government in the year ahead. Last week, the Minister's paltry excuse was that he had to prioritise his health policy for the coming year. The Minister has a strange sense of priorities if he is telling us that old age pensioners or a married couple on low income represent a lower priority than a national stadium.

The Independent TDs who support the Government have much explaining to do to their constituents. They have been trying to limit the damage caused by this decision on the plinth all day, sending out conflicting signals about the extension of the medical card scheme. The Government's amendment to our motion, however, only says that it is committed to extending the medical card scheme to 200,000. Crucially, though, it does not say when it will do this. For that reason, the Government amendment must be defeated.

This important topic affects some of the poorest people in my constituency who often attend my advice centres in conditions of great stress. The view of the Minister, Deputy McDaid that 80% of those who might qualify if the medical card scheme was extended would never use it illustrates the fundamental distinction between our viewpoints on health. The issue is not whether one would use the scheme, but having the social protection it affords. There is an enormous difference between two things that divide us in the House. One is the restructuring of the sickness industry, which will welcome private money into what might be regarded as highly profitable activities that are now tax assisted and subsidised by the public purse for private gain – the sickness industry is yielding profit. The other is the health service with a set of guarantees.

When the history of the past five years comes to be written, the question will be asked what people said, or failed to say, about the health service. Claiming credit, often where it was not due, mention was made of the fact that we have the highest growth in the European Union. Many Ministers mentioned that, but few said that over this period of extraordinary wealth we were in the bottom two or three countries concerning social protection.

We have a miserable record in providing social protection for women, for example, who may be under great stress due to high rent, low income and many other problems. The rising cost of housing has had a major influence in the past five years. Rents have escalated while people have had to live in poor social housing conditions. The last straw for such people is when somebody becomes ill. There is nowhere for them to go because they cannot afford to be ill. The guaranteed social protection of the medial card, of its nature, addresses rights to health care. There are many good proposals in the health strategy with which I agree and some proposals for reform but I wonder how they came to gestation just six months before the election. Leaving that aside the fundamental question is what quality of social protection is available to citizens? That is what a health system is about. The stress is not even at the time of illness. At advice centres, one case after another – all Deputies on the other side know this – the question is what happens if one of us gets sick. It is the last straw that pushes people in poverty below the floor of poverty altogether. That is what this motion is about. It would cost £80 million to remove 200,000 of the most vulnerable citizens from such a situation. When the history comes to be written people will know that £80 million was not available in the best of times with the greatest surpluses. There is no need to go back over history about who did what. The question will be put this way: when the economy turned who had to wait? I can say who had to wait. In relation to the housing crisis, which I mentioned earlier, the landlords did not have to wait but the tenants had to wait. The tenants were told they would get their protection in 2002 but the landlords were looked after. In this case the 200,000 people have to wait until 2003 and even then there is no guarantee, it is conditional on what Government revenues will allow.

What always struck me at advice centres was that there are parents who would sacrifice anything for their children. The greatest stress that faced them was the possibility of not being able to bring their child to a doctor. There is another side to this as well. All the evidence of a socio-medical kind indicates that a visit deferred is putting the person at risk, that it would be more costly for the person in terms of their life and more costly for the State in relation to later care. Who has to wait and why? Those who have to wait have to do so because they have not been accorded the priority that an egalitarian approach would accord them. They are entitled by right to a health service. I have listened to all the speeches this evening. The fundamental difference is that on one side of the House, the Government says they will get it when the Government can afford to give it while people on this side talk about an extension of rights, the right to social protection, good health care and the right in a citizenship count.

I will say a word about what I believe to be the kind of degradation of politics that unfortunately is not sufficiently commented upon in this House. That is the suggestion that the medical card has a pre-history which goes back to the old blue card and the time when a person would get the notable in the parish who represented him on the board of guardians of the grand jury to put in a word for him for a blue card. That is what Deputy Jackie Healy-Rae reminds me of. He will not come into the House to speak of the right of every citizen to have a medical card but he will go to the Chief Whip's office where he can meet the Minister for Finance and the Minister for Health and Children and get whatever he likes. That is the kind of statement about behaviour that has degraded politics. I hope the public will have an opportunity soon to express their opinion on it.

I knew people who put the health system before the sickness industry. I knew people such as the late Dr. Paddy Leahy and others who looked at people and saw what they needed and were willing to fight publicly for it. I feel like that about what is happening this evening. Deputy Lenihan argued that a person can get his rights when everything else is in place. Speaking about medical cards for 200,000 people is playing a cheap political game. It is about when the economy turns and those who are asked to wait. It is not speculators in housing who will have to wait but tenants, not those who will invest and make money out of the sickness industry but the 200,000 who might have got medical cards that would have given them some social protection. That is why the motion is important.

I thank the Labour Party Deputies who contributed to this debate and the Members of the Opposition who supported the motion. I listened with interest to Government Deputies who contributed and I was reminded of Alice in Wonderland because it appeared that the one message to the people in need was that they could have had the medical card yesterday, maybe they will get it tomorrow but they should not expect it today. It is worth reminding the Government that a promise was made and commitments were indicated in the run up to the health strategy that were dashed when the Minister for Health and Children announced that far from the expectation being realised there would be no granting of medical cards for 200,000 people in 2002. Is it any wonder that organisations such as the Society of St. Vincent de Paul were appalled and shocked when that news became known and expressed their views so forcefully.

It is dispiriting that a once great party like Fianna Fáil should be so out of touch with the needs of ordinary working people. That was not always the case. Ordinary working people, many of whom voted for Fianna Fáil at the last election, believed in the slogan "people before politics". When Fianna Fáil was elected to Government the same people believed the Government when it said it would tackle the hospital waiting lists. Fianna Fáil and the Progressive Democrats poured money into hospital waiting lists but the numbers have not reduced significantly. There are 26,000 approximately on hospital waiting lists after millions of pounds have been squandered in trying to tackle a problem that requires structural reform, if it is ever to be tackled. Some 200,000 people thought matters would get better for them in the same way that they have got so much better in the country generally, particularly for the better off.

We have seen a growing disparity between rich and poor. If one is very poor and on social welfare one has a medical card. For those whose income just exceeds the limit, life is still a struggle. Parents are worried that maybe a child will get sick and that they may have to call out the doctor. Even if they can afford to pay for the doctor how in God's name will they pay for the medication? That the Minister for Tourism, Sport and Recreation, Deputy McDaid, should say 80% of these people would not need or use a medical card is extraordinary coming from a man who is surely better able to understand what happens in society. When one is living on a low income one runs a far greater risk of experiencing sickness. You, a Leas-Cheann Comhairle, would understand that the better off in society live longer and generally have healthier lives and that those on low incomes suffer to a greater degree from ill health and stress. One can imagine how much greater the stress levels when one is worried about whether one can afford to pay the doctor. This is a simple measure and one that would have transformed the lives of thousands of people in terms of providing security and freedom from worry for themselves and their children.

I urge the Fianna Fáil Deputies, quite apart from the Independent Deputies, who know what I am saying is right, to ensure this is done. This is the legacy that should be left by the Minister for Health and Children who so far in his career has only increased the divide in the health service and introduced a new inequality where it did not exist previously. He has provided medical cards for people who are relatively well off and who happen to be over 70 and is denying medical cards to people on low incomes who simply cannot get a doctor and medication when needed. I urge the Independent Deputies to come in here tonight and defend the interests of poor people who cannot have that entitlement unless they make a decision now to support these thousands of people.

Amendment put.

Ahern, Bertie.Ahern, Dermot.Ahern, Michael.Ahern, Noel.Andrews, David.Ardagh, Seán.Aylward, Liam.Blaney, Harry.Brady, Johnny.Brady, Martin.

Brennan, Matt.Brennan, Séamus.Briscoe, Ben.Browne, John (Wexford).Byrne, Hugh.Callely, Ivor.Carey, Pat.Collins, Michael.Cooper-Flynn, Beverley. Coughlan, Mary.


Cowen, Brian.Daly, Brendan.Davern, Noel.de Valera, Síle.Dempsey, Noel.Dennehy, John.Doherty, Seán.Ellis, John.Fahey, Frank.Fleming, Seán.Flood, Chris.Foley, Denis.Fox, Mildred.Gildea, Thomas.Hanafin, Mary.Haughey, Seán.Healy-Rae, Jackie.Keaveney, Cecilia.Kelleher, Billy.Kenneally, Brendan.Killeen, Tony.Kirk, Séamus.Kitt, Michael P.Kitt, Tom.Lawlor, Liam.Lenihan, Brian.Lenihan, Conor.McDaid, James.

McGennis, Marian.McGuinness, John J.Martin, Micheál.Moffatt, Thomas.Molloy, Robert.Moloney, John.Moynihan, Donal.Moynihan, Michael.O'Dea, Willie.O'Donnell, Liz.O'Donoghue, John.O'Flynn, Noel.O'Hanlon, Rory.O'Keeffe, Batt.O'Keeffe, Ned.O'Kennedy, Michael.O'Rourke, Mary.Power, Seán.Roche, Dick.Ryan, Eoin.Smith, Brendan.Smith, Michael.Treacy, Noel.Wade, Eddie.Wallace, Dan.Wallace, Mary.Woods, Michael.Wright, G.V.


Allen, Bernard.Barrett, Seán.Bell, Michael.Belton, Louis J.Boylan, Andrew.Bradford, Paul.Broughan, Thomas P.Browne, John (Carlow-Kilkenny).Bruton, Richard.Burke, Ulick.Carey, Donal.Clune, Deirdre.Connaughton, Paul.Cosgrave, Michael.Coveney, Simon.Creed, Michael.Currie, Austin.D'Arcy, Michael.De Rossa, Proinsias.Deasy, Austin.Deenihan, Jimmy.Dukes, Alan.Durkan, Bernard.Farrelly, John.Finucane, Michael.Fitzgerald, Frances.Flanagan, Charles.Gilmore, Éamon.Gormley, John.Gregory, Tony.Hayes, Brian.Hayes, Tom.Healy, Seamus.Higgins, Joe.Higgins, Michael.Hogan, Philip.

Howlin, Brendan.Kenny, Enda.McCormack, Pádraic.McDowell, Derek.McGinley, Dinny.McGrath, Paul.McManus, Liz.Mitchell, Gay.Mitchell, Jim.Mitchell, Olivia.Moynihan-Cronin, Breeda.Naughten, Denis.Noonan, Michael.Ó Caoláin, Caoimhghín.O'Keeffe, Jim.O'Shea, Brian.O'Sullivan, Jan.Owen, Nora.Penrose, William.Perry, John.Quinn, Ruairí.Rabbitte, Pat.Reynolds, Gerard.Ring, Michael.Ryan, Seán.Shatter, Alan.Sheehan, Patrick.Shortall, Róisín.Spring, Dick.Stagg, Emmet.Stanton, David.Timmins, Billy.Upton, Mary.Wall, Jack.Yates, Ivan.

Tellers: Tá, Deputies S. Brennan and Power; Níl, Deputies Bradford and Stagg.
Amendment declared carried.
Question put: "That the motion, as amended, be agreed to."

Ahern, Bertie.Ahern, Dermot.Ahern, Michael.Ahern, Noel.Andrews, David.Ardagh, Seán.Aylward, Liam.Blaney, Harry.Brady, Johnny.Brady, Martin.Brennan, Matt.Brennan, Séamus.Briscoe, Ben.Browne, John (Wexford).Byrne, Hugh.Callely, Ivor.Carey, Pat.Collins, Michael.Cooper-Flynn, Beverley.Coughlan, Mary.Cowen, Brian.Daly, Brendan.Davern, Noel.de Valera, Síle.Dempsey, Noel.Dennehy, John.Doherty, Seán.Ellis, John.Fahey, Frank.Fleming, Seán.Flood, Chris.Foley, Denis.Fox, Mildred.Gildea, Thomas.Hanafin, Mary.Haughey, Seán.Healy-Rae, Jackie.Keaveney, Cecilia.

Kelleher, Billy.Kenneally, Brendan.Killeen, Tony.Kirk, Séamus.Kitt, Michael P.Kitt, Tom.Lawlor, Liam.Lenihan, Brian.Lenihan, Conor.McDaid, James.McGennis, Marian.McGuinness, John J.Martin, Micheál.Moffatt, Thomas.Molloy, Robert.Moloney, John.Moynihan, Donal.Moynihan, Michael.O'Dea, Willie.O'Donnell, Liz.O'Donoghue, John.O'Flynn, Noel.O'Hanlon, Rory.O'Keeffe, Batt.O'Keeffe, Ned.O'Kennedy, Michael.O'Rourke, Mary.Power, Seán.Roche, Dick.Ryan, Eoin.Smith, Brendan.Smith, Michael.Treacy, Noel.Wade, Eddie.Wallace, Dan.Wallace, Mary.Woods, Michael.Wright, G. V.


Allen, Bernard.Barrett, Seán.Bell, Michael.Belton, Louis J.Boylan, Andrew.Bradford, Paul.Broughan, Thomas P.Browne, John (Carlow-Kilkenny).Bruton, Richard.Burke, Ulick.Carey, Donal.Clune, Deirdre.Connaughton, Paul.Cosgrave, Michael.Coveney, Simon.Creed, Michael.Currie, Austin.D'Arcy, Michael.De Rossa, Proinsias.Deasy, Austin.Deenihan, Jimmy.Dukes, Alan.Durkan, Bernard.Farrelly, John.Finucane, Michael.Fitzgerald, Frances.Flanagan, Charles.Gilmore, Éamon.Gormley, John.Gregory, Tony.Hayes, Brian.Hayes, Tom.Healy, Seamus.

Higgins, Joe.Higgins, Michael.Hogan, Philip.Howlin, Brendan.Kenny, Enda.McCormack, Pádraic.McDowell, Derek.McGinley, Dinny.McGrath, Paul.McManus, Liz.Mitchell, Gay.Mitchell, Jim.Mitchell, Olivia.Moynihan-Cronin, Breeda.Naughten, Denis.Noonan, Michael.Ó Caoláin, Caoimhghín.O'Keeffe, Jim.O'Shea, Brian.O'Sullivan, Jan.Owen, Nora.Penrose, William.Perry, John.Quinn, Ruairí.Rabbitte, Pat.Reynolds, Gerard.Ring, Michael.Ryan, Seán.Shatter, Alan.Sheehan, Patrick.Shortall, Róisín.Spring, Dick. Stagg, Emmet.


Stanton, David.Timmins, Billy.Upton, Mary.

Wall, Jack.Yates, Ivan.

Tellers: Tá, Deputies S. Brennan and Power; Níl, Deputies Bradford and Stagg.
Question declared carried.