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Dáil Éireann díospóireacht -
Wednesday, 5 Nov 2003

Vol. 573 No. 4

Private Members' Business. - Hospital Services: Motion (Resumed).

The following motion was moved by Deputy McManus on Tuesday, 4 November 2003:
That Dáil Éireann:
– aware that after more than six years in office at a time of unprecedented economic growth, the Fianna Fáil-Progressive Democrats Government has failed to deliver an acute hospital service that meets public need;
– aware that despite the publication in 2002 of the national health strategy and the Brennan and Prospectus reports in June of this year and the promise that hospital waiting lists would be eliminated by May 2004, no fundamental reform of the health service has taken place;
– notes the report of the national task force on medical staffing, the Hanly report;
– believes that equality and ease of access to the highest quality possible of medical care should be a central feature of our hospital service;
– calls for an immediate commitment, as required in the Hanly report, to the provision of and funding for:
– 3,000 additional hospital beds,
– a doubling of hospital consultant numbers to 3,600,
– the establishment of regional speciality self-sufficiency, and
– the upgrading and retraining of emergency medical technicians; and
– further calls for the absolute recognition of the principle that all citizens in every part of the country must have access in reasonable time to world class accident and emergency services.
Debate resumed on amendment No. 1:
To delete all words after "Dáil Éireann" and substitute the following:
"– notes the extensive additional resources, both capital and revenue, which have been allocated to the health services since 1997 and welcomes the increase of over 25% in the number of patients treated in acute hospitals in the period;
– endorses the innovative health service reform programme which has been initiated by the Government as reflected in the health strategy,Quality and Fairness – A Health System for You, and in its consideration of the Brennan and Prospectus Reports;
– welcomes the Report of the National Task Force on Medical Staffing, the Hanly report, which outlines a blueprint for the reduction in the working hours of non consultant hospital doctors and provides a model for the configuration of the acute hospital services;
– notes the reduction in waiting lists, and in particular notes the significant reductions achieved in the last year in the number of adults waiting more than 12 months for inpatient treatment in certain specialties e.g. cardiac surgery down by 78%, gynaecology down by 65%, vascular surgery down by 60%;
– commends the national treatment purchase fund for arranging treatment for over 8,000 patients since July 2002;
– recognises that equity of access is one of the key objectives which underlines the health strategy;
– acknowledges the 34% increase from 1,292 to 1,731 in consultant numbers which has taken place in the last six years;
– welcomes the Government's commitment to increase the number of acute beds by 3,000 of which close to 600 are already in place; and
– endorses the Government's commitment to improve emergency medicine services and, in particular, welcomes the approval of a significant increase in the number of emergency medicine consultants."

In opening the debate this evening, I would like to comment on some of the issues raised in last night's debate. Deputy Olivia Mitchell raised the issue of the future of private health insurance in this country. Currently, 49% of the population has private health insurance cover. Private health insurance is a long-established feature of our health care system and the health strategy affirmed that it would continue to play a vital part in the overall resourcing of health care.

The policy of my Department in relation to services for older people is to maintain them in dignity and independence by providing the necessary supports and to provide a high quality of hospital and residential care for older people when they can no longer be maintained at home. The home help service plays a role in the implementation of my Department's policy. Since 2000, the total increase in expenditure on the home help service across all health board areas has been 113%.

I am also pleased to advise that a number of health boards are developing personal care packages that are more focused on individual care needs involving the public health nurse service, attendance at day care, day hospital, rehabilitation, respite care and home help and care assistance. I am actively encouraging all health boards to explore the benefits of such care packages. It is important to acknowledge that many positive things are happening in our services for older people. Of course, I also appreciate that there are gaps in service provision in the regions that we must address and I will be working with all the relevant authorities to further improve services.

Listening to the Labour Party contributions last night, they seemed to be hedging their bets, speaking out of both sides of their mouths, but clearly refusing to make any real decisions. If the Labour Party is serious about health reform, it is time to drop the cherry-picking approach. Indeed, one would think they would be present in the House for this debate.

I take serious issue with their motion that claims no health reform has taken place. This suggestion is as dishonest as it is unworthy. Unlike the Labour Party, the Government parties will not cherry-pick expert reports. We will not engage in each way bets and we will, at all times, do what is in the best interest of patients. This will involve some difficult choices along the way but our approach, from which the Labour Party could learn much, is founded on two key concerns – first to invest in services and second to bring about significant reform.

In terms of investment, we have made considerable progress since the days the Labour Party was last in government. This year the Government will invest almost €9.2 billion in health and that compares to a paltry £2.5 billion donated by the rainbow Administration when it was last in office six years ago. Put simply, it is the parties on this side of the House that have increased the health spend by 162%.

What about services?

While it might pain the Deputies opposite to admit it, the facts show that Fianna Fáil and our partners, the Progressive Democrats, have shown the political will to reverse the historical under-investment in our health services. We are proud of this record and can stand over the level of investment we have allocated to health. The Labour Party must ask itself if it is proud of what took place on its watch.

Regarding the Labour Party's criticism of our reform record, we are now set forth on implementing the most comprehensive reform programme in the recent history of Irish health care. As Deputy McManus is well aware, earlier this year the Government announced decisions regarding a new health service executive, which will include a national hospital office, a primary and continuing care directorate and a shared services centre. Taken together, these structural reforms represent the biggest single national reorganisation of the health system since 1970. Work is well under way to make these changes a reality. The Labour Party motion talks about a belief that "equality of access to the highest quality possible of medical care should be a central feature of our hospital service". I suggest to Deputy McManus that if she were really sincere about this sentiment, she and her colleagues would row in behind the Government in support of the reforms we have set in train.

While this might be too much to hope for, it is surely not too much to ask Deputy McManus to stop engaging in scaremongering on such a sensitive issue. I was disappointed to hear the unworthy suggestion that it is the Government's intention to downgrade local hospitals around the country. She knows, as Members of this House know, that nothing could be further from the truth.

Some members of the Minister of State's party are upset.

The Hanly report is about providing a higher quality of care in local hospitals – it is not about downgrading or closing them down. The reality is that it is Labour policies, not Government policies, that would close local hospitals. Current Labour Party policy entails a diversion of urgently needed funding away from the patient and into bureaucracy; the effect of this on local hospitals would be detrimental. The universal health insurance system the Labour Party advocates entails doubling the spending on administration costs and this is borne out by international studies.

Labour has previously told us that it is committed to fully funding the health strategy. Last night members of the party came into this House and demanded immediate financial commitment in regard to the Hanly report. If Labour is still committed to funding the universal health insurance system it must add that expenditure too to its published spending plans. I look forward to seeing how Deputy McManus will make these figures stand up.

I would do a better job than the Minister of State.

Of course Deputy McManus knows this is an impossible task. In the most damning indictment of Labour's credibility on health issues, two days before the last general election she conceded that her party's health policy was not workable for five years.

What is the Minister of State going to do?

What about the waiting lists?

Bearing this in mind, I would suggest that if the Labour Party wants to make a meaningful contribution to public debate, rather than wasting time coming here with futile motions, its time might best be spent resolving how it has no policy or credibility to deal with the present challenge to the reform the health service.

I am not going to compete with the Minister of State who made Deputies on the Opposition benches smile so heartily. I compliment Deputy McManus on tabling this motion. It is important that these issues are raised and I always take the opportunity to outline the opinions of my constituents.

I support the Minister for Health and Children and his Ministers of State in their determined efforts to give this country a health service that should be customer focused. I think all Members should support the Minister in his endeavours. By all means, we should examine and highlight the areas of concern. Offering the alternatives for discussion in the Chamber is something we should do.

Members will know that I represent Tallaght. It is not unusual for me to mention Tallaght in a debate like this as there is a major general hospital in the area. Not only have I been on its board since 1987, I have had the pleasure of being a patient there and experienced at first hand the good work that is done there. I often visit neighbours and friends in the hospital and see the great work that is done. Of course, this work is not only done in Tallaght, it is also done in other general hospitals around the city, county and country and it is important that we support this work in every way. While I accept that a little bit of politics will always go on, we should understand that great work is carried out in our general hospitals.

I accept that at a time when the Exchequer is spending so much money on our health services – I understand it is €10 billion this year – somebody will have to find a solution to the problem where people are seeking beds and assistance in our hospitals. Just to be fair, I checked with Tallaght hospital this evening and I understand 27 patients are waiting for beds in the accident and emergency unit and there were 18 majors and 15 minors waiting to be seen.

I hope the Minister of State is listening.

As a Government backbencher, my job is to represent the concerns of my constituents. I am not afraid to do this and will not hesitate to do so. I am positive about Tallaght hospital, I am positive about the work of the Department of Health and Children and I am certainly positive about the commitment of the Minister. I believe the health service is in very good hands and the Minister is doing a good job. We should let him continue with this good work and should support him in any way.

We in Tallaght are pleased that the National Children's Hospital is expanding its services. I understand that a new paediatric post has been approved, as has a further academic paediatric post. The hospital has also told me that all the relevant participating bodies are evaluating proposals for further posts. I am positive about the health service. We must keep the pressure on the Department and as a Government backbencher I am prepared to do this. I am proud of what is happening in Tallaght and I am happy to support the Government, as I always do.

While it is always a challenging time to be in charge of the health portfolio, the current Minister has had the benefit of presiding over a time when record amounts of money have been made available. He also has the benefit of recognising and knowing that finance is no longer the problem, that it is management and structures which need reorganising. With the three reports now completed, together with the health strategy, we finally have a strategic plan with which we can improve health care.

Those of us who are members of the Joint Committee on Health and Children had the benefit of meeting Mr. David Hanly last week. As he pointed out, we have no alternative but to implement the report which has a lot to do with the working time directive. The motion before us is a little ill-considered because these reforms must take place. Everyone now recognises that we are tired of receiving reports that sit on shelves. This time it will be different, perhaps because we have requirements under the European working time directive which has become the catalyst. For whatever reason, it is going to work while the requirements will be managed.

The Government alone cannot deliver a better health care service to patients. All of us, including health workers, politicians and the Department of Health and Children, recognise that patients are at the centre, the beginning and end of the health care reforms. We must look to the consultants and the work they will do in delivering what is set out in the report. The Government and politicians cannot do it alone. We need the co-operation of the consultants.

Those of us who are members of the Joint Committee on Health and Children hear consultants time after time looking for more money because there are not enough of them employed. The reports shows where we need to go. I call on the consultants to recognise their responsibilities to their patients, and urge that we all adopt a "can do" and deal making attitude in order that we will deliver better health care to patients.

The other notion being spread is that local hospitals will diminish in responsibility and activity. We need to nail this lie. It was nailed by Mr. David Hanly and others who appeared before the joint committee last week.

The Deputy should read the report.

Rather than queue and move forward and back, there will be a lot more important activity in hospitals. Health care will become more focused and strategic. Particularly in more peripheral areas, we all know that it is the level of care one gets in the first hour after a trauma that is important. That is the reason the report recognises the importance of the ambulance service, and the improvements needed to it. The Government has resolved to have the report, which I commend, delivered. Budgets are mounting. It is now time that those of us concerned with patient health care, particularly those working in the service, recognise the changes that must be adopted in delivering better health care to patients.

I welcome the opportunity to support the Minister in the matter of the recently published Hanly report. The main task of the report was the implementation of the working time directive which requires that non-consultant hospital doctors reduce their hours of work to 48 by 2009. The task force took account of two previous reports, the forum report which had recommended a consultant-provided service and the report on non-consultant hospital doctor working hours. A consultant-provided service replacing the consultant-led system is certainly the way forward. The present system is largely consultant-led where consultants lead and advise teams of junior doctors rather than taking a continuing and direct role in the provision of care in all cases. It means that patients have limited access to senior clinical decision makers, namely, consultants, relying instead to a significant degree on doctors in train ing. It is vital that they are seen by a doctor who has the skills, training and experience to diagnose, treat and plan the management of patients.

In the context of the Hanly report, I made a case in my constituency that in the South-Eastern Health Board we had a regional hospital which is misplaced on the edge of the constituency. Some of my colleagues in the Labour Party were critical of my statement at the time but it is not conflict with anything contained in the report. The South-Eastern Health Board, or any health board, can decide to change the location of a regional hospital. Waterford Regional Hospital is misplaced as a regional centre. Kilkenny would be a far more suitable location. The report does not deal with the specific location of regional or general hospitals. I, therefore, call on the South-Eastern Health Board to review the decisions of the early 1970s when Waterford was designated as the location of the regional centre.

In order to create a consultant-provided service that allows for reduced working hours for junior hospital doctors, we need to reorganise acute hospital services. Patients achieve a better outcome when treated in units dealing with sufficient numbers of cases, with specialist staff and diagnostic facilities. Hospitals with low volumes of patients cannot sustain large numbers of consultants who become deskilled if they do not treat sufficient numbers of patients. This means, in turn, that they cannot guarantee high quality care or adequately train junior hospital doctors.

Local hospitals will provide minor injury and illness units. It is important to emphasise that some 60% of those who attend hospital emergency departments require non-urgent care. Typically, about one third of patients require urgent or semi-urgent care while only 5% to 10% have major trauma which needs to be attended to in accident and emergency units. The minor injury units in local hospitals will, therefore, be able to cater for a very high proportion of cases presented to them.

I support the Hanly report. Perhaps there are aspects of it which need to be streamlined but, in general, it is a good report which will go a long way towards alleviating some of the current difficulties in the medical care system.

When I was first elected, the Minister for Health and Children at the time was Deputy Rory O'Hanlon, now the Ceann Comhairle. He was put under a lot of pressure and the scene has not changed much for those fortunate or unfortunate enough to occupy the position of Minister for Health and Children. We have to acknowledge that despite the huge investment made in the health service, all is not well and change is badly required. In fairness to the Minister, he has shown a willingness to make the necessary changes and it is important that we support and help him in that task.

When change is proposed, we can be certain of one thing, that there will always be resistance. It is vital that workers, in particular, and the public are fully informed of what changes and reforms will take place. Unless we get the full support of those employed in the health service, the necessary reforms will not be possible. Last night I listened to a number of Labour Party speakers and it is difficult to understand their approach. It appears that they are keen to have some elements of the Hanly report implemented but are not so sure about other aspects.

That is perfectly reasonable.

The report forms part of the Government's health strategy. It comes as one unit; it is not possible to adopt an à la carte approach. We cannot pretend that we are in a position to provide multidisclipinary specialist teams within immediate reach of all households. Tough decisions will have to be taken but we cannot and should not try to fool the public. If we explain clearly the reasons behind the reforms, the public will understand and accept them. We have a population of four million; we are not living in Tír na nÓg.

Hospitals with small numbers of patients cannot sustain big numbers of consultants. We will see a new role for local hospitals. It is important to emphasise to local communities that no hospitals will close as a result of implementing these reforms. We cannot allow a negative attitude to prevail. We have seen major changes taking place and major benefits in the health service. We have made great strides, despite the difficulties we are encountering.

In the area of children's cancers we have treatment available that is as good if not better than what is available anywhere else in the world, and recovery rates are very high. In Naas Hospital in my area there was talk of closure for many years, yet in recent years we have seen huge investment taking place in the provision of new facilities. While there are teething problems, we are making real progress.

I would like to refer to Peamount Hospital in the context of the five year strategy. That hospital specialises in the treatment of chest illnesses. It is now to be replaced by a rehabilitation unit. I ask the Minister of State to examine how this decision was reached. It is peculiar that a hospital specialising in a particular area is to be replaced. I ask the Minister to reconsider that decision and get directly involved with the staff in that regard.

I am delighted to have an opportunity to speak on this Private Members' Bill proposed by the Labour Party. This Government is delivering on its promise to provide an acute hospital service that meets the public need. Unlike the Opposition, who feel everything can be done in a flash, the public know real change and real improvements take time. The current Minister for Health and Children, Deputy Martin, recognises this and has carried out widespread consultation with all the stakeholders in medicine and health to ensure the best health care service is created. It has taken time.

With the publication of the Brennan, Prospectus and Hanly reports during the past few months, the way is now clear to implement the changes required in our hospital service. I said before – I feel strongly about this so I will repeat it – that the most important person in medicine is the patient. Implementation of the Hanly report will ensure every citizen has access to the highest level of care appropriate to their illness. A patient with a minor illness or injury should attend his or her family doctor to have it treated. If such person suffers or sustains a more serious illness or injury he or she can attend the local hospital to receive treatment. However, a person unfortunate enough to sustain a major injury or illness would expect to be treated in a hospital equipped to deal with such an occurrence.

If a person suffers a heart attack the best treatment involves him or her having a cardiograph and immediate fibril-electric treatment and he or she should be transferred to a modern coronary care unit with appropriate back-up such as invasive cardiology, radiological and laboratory facilities. This must be available to all citizens equally and not only to those in Dublin and Cork as is currently the position. Implementation of the Hanly report will ensure equality of access.

It is worth remembering two further points. Only the first part of the Hanly report dealing with the mid-western and south eastern areas in terms of health care is currently available. Mr. Hanly recently told the health committee that the remainder of the report covering the rest of the country will be available in approximately nine months' time. When questioned, Mr. Hanly acknowledged that the concept of further developing certain general hospitals which would be suitable for areas of the country which for geographical reasons are too far removed from major cities of tertiary care can be worked on.

I welcome the Minister's announcement that €2 million has been allocated to the renal dialysis unit at Sligo General Hospital.

I congratulate the Deputy.

I thank Deputy Neville for his remark.

Certain members of the Deputy's party would not be as open in their congratulations.

It is an example of the Government's commitment to health. The current unit, as Deputy Perry knows, is far too small and cramped for the great work being carried out there. This money will mean an increase in beds from six to 11. The end result will be a modern and comfortable dialysis unit for patients and staff on a par with any other in the country.

It is great news.

This announcement exemplifies the Minister's commitment to the hospital service. I take this opportunity to thank the Minister of State, Deputy Callely, for meeting with the chief executive officer and members of the North-Western Health Board today to impart this good news to them.

After the fact.

I totally reject the Labour Party motion.

I wish to share time with Deputies Cowley, McGrath, Connolly, Gormley and Caoimhghín Ó Caoláin.

The failure of this Government to deliver a proper health service is a shame and a disgrace. What it has squandered in terms of health is nothing short of a crime. Where are the shorter waiting lists for acute treatment? They are not in County Clare – of that much I am sure.

A distraught constituent rang me on Friday. He had to accompany his wife by ambulance from a village six miles outside Ennis to the regional hospital in Limerick, a 32 mile journey which took nearly two hours because of traffic gridlock. Having spent some time in casualty he waited half an hour for a porter who never arrived, resulting in his having to bring his wife to the ward. That is not acceptable.

What will happen in County Clare when the Hanly report is fully implemented? Will patients in Clare have to go to Limerick for treatment? Will we have to ask people not to get sick during rush hour? Ennis General Hospital serves a population of 103,000 within Clare county and a fast increasing urban population in Ennis town. It provides acute services to patients within the Clare catchment area. It provides in-patient and out-patient services and a busy accident and emergency unit. Not only does the casualty department serve the population of Clare, it serves the transitory holiday population and the north-south route from Galway to Limerick.

The Hanly report sets out to rob us of our accident and emergency service. It is proposed that the acute psychiatric service be moved to Limerick. That is ridiculous. We cannot be subjected to such measures in any shape or form given the size of the Clare catchment area as already outlined. Some €15 million is to be spent upgrading Ennis General Hospital. Can we be sure of that when in a recent interview on Clare FM the Minister of State said he was not aware of it? That does not instil confidence in the electorate of Clare.

It is great to hear Fianna Fáil Deputies say the experts know what they are talking about. Do they live in Loop Head or any other remote part of Clare? The people of Clare are to hold a mass rally on 15 November to voice their concerns and disgust in this regard. They will let this Government know we will not be robbed of the right to a decent and full health service.

It is time this Government put some weight behind its empty promises and provided beds, consultants and the modernisation of the Irish health service.

That is exactly what we are doing.

The Minister of State is proposing to downgrade Ennis General Hospital by removing its accident and emergency service. Is that downgrading or not? Some 70% of people will be—

The Deputy is totally wrong.

I am not wrong. We have heard all this before. We will not listen to it again. The people of Clare are wide awake to this Government and will not be hoodwinked by a Minister who did not know that €15 million was to be spent on upgrading Ennis General Hospital.

Is that not good news?

What is going on in Government? Does the Minister of State not keep in touch? The Minister has failed the people of Ireland and the people of Clare and they have told him so.

I am glad to have an opportunity to speak on this motion. I know we will have more time to discuss the Hanly report next week.

It is difficult to believe what the Minister says when we witness what is happening in our hospitals. Last night, there were 11 people on trolleys in the accident and emergency unit at Mayo General Hospital. Most of them were elderly. There is a shortage of paediatric beds at Mayo General Hospital. This is not an isolated incident. People are being left on trolleys every night and that is wrong. The problem is not a lack of planning. It is welcome that we now have a plan and are to receive a consultant provided service but at what cost?

We should be helping local hospitals rather than taking from them. The problem has not been the lack of a Hanly report but the lack of resources. We have had loads of reports. We had the health strategy. The problem with them all has been a lack of finance, and the problem with our health service has been a lack of money. Some has been put in, and I agree that it happened, but it was only right that money should be put in. Only now has it reached a level comparable with that of other countries in a similar position to us. The bottom line is that money has been put into the national treatment purchase fund, about which the Minister spoke last night. Would it not have been much better if that money had been put into developing local services? What we intend is to take from them.

I also question those who wrote the Hanly report. I would never say that they had spent time in my constituency, for example, or dealing with the people with whom I deal. The Minister spoke last night about all the wonderful people who were removed from the waiting lists. The Minister may not have seen The Irish Times today, but it reported that there had been a 200% increase in waiting lists. Where does that get us in Mayo? There has been a gross underspend on regional development, which I call unbalanced. The bottom line is that we are not at the races. I will conclude now, but I will welcome the opportunity to speak on the Hanly report in much more detail.

I am grateful for the opportunity to speak on this Private Members' motion on the health service. I was elected on a strong health mandate, and I intend to live up to those principles in this debate. All citizens, in every part of this country, must have access within a reasonable time to world-class accident and emergency services. I give my support and commitment to radical reform in the health service. However, reform must go hand in hand with investment. If we do not face up to that reality, we are turning our backs on our citizens. I welcome the sections in the Hanly report that call for the provision and funding of 3,000 additional beds, a doubling of hospital consultant numbers to 3,600, and the upgrading and retraining of emergency medical technicians. Those are all positive recommendations, but I have major concerns about the Government's commitment. As I have said many times before, reforms must go together with funding and investment in the health service.

We must also face up to the current crisis in accident and emergency services. The Government has failed to deliver an acute hospital service that meets the public need. We can have all the reports and recommendations we like, but having patients on trolleys in Beaumont Hospital is simply not good enough. It might be trendy and fashionable to hammer the decent taxpayers of this country while ignoring the broken lifts at Temple Street Hospital or the 25 people on trolleys at Beaumont Hospital. When will the Minister wake up to that fact and deal with the real issues confronting our people? The health service is seriously sick, and I ask him when he will make it better.

While I support the motion, in the interests of all our citizens and taxpayers it is only fair to point out that successive Governments have failed to provide the necessary infrastructure to deal with health and social service waiting lists. The motion is about the health service. Above all, it sends out a caring and compassionate message to a society that is already riddled with greed. I urge all Deputies to support it.

Last night the Minister for Health and Children asked this side of the House whether it was supporting or rejecting the Hanly report. I do not believe he got an answer, but I am rejecting it. I strongly suggest that the Minister contact his own members on the North-Eastern Health Board, whose welcome consisted of binning the report. They did not accept it in the north-east, and I am surprised that the Minister had to wait here to find out the response. Any report that has as its terms of reference setting aside cost implications and accepting the fact that one will have industrial relations implications, is not for the real world. It will be consigned to the shelf. It will be put up beside the Fitzgerald report and the 150 others. A few more spaces are left, and that is where the report is going.

They are all effectively proposing the same thing – 14 regional centres of excellence. Governments have been trying that for 30 years, and it simply will not happen. At the launch in Government Buildings, both the Minister for Health and Children and Mr. Hanly himself denied three times that what was in the report amounted to downgrading. If one speaks to the ordinary man or woman on the street, he or she will tell one that removing an accident and emergency department or maternity unit from a general hospital amounts to its downgrading. It does not matter an iota how one window-dresses that.

I know that the Minister tried to balance matters by stating that he would give them a dermatologist, rheumatologist or geriatrician as a kind of quid pro quo for the loss of accident and emergency services and maternity units. It does not work that way. Those services are needed regardless of the Hanly report. We are far behind the European average in such specialties. We should not have to wait for Hanly to say that the Government will take away accident and emergency services, but that communities will get something else in its place.

In an emergency, people want access to a hospital. They want to see a doctor and ensure that the person they have with them will be stabilised. Someone could be suffering a severe haemorrhage, or there might be a mother whose child is suffering an asthmatic attack. Someone could be suffering a heart attack. That person probably arrives in a car, and every minute in it is probably an eternity. The person wants service straight away. If a woman is in labour, she does not want to be told to wait while someone checks the protocols to see how he can save himself or herself and send the person on ahead. If the birth happens when the woman is outside the hospital, the hospital saves, since it need not make an insurance claim. Such things are morally wrong, and we should never refuse to cater for an emergency. People see it as a basic and vital service.

We spoke about the golden hour. The treatment that a patient receives in the initial hour following an accident or injury can provide a much better outcome, depending on how early it occurs. I know that my time is running short. There is an expectation in all those reports that GPs in their co-operatives will provide a service. In the North-Eastern Health Board area, for example, in Our Lady's General Hospital in Navan, doctors have stated that, if they are asked to take on the role of accident and emergency doctors, they will move from the site. They are not trained for that role but to provide a GP ser vice. We will be taking every form of emergency, including people with broken fingers or who need four or five stitches, to a regional centre of excellence and treating them there. Where else will they be catered for if not there? The other hospitals are closed. Accident and emergency departments are closed at weekends. Football injuries and minor accidents will all have to go there, for GPs will not treat them. We need people to be stabilised in general hospitals. I see that my time is up. I got good value for money.

Perhaps Deputy Gormley might wish to speak before me if I might change the order of speakers.

I welcome the opportunity to speak on this important issue and fully support the motion put forward by the Labour Party. The Government has failed spectacularly to deliver equality of access to our health service. The two-tier health system is now fully embedded and will continue because of the Government's failure to invest the fruits of the boom wisely in the health system and fully recognise the importance of preventive care. We have seen the publication of report after report. They are not, and sometimes cannot be, implemented. On the Hanly report, it is not at all clear whether the Minister for Finance is prepared to countenance further spending to ensure its implementation. Given that he has done so much to ensure a two-tier society, we should not be surprised if he is happy to continue with our two-tier health system. In the Hanly report, that two-tier system is taken to a new level. It is no longer a question of how much money one has but of where one lives. If one lives in Dublin or a major city, it seems one will not have to travel that far to receive good care. If one is unlucky enough to live in a rural area such as near Ennis, which has been mentioned, one will not have a proper accident and emergency unit in one's area. Mr. Hanly and the Minister have been at pains to stress that this does not represent a downgrading, but that is not how it seems to people who live in the areas to which I have referred. My Green Party colleagues in County Clare, particularly Mr. Brian Meaney, do not see it that way. I compliment Mr. Meaney on the amount of work he has done to try to retain services in Ennis.

The Hanly report proposes that more consultants be put in place, something that is badly needed. I would welcome such a move. I want to see results and I want to know where the money will come from. Mr. Hanly told the health committee that the figures add up and that the plan will not involve huge extra expenditure. I am not so sure, however, as we are talking about an extremely powerful group. As I said at the committee meeting, if I were the Minister I would rather take on the local opposition groups than the consultants.

I do not doubt that the Minister will respond to this debate by saying that health spending has increased dramatically under Fianna Fáil and the Progressive Democrats, which is true. We have not made up for years of under-investment and cutbacks, however. The Minister admitted on "The Late Late Show" that he favours tax increases to fund a better health service. The Deloitte & Touche value for money audit of the health system states, "If a superior system is demanded by the public (and there is much evidence to believe this to be the case), then, as taxpayers, the financial implications of addressing the current health service deficits need to be accepted." I agree with that statement.

While this country's health spending has reached the EU average, we are still bottom of the EU league in many areas such as rheumatology and neurology. The average life expectancy in the State is falling behind the EU average. According to the figures for 2001, we had three acute hospitals for every 1,000 people, compared to an EU average of 4.81. There is no doubt that while we have reached the EU spending average, our services are far behind those elsewhere in the Union and we continue to mis-spend.

This morning's Supreme Court judgment is a reminder of how we get things wrong. As a result of the judgment, home births will be a privilege of the well-off. The trend of centralising maternity care services in high-technology units is being continued. There were 108 maternity units in this country in 1973, but there are only 22 now. The medical manpower forum has recommended that a further 12 maternity units be closed. We have to ask if this is cost efficient. Almost 40% of Irish babies are born in three major maternity hospitals in Dublin. We know that the larger the institution, the more costly it is to service.

Many sets of figures demonstrate that the highly interventionist approach that marks out the Irish maternity care service is extremely costly. I will back up that statement by citing some figures that show that certain services are particularly costly to maintain. It has been estimated that a caesarean section costs over three times more than an ordinary delivery. Dutch health care insurance data on the cost of births show that the caesarean rate of 10% in Amsterdam in 1997 accounted for 44% of the total cost of maternity care in the city that year.

If the Green Party ever has the opportunity to serve in Government, it will amend the Health Act 1970 to ensure that all women have access to proper maternity care services, regardless of how much money they have. If they wish to have a home birth, they should be allowed to have a home birth.

I wish to record my support for the Labour Party's motion. We do not need repeated public surveys to tell us that the biggest political issue of concern is the state of the health services. We know from our personal and family experience, our work as elected rep resentatives and our membership of local communities that the greatest cause of public disillusionment with the political system is its failure to correct the problems in the health system. Although this is a failure of successive Governments, no previous Government had the resources available to this Government to deliver increased funding and fundamental reform. The Government has failed miserably in its six years in office.

If there is one factor that the Government can examine to explain its massive unpopularity in successive opinion polls, it is its broken promises in respect of health. Fianna Fáil's pre-election promises to abolish hospital waiting lists within two years and to extend the medical card to 200,000 more people have become bywords for broken political promises. People know the difference between Government rhetoric and the reality.

I will be obliged later this month to step down as a member of the North-Eastern Health Board. My time as a member of the health board has been dominated by the fight to save Monaghan General Hospital, as well as Dundalk General Hospital in County Louth, from being downgraded and eventually closed. The axing of the maternity unit in Monaghan, combined with the attendant gynaecological and paediatric services, has hit women and children in County Monaghan hard. The closure of accident and emergency units is equally devastating.

When Mr. David Hanly addressed the Joint Committee on Health and Children last week, he justified the planned closure of such units in local hospitals by saying that between 60% and 70% of those attending them require non-urgent care. That means, however, that between 30% and 40% of people presenting at accident and emergency wards require urgent care.

These changes are being proposed in the absence of the promised massive upgrade in primary care, which is still inadequate and under-resourced. I have said repeatedly that Monaghan will be used as a blueprint or a template for the diminution of services across the State. As I listened to the presentation at the launch of the Hanly report, I saw that blueprint unfolding. The fight to save Monaghan General Hospital and other hospitals is repeatedly portrayed as "parish pump" local politics. We have been patronised by those who wilfully ignore the needs and wishes of local communities. The centralisation agenda has been pursued by Ministers, bureaucrats from the Department of Health and Children and representatives of the professional bodies. This agenda is driven by various interests and not by the interests of real people – those who use the health service. I refer in particular to those who depend on our public health service.

Many services in local hospitals will be removed if this aspect of the Hanly report is implemented. The Minister's claim that there will be no downgrading will not wash with concerned citizens and health care providers at many of these locations. The commitment not to close hospitals is a well-worn response from the Minister, Deputy Martin. It has been repeated many times in the case of Monaghan, while services diminish. The people of County Monaghan are very familiar with the language used by the Minister and his colleagues.

I welcome the planned reduction in the working hours of junior hospital doctors, in line with EU directives. While the Government is indicating that more consultants will be employed, there will not be a substantial increase in the aggregate number of consultants and junior hospital doctors in the next ten years. There is a total of 5,800 such workers at present, a figure that will have increased to 5,900 by 2013. This is hardly a dramatic increase.

The national health strategy, which was published in 2001, promised to renegotiate the consultants' contracts. The preliminary negotiations have not yet been concluded, over two years later, however. The Minister is promising a renegotiation on the back of the Hanly report. It seems that everything had to wait for the report. Consultants should be working exclusively in the public health system and should be paid by the State. The Brennan report recommended that all new consultant posts should be in the public system. The fact that the Hanly report does not address this issue directly is a major deficiency. The Brennan recommendation is essential if we are to end the two-tier system of apartheid in the health sector. The Government does not want to end that system. While the Minister is talking about further centralisation and centres of excellence – local hospitals will suffer as a result – he should note that we have a centre of excellence currently under threat at Peamount, which is noted for specialising in TB and its expertise of service. Will he intervene to ensure that the experience and expertise built up at Peamount in respect of TB be retained, resourced and not scattered to the winds at different sites around the city and beyond?

I wish to share my time with Deputies Sherlock, O'Shea and Wall.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

I will make my points in the context of yesterday's Exchequer returns, which call for an explanation from the Minister. There has been a 12% fall in the capital spend compared to that of last year. There has been an under-spend of over €700 million in respect of current spending, which contradicts the forecast the Minister for Finance made on budget day last year.

Has the Minister made a sufficient case to the Minister for Finance, in the context of yesterday's Exchequer figures, regarding the various areas of the health services that are under-funded and in which there are severe and acute staffing shortages? In many areas, people have been accepting the argument that economic circumstances are not as good as they once were. However, the Exchequer returns show this is not the case.

Certain facilities have not been opened or established for want of small amounts of capital. Yesterday's Exchequer figures belie the fact that this should have been so. Similarly, the Minster, were he to make the political argument, could no doubt argue with the Minister for Finance that relatively small staff deficiencies could be addressed.

My second point, which has not been sufficiently debated by the Dáil, is that, despite the evident cutback in both capital and current spending, the Minister for Finance chose in last year's budget to forge ahead in one particular area. In spite of his statement in the budget on the cutting back of tax breaks, new tax breaks were introduced at the very last minute for the construction of private hospitals. Therefore, tax based spending for the private sector in the health service has been initiated in spite of the failure to open public facilities, such as the new facility at Blanchardstown, and the failure to employ the staff the health service needs.

The Minister for Health and Children needs to tell us what the tax breaks for private hospitals have added to the health service this year and whether they benefited private patients primarily or some public patients, perhaps through the treatment purchase fund. As recently as last Sunday, the front page of one Sunday paper referred to a €17 million scheme, in terms of tax costs, which is to get the go-ahead under the schemes announced in last year's budget. If the Minister has any notion of a health service for all people, he should realise that the creation of very lucrative tax breaks for the private sector while starving the public sector is absolutely wrong and unjustifiable.

I do not know if the Minister ever saw the Fitzgerald report. It was introduced in 1968 and was the first document I received as a public representative. It recommended certain cutbacks pertaining to hospitals, including Mallow General Hospital, but they were not followed through because we fought them. The previous leader of the Deputy's party shelved that report, as another Deputy stated earlier. I hope the current proposals will be shelved and the sooner the Minister does so the better.

And incinerated as well.

Absolutely. In light of the non-consultant hospital doctors issue, the Minister is introducing the report by Hanly and, I might as well say, Dr. Cillian Twomey from Cork. Mallow hospital, which was to be downgraded in 1968, is a general double consultant hospital and a valued facility in the local community and its catchment area. A total of 90% of patients requiring hospitalisation can be treated in the general hospital system. The remaining 10% are referred for specialist treatment. The north Cork area is taking in many people from the west Limerick area.

That is correct.

In Mallow, the figure pertaining to bed days in 2002 was 12,007 in the medical category and 10,761 in the surgical category, amounting to 22,768. A total of 2,284 patients falling under the medical category were treated, and 1,194 falling under the surgical category were treated, amounting to 4,278 in total. The average length of stay was 5.26 days in the medical category and 5.40 in the surgical category. The average is approximately 5.3 days, which represents an excellent service in a general hospital. The accident and emergency unit in Mallow general hospital provided for 10,705 patients, with returns of 1,704, amounting to 12,409 in total. This demonstrates the service provided by Mallow General Hospital. If the recommendation in the Hanly report to reduce this hospital to a local hospital is to carried out, like other hospitals in the same category it will become a half-way house for half-cured patients. This is exactly what the Minister is proposing to do. He should not do so because it would be wrong.

Cork University Hospital benefited from a grant of €254 million under the national development plan but we did not get such a grant in Mallow. Week after week and year after year, we are fighting and striving to obtain additional funding.

The Labour Party motion calls for a commitment to the provision and funding of 3,000 additional hospital beds, the doubling of hospital consultants to 3,600 and for all citizens to be able to gain access, within a reasonable time, to world-class accident and emergency facilities in their own areas.

The Minister has made no reference to the two private hospitals in Cork. He is dealing with the hospitals under the Health Act and I know he will require a change of legislation if he wants to implement the recommendations in the Hanly report. I presume he will state this in his response.

There is a better relationship between medical staff and patients in general hospitals compared to that in others. From a sociological point of view, the general hospital system is better in terms of facilitating visits to patients from relatives and friends. We are demanding and defending this system and the people will support us. Small is beautiful, unlike the major centres.

Tá áthas orm labhairt ar rún Pháirtí an Lucht Oibre. The Labour Party motion states Dáil Éireann believes that equality and ease of access to the highest possible quality of medical care should be a central feature of our hospital service. That is not the case when one considers the recent decision of the Minister and the Government to endorse the recommend ations of the report on the development of radiation oncology services.

Yesterday, the Minister replied to a number of parliamentary questions I had tabled on cancer services. Eminent people in the cancer treatment area have stated it is not necessary to locate a second supra-regional centre for cancer care in Dublin, as one centre would cater for the needs of the city. My proposal to locate radiotherapy services in centres in Waterford, Limerick and the north-west, rather than establishing another supra-regional centre in Dublin, originated among eminent people in the field. It is all very well to speak of a model which will deliver the best possible outcomes but people are stuck in pain in traffic as they make long journeys to Dublin from other areas to receive palliative care or treatment to facilitate recovery. It is neither right nor acceptable in a civilised society that people should be exposed to pain and suffering at a time when they need the greatest possible degree of care, attention and support. The Minister must reconsider this issue and seriously examine the proposal to provide the required centres in Waterford, Limerick and the mid-west, rather than locate a second supra-regional centre in Dublin.

It has been brought to my notice that we face a problem in the area of primary care. It is becoming increasingly difficult to attract doctors to work full-time in general practice. Regardless of the kind of hospital system one has, the first point of referral for most people is the general practitioner. I have been informed that a real crisis in general practice will occur in the next five to ten years. Regardless of how the hospital plan materialises, if it soon transpires that the referral system, the basis of the health system, is not delivering adequate provision, we will have a major problem. This matter needs to be addressed urgently.

The Hanly report states there is scope for assistant grades. I have been tabling parliamentary questions concerning the speech and language therapy assistant grade for a long time. As the Minister is aware, we have a major problem in terms of the number of speech and language therapists. If an assistant grade was introduced, new recruits could be trained relatively quickly as compared to speech and language therapists. They could work under the supervision of a senior speech and language therapist, thus allowing those children and others such as post-stroke patients, who have had a poor service or no service for a considerable period, to obtain a service. While I welcome the fact that additional speech and language therapists will be trained, the dividend, even in terms of the first tranche of qualified therapists, will be in four years' time. The Minister has failed to deliver in terms of the assistant grade.

Much of the Hanly report is pie in the sky, for which I do not criticise Mr. David Hanly. When he told us how he arrived at his conclusions, he stated, for instance, that he ignored IR problems. The Minister has had no success in terms of the development of assistant grades and I find it difficult to believe this position will change in the future. There is considerable scope to transfer some lower grade functions from nurses to nursing assistants. While it goes without saying that the nurse will always be at the bedside, upgrading the profession will be an important component in delivering the kind of health service we all want to see.

In a letter to the Minister, dated 14 November 2001, the Minister for Finance, Deputy McCreevy, stated he wished to make clear that initiatives contained in the health strategy involving expenditure implications for 2002 were included without his approval and carried no commitment on his part to the allocation of any particular sums to the Department of Health and Children in the budget. Unfortunately, this statement still haunts the people of County Kildare. Three Deputies from the county, who have made numerous representations to the Minister for Health and Children with regard to making Naas General Hospital 100% efficient, are present for this debate. Each time we ask the Minister a question we receive a similar reply, namely, that our question has been sent to the chief executive of the Eastern Regional Health Authority for comment. He then sends it to the chief executive of the South-Western Area Health Board, Mr. Pat Donnelly, who unfortunately must send me an identical reply every time in which he states that the South-Western Area Health Board is not in a position to provide funding to bring Naas General Hospital up to 100% efficiency and that representations to the ERHA are ongoing. I am sure the same position obtains for Deputy Stagg and the other four Deputies from County Kildare.

Unfortunately, despite millions of euro in Exchequer funding being spent on Naas General Hospital, its capacity has not been increased to the 100% required in a county with a growing population. The latest census will reflect the increasing number of people in the county and the other part of the region, west Wicklow. Time and again, the Department of Health and Children escapes under a cloud by referring questions to the ERHA. The Minister has been unsuccessful in his efforts to seek funding from the Minister for Finance.

Having listened to David Hanly's assessment of his report, it appears Naas General Hospital will not become what we had anticipated, namely, an efficient accident and emergency department for the people of County Kildare and west Wicklow. Mr. Hanly stated that the South-Western Area Health Board had not yet been assessed but that any future evaluation would reflect his assessment of the Eastern Area Health Board and the Mid-Western Health Board. If we take as an example Ennis General Hospital, where a major initiative in the accident and emergency department on behalf of the people of County Clare will be abandoned, we can assume that the cost to the Exchequer of a major initiative on behalf of the people of County Kildare will be foregone.

In my area, the assessment and respite unit of St. Vincent's Hospital in Athy has been closed. This was a major initiative by the South-Western Area Health Board which benefited families whose loved ones receive 24 hour care. It is a major loss to south Kildare, north Kildare and west Wicklow.

The Minister has tabled an amendment to the motion. The sufferers are the 24 hour carers who have lost this facility. We were unsuccessful in obtaining a guarantee from the South-Western Area Health Board that the facility would be restored. Where will assessment and respite take place for patients in Naas General Hospital or any of the Dublin hospitals that cater for Kildare patients? There does not seem to be a policy to provide it.

Having listened to Deputy Twomey, I wonder where the Hanly report will go. I was a shop steward for 22 years and I have many grey hairs to show for it. I can assure the Minister that he will have as many, if not more, before that report is implemented.

That is an awful thing to visit on any man with a head full of dark hair.

They are on their way. I am three years in the job.

I welcome the opportunity to respond to a number of points made about the Hanly report. I will deal with them in turn.

The suggestion was made last night that under the Hanly proposals there would be no full-scale accident and emergency services available between St. Vincent's Hospital in Dublin and Waterford Regional Hospital in Ardkeen. It is important to emphasise that the task force on medical staffing did not make proposals beyond the East Coast Area Health Board and the Mid-Western Health Board. It reached no conclusions about, for example, the role of Wexford General Hospital or Waterford Regional Hospital. The group chaired by David Hanly that will look at the organisation of acute hospital services for the rest of the country will take account of demographic and geographic factors when making recommendations about the role of individual hospitals and on the availability of accident and emergency services throughout the country.

A question was raised about the studies cited in the Hanly report which conclude that better clinical outcomes are achieved in units with high volumes of activity and appropriate specialist staff. The claim has been made that these refer only to the over 65 age group. This is not correct. The Nuffield Institute study, for example, specifically covers the full age range. While the body of the report points to three studies, the extensive bibliography in the report lists a large number of other such studies. They all reach the same basic conclusion about better outcomes.

Some Deputies raised questions about whether it is feasible to double the existing number of consultant posts. This is not just possible but necessary. First, the Hanly report proposes that this should be done over a period of ten years. Second, there is no doubt that there are many specialist registrars already in the system, and others who will become specialist registrars over the next few years, who will be ready and eager to be appointed to consultant posts. There are also many consultants abroad who qualified in Ireland and who are extremely anxious to return. I have met them, as have many other Members of the House. That is mentioned in the Hanly report.

When the Tierney report on medical staffing was published in 1993, there was the same scepticism and cynicism about our ability to recruit the extra consultants. The Tierney report recommended in 1993 that we should have 1,500 consultants by 2003. In fact, we had 1,731 consultants by 1 January this year—

There will be another 200 of them in Britain.

If the Deputy had his way, I am sure they would be gone long ago.

The Minister did not know about the downgrading of Ennis hospital despite being a member of the Mid-Western Health Board.

Allow the Minister to speak without interruption. He has a limited amount of time.

This demonstrates that it is possible to recruit the number of consultants envisaged.

Did the Minister not tell the Minister of State what is happening?

However, we do not propose simply to increase the number of consultants under the present system. We need a new consultant contract under which consultants will work in teams and under new rosters so they will be more easily available to patients. In other words, we need a consultant provided service.

The Minister's time is concluded.

That is not fair.

The Opposition might want to close its ears to the following facts. Since 1997, overall health spending has increased by 162%, acute hospital activity has increased by 25%, the number of medical consultants has increased by 34% and the number of adults waiting more than 12 months for in-patient treatment is down by 43%.

The Minister must conclude. He is obliged to conclude under Standing Orders.

On this side of the House we deal with facts. The Opposition can deal with fiction.

On a point of order, the Minister of State's time was taken up by the Opposition Deputies. After he had spoken for two or three minutes, he was told to conclude. That is not fair.

Deputy Seán Ryan has 15 minutes.

I wish to share my time with Deputies Penrose and McManus.

Is that agreed? Agreed.

I am pleased to have the opportunity to speak on this motion. As the Labour Party's spokesperson on older people's issues, I wish to refer to the inadequacy of the services for older people.

Older people have been severely affected by the cutbacks in the health services. Services have reached crisis point in many health boards. Older people made severe sacrifices over the years and in difficult times to care for their children and to provide them with the education which in many ways has been responsible for the Celtic tiger and made this country one of the richest in the world. What have they received in return? They are lying on trolleys, for up to 30 hours in some cases, in accident and emergency units awaiting access to a hospital ward. This is unacceptable when an increasing number of beds are left unoccupied or inappropriately occupied in the same hospitals. Similarly, they might have to wait for more than three years to secure a bed in a long-term nursing home while, at the same time, beds for the elderly remain unoccupied. This is a scandal.

The key community care services for older people and their carers are home help services, respite and day care centres, meals and transport services and paramedical services such as occupational therapy, physiotherapy, chiropody and speech therapy. Home and community care must be a cornerstone in the care of older people and it has been denied to them by the Government. I read the Hanly report in detail and there is little or no reference in it to the community care area. It is reported that home help services have been reduced in some areas by up to 50%. Hundreds of people have been denied a minimal amount of care due to cutbacks.

I can give an example of the numerous representations I have received on this issue. The person concerned wrote to me about her Aunt Kathleen, who is almost 88 years of age. The aunt received a letter a week ago informing her that her home help hours have been reduced from eight to four hours per week. The woman has had several strokes but has managed to live independently and happily in her home since she was discharged from St. Mary's in the Phoenix Park with the promise of the support of all services. Like thousands of other elderly people, she has been dealt a huge blow by this decision. She has a wheelchair and a zimmer frame but must be assisted. She found her home help invaluable but the hours have been reduced dramatically. The Government is standing over this.

It is a scandal that the Minister of State, Deputy Callely, who has responsibility for the elderly, should state to the media that the service providers on the ground are happy with their allocations. Older people are entitled to a little honesty from the Minister of State who is supposed to look after them but the health services provided by the Government are an utter disgrace. This is about making hard choices and putting the needs of ordinary people, including the elderly, above the Minister's friends. Some €5 billion or €6 billion has been spent on those who are well off, yet those most in need of care are being deprived of it. That is a scandal and nothing that I can see in the Hanly report will help. The situation will not improve until the Government is thrown out.

Deputies

Hear, hear.

For some time we have had a lot of spin, froth and fudge concerning the Hanly report. It is high time that not just this report but also the matters at issue were discussed at length in this House. I welcome some aspects of the report which deal in detail with the required EU reduction in working hours for junior hospital doctors but this should have happened many years ago. However, junior hospital doctors had to wait until the Government was dragged kicking and screaming into the 21st century. It has delayed action until virtually the last minute – just a few months before the EU working time directive is enforced – to provide young doctors with civilised working hours.

I also welcome the decision to move to a consultant-provided health service. The Hanly report quantifies the implications of the decision to provide 1,870 new consultant posts throughout the health service, which will represent a considerable improvement on the current position. In our two-tier health service most public patients rarely get to see a consultant, while private patients can have access to one whenever they want by paying the appropriate fee. With a large number of new consultants in the health service, the prospects for public patients getting access would be enhanced but I take the number of additional consultants, as projected by the report, with a grain of salt.

There is more than a touch of cloud cuckoo land about the Hanly report. The terms of reference of the study team required that they assess the financial implications of their recommend ations. The financial projections they make with reference to the 1,870 consultants exclude substantial cost elements. One does not have to be an accountant to conclude that the financial projections are not for real, although that will not trouble the Minister for Finance who will almost certainly dismiss them as meaningless and irrelevant. His mandarins, likewise, will cast a beady eye on them. The Minister for Health and Children knows the cut of the Minister for Finance's cloth.

I welcome some aspects of the Hanly report into which much work has been put but, from my perspective in representing the people of County Westmeath, it has some fatal flaws. I am concerned about two vital aspects. The Hanly team claims to have consulted far and wide at both national and local level about the matters dealt with in the report. However, when one looks at the detail, where the devil tends to reside, one finds that it did not consult public representatives, nor their constituents. Neither did it consult those who will be most affected by any decisions taken arising from the report. This is notwithstanding the Government's aspiration to develop "a health system that listens to you and ensures that your views are taken into account", according to page 8 of the Minister's health strategy report.

The Hanly team consulted the medical establishment and is proposing a health service that listens to hospital consultants and sets up a hospital structure that accords with their views. It is adopting the "doctor knows best" principle, rather than listening to ordinary people and taking their views into account. This strategy fundamentally underpins the report. The Hanly team claims that it confined its consultation to medical professionals and health board staff – I agree that staff at all levels should be consulted – in order that it would not be tainted by political involvement. It is high time, however, that the report was subjected to the closest political scrutiny in order that people in County Westmeath and other constituencies, the recipients of health services, will have a voice in deciding how they should be developed.

My second concern about the Hanly report relates to its commitment to the principle that bigger hospitals are better. The report's authors have dressed this up by talking about the concept of a few centres of excellence where most treatment options and specialists will be concentrated. Hospitals outside these centres, however, will provide some elective procedures, principally on a day care basis. The medical establishment has for years been pushing the line that bigger hospitals achieve better outcomes for patients and this nonsense is becoming increasingly the accepted wisdom. I seriously question this on the Hanly report's own terms.

Perhaps I am old fashioned but I like to have some evidence to justify my proposed actions. The Hanly report invokes three publications to justify its proposition that bigger hospitals in key treatment centres of excellence are virtually the only way forward but the its authors cannot have read the publications in question. At least two could more plausibly be cited in justification of the contrary argument, that is, the development of medium-sized hospitals with 200 to 300 beds, regionally dispersed, to meet the requirements of our future health service. I have a clear interest in this matter and will lay my cards face up on the table. If the Minister or the health boards want to truncate the services currently available to people in County Westmeath – I am referring to the hospitals in Mullingar and Athlone – they should have a better justification than what the Hanly report has come up with for so doing.

Let us equip what we already have. It is a scandal that we have been waiting seven years for an extension to Mullingar Hospital, while the site has been lying idle. The disgraceful long-fingering of phase 2B of Longford-Westmeath General Hospital is a matter the Committee of Public Accounts should be called upon to examine. The message to the Minister is loud and clear: he should finish the work at Longford-Westmeath General Hospital for the 110,000 residents of the area. The hospital extension should be staffed, equipped and opened quickly to ensure the people of counties Longford and Westmeath get what they deserve.

Hear, hear. Well done. Let us now bring in Deputy Howlin to explain what he did.

I thank every Deputy who participated in the debate. Naturally, the Hanly report has figured large and it contains much that is good. Let us remember, however, that they are only words on pages. The question is, what does the Government intend to do about it? Does it intend to apply the report's cost-cutting elements, while holding back on the positive agenda? It is not an issue of the Labour Party cherrypicking. What is of concern to the public is whether the Government will cherrypick by leaving aside aspects of the report that will cost money. Its track record on other reports is abysmal.

I ask Members to consider the following:

I think the Minister for Health and Children should reconsider his position. Maybe it is time for him to move over and let somebody else take over who can do the job.

They are not my words but of the eminent cardiac surgeon, Mr. Maurice Neligan. Yesterday's performance by the Minister only confirms that view. I do not know if it is true but I have heard that when he was at school, the Minister was known as "Ducky Martin". If that is the case, he has certainly lived up to his nickname.

The old scriptwriter is over there again.

He ducked, weaved, evaded and avoided. The Labour Party put straight questions to him yesterday.

The Deputy did not answer the questions I put to her.

Please allow Deputy McManus to continue without interruption.

From where is the funding coming? How much money will the Minister put in to implement the report? How many consultants will be in place by August 2004? Will the Minister guarantee that we will not end up with no accident and emergency department in the eastern regional area between St. Vincent's Hospital and Waterford? These are plain questions that elicited no answers.

Senator O'Meara has visited Nenagh Hospital, one of the hospitals under threat of being downgraded. Yesterday morning the hospital found itself inundated with admissions. As a result, both the female and male medical wards were full to overflowing. There were patients in beds on both corridors. The Senator saw one man getting oxygen in a bed in a corridor. Not all of the patients were elderly but they were all in need of acute care. Officially, there are 86 acute beds in the hospital but up to 100 patients are being treated there almost all of the time. If, as recommended, these beds are closed and the accident and emergency department is closed, all such patients will have to travel to Limerick Regional Hospital. How will that hospital cope because it is already overstretched? There is no commitment in real terms to ensure bed capacity, consultants and training will be in place in order that the benefits of the the report can be realised for patients.

Our motion asks the Government to ensure the changes are funded and that provision is made for them but it is refusing to support it. We ask for a principled commitment that, regardless of where one lives, one can access world class accident and emergency services within a reasonable distance. The Government has again refused to support this principle. Instead, it has presented its own anodyne amendment which amounts to a warning. It is asking us to welcome the Hanly report but is that all it has to say? What about saying it will implement or pay for the report? It did not say anything like that; it only welcomed it. The reason that is happening is that it is divided. The Minister evades the hard questions while the Minister for Finance says nothing.

I challenge the Taoiseach to start telling us about the future of the health service. It is a remarkable achievement to have spent so much money for so little return. Every time there is a debate on health the Minister comes in and trumpets the amount of money he has spent. He should hang his head in shame. While he has spent the money, he has not got the return. There has been a 2% reduction in hospital waiting lists. Thousands are waiting in pain for treatment which they know those with private health insurance can access as soon as they require it. However, a public patient must wait months or even years for the treatment needed. Until the Government faces this harsh reality and starts to make decisions focused on the experience of patients and what is happening in our hospitals and the health service instead of abstract notions which only relate to an ideal world where there are no industrial relations or funding issues, we will not get the Government response which patients deserve and to which they are entitled.

Amendment put.

Ahern, Noel.Andrews, Barry.Ardagh, Seán.Aylward, Liam.Brady, Johnny.Brady, Martin.Brennan, Seamus.Callanan, Joe.Callely, Ivor.Carey, Pat.Cassidy, Donie.Cooper-Flynn, Beverley.Cregan, John.Curran, John.Davern, Noel.Dempsey, Noel.Dempsey, Tony.Dennehy, John.Devins, Jimmy.Ellis, John.Finneran, Michael.Fitzpatrick, Dermot.Fleming, Seán.Glennon, Jim.Grealish, Noel.Hanafin, Mary.

Haughey, Seán.Hoctor, Máire.Jacob, Joe.Keaveney, Cecilia.Kelleher, Billy.Kelly, Peter.Killeen, Tony.Kirk, Seamus.Kitt, Tom.Lenihan, Conor.McDaid, James.McEllistrim, Thomas.McGuinness, John.Martin, Micheál.Moloney, John.Moynihan, Donal.Moynihan, Michael.Mulcahy, Michael.Nolan, M.J.Ó Cuív, Éamon.Ó Fearghaíl, Seán.O'Connor, Charlie.O'Dea, Willie.O'Donnell, Liz.O'Donovan, Denis.O'Flynn, Noel. Tá–continued

O'Keeffe, Batt.O'Keeffe, Ned.O'Malley, Fiona.O'Malley, Tim.Parlon, Tom.Power, Peter.Power, Seán.Ryan, Eoin.Sexton, Mae.

Smith, Brendan.Smith, Michael.Treacy, Noel.Wallace, Dan.Wallace, Mary.Walsh, Joe.Wilkinson, Ollie.Woods, Michael.

Níl

Allen, Bernard.Boyle, Dan.Breen, James.Breen, Pat.Broughan, Thomas P.Burton, Joan.Connaughton, Paul.Costello, Joe.Coveney, Simon.Cowley, Jerry.Crawford, Seymour.Crowe, Seán.Cuffe, Ciarán.Deasy, John.Deenihan, Jimmy.Durkan, Bernard J.English, Damien.Ferris, Martin.Gilmore, Eamon.Gogarty, Paul.Gormley, John.Harkin, Marian.Healy, Seamus.Higgins, Joe.Higgins, Michael D.Hogan, Phil.Howlin, Brendan.

Kehoe, Paul.Lynch, Kathleen.McGrath, Finian.McHugh, Paddy.McManus, Liz.Naughten, Denis.Neville, Dan.Noonan, Michael.Ó Caoláin, Caoimhghín.Ó Snodaigh, Aengus.O'Dowd, Fergus.O'Keeffe, Jim.O'Shea, Brian.O'Sullivan, Jan.Pattison, Seamus.Penrose, Willie.Perry, John.Rabbitte, Pat.Ring, Michael.Ryan, Eamon.Ryan, Seán.Sargent, Trevor.Sherlock, Joe.Shortall, Róisín.Stagg, Emmet.Stanton, David.Timmins, Billy.Upton, Mary.

Tellers: Tá, Deputies Hanafin and Kelleher; Níl, Deputies Stagg and Durkan.
Amendment declared carried.
Motion, as amended, put and declared carried.
Barr