Hanly Report: Statements.

Minister for Health and Children (Mr. Martin):

I welcome the opportunity to debate the report of the national task force on medical staffing which I published last month. It is a significant contribution to health policy as it maps out the only way forward for our acute hospital services. I established the national task force on medical staffing to deal with a number of key concerns. These were to identify how best to reduce the average working hours of non-consultant hospital doctors as required under the European working time directive, to explore the practical implications of developing a consultant-provided service and to recommend how to structure medical education and training within a shorter working week.

From these three tasks – all of them substantial in themselves – arose a further important issue, namely, how to organise our acute hospital services in order that they allow doctors to work and be trained within much shorter hours than at present. Above all, the concern was to organise services to provide the best possible service for patients.

By now, Members will be well aware of the report's main recommendations. Therefore, I do not intend to go into their detail again. Instead, I wish to concentrate on a number of key issues which should help to inform the debate ahead. As a result of the slant which has been put on the Hanly report, it is not surprising that some people have concerns about the future of their local hospital. If we believed every claim made in recent weeks, we would think that hospitals would no longer cater for patients safely and that a host of existing services would be taken away from local communities. This is untrue, so let us set the record straight.

Tonight is a good opportunity to state what is really proposed in the Hanly report. We should debate this report responsibly and with all the facts. As legislators, we owe it to the people to have an informed discussion which will help everyone see what is really proposed. Unfortunately, some will seek to manipulate the report to suit their own ends. I call on Members to concentrate on what the Hanly report actually says and on its real implications. Let us deal with facts, not fear.

Ms O. Mitchell:

The Minister should not talk about his Government colleagues like that.

Mr. Martin:

Let us look at what the implementation of the report will mean for patients and not forget that this report is about finding the best way to deliver the best possible services to patients.

A great deal of concern has been raised about the availability of accident and emergency services in smaller hospitals under the Hanly proposals. Therefore, we need to be clear what the report states. It is perfectly safe for local hospitals to continue providing the great majority of the services they provide for people who have minor injuries or illnesses. Contrary to some claims, there is no question of closing these departments and transferring all their patients elsewhere. Local hospitals will continue to cater for a high proportion – some 70% – of the patients they see at present.

However, the task force report states that the best possible care for life-threatening situations is provided in a major hospital with all the neces sary specialties available on-site, including diagnostic and support facilities and intensive care.

Much of the debate has centred on what would happen to patients in need of emergency treatment if their local hospital no longer provided a full accident and emergency service. In that context, it is useful to look at a few practical examples. Medical advice is that if a person has a heart attack, there are a number of critical interventions which have a direct effect on patient survival and outcome. These include the prompt administration of thrombolytic or clot-busting drugs, the possible use of life-saving cardiac defibrillation to reverse irregularities in the heartbeat, and cardiac resuscitation, including heart massage and mouth-to-mouth breathing. In each of these cases, with appropriate training, health professionals such as trained ambulance personnel and emergency medical technicians can provide these critical interventions. These three important urgent interventions are the best means of improving a patient's chance of survival from a heart attack and are not dependent on having a hospital close by.

The key concern, which the medical advice emphasises to us, is that the patient should receive urgent treatment at the point of first contact. Thereafter, the priority is to get the patient to the hospital best staffed and equipped with the full range of diagnostic and treatment options. In the North Western Health Board area, general practitioners have commenced administration of thrombolytic drugs to patients with suspected acute heart attacks at the point of first contact, reflecting the urgency of the timing of this intervention.

If a person is severely injured in a road traffic accident, the medical advice is that there are two main urgent treatments which influence the immediate chance of survival, namely, maintaining the patient's airway at the site of the accident in order that he or she can breathe, and immediate action to stop or reduce loss of blood. The administration of intravenous fluids or plasma expanders can also be critical. Again, health professionals at the scene of the accident can administer these treatments. After that, the next major influence on survival is to treat the patient in a hospital with the comprehensive range of surgical, medical and anaesthetic skills and diagnostic facilities.

Some people have quoted cases of smaller hospitals stabilising seriously ill or injured patients before transferring them to a larger more specialised hospital. They argue that patients' lives are saved every year by this means and that this will be hampered by the Hanly proposals. However, the international experience in Australia, North America and Scotland is that advanced-trained emergency technicians, EMTAs, can deal with the immediate pre-hospitalisation needs of the patient. This includes basic life support such as airway intubation, intravenous access and advanced cardiac life support as well as thrombolytic treatment, defibrillation and the administration of other oral and, if required, intravenous drugs, especially to control pain.

The Hanly report recommends the development of the EMTA service in terms of numbers and training, together with strategically placed ambulance stations throughout the designated catchment areas of the proposed hospital network. This enhanced emergency service needs to be augmented by a corresponding development in primary care and general practitioner services. The clear international expert advice available, therefore, is that immediate proximity to a local hospital is not the critical issue in the case of serious accidents or life-threatening emergencies.

Concern has been expressed about the type of accident and emergency services which will remain in local hospitals. I emphasise that patients needing treatment for most injuries will continue to be treated there. If one's child has a minor injury, one can still bring him or her to a local hospital and if one has an asthma attack, one can still be treated locally. Contrary to some claims, the opening hours of minor injury and illness units do not automatically have to be nine to five. Opening hours will be set by the volume of demand for services. The experience in Ireland, for example, is that the great majority of non-urgent injuries and illnesses present between about 8 a.m. and midnight. Exact opening hours of local facilities can then be organised accordingly.

In addition to the future organisation of accident and emergency services, the overall role of local hospitals has been the subject of considerable debate since the task force report was published. As the House will be aware, the Hanly report distinguishes between major hospitals, which provide the full range of specialist services appropriate to a region, and local hospitals, which work closely as part of an integrated network with the major hospitals. The concept of a general hospital is also advanced in the report. Local hospitals are ideally placed to provide an increasing volume of elective procedures and the kind of multi-specialist day and out-patient care performed in larger hospitals.

Local hospitals should be developed further to provide excellent locally available services to their communities. We should be clear about what this development entails. It means that we would have a wider range of medical and surgical specialties in a number of areas, including cardiology, respiratory medicine, general medicine, oncology and urology as well as ear, nose and throat, ophthalmic and plastic surgery. When one considers the scope of the services proposed by the task force for local hospitals, it is not valid to describe their future role as a downgrade from the services they provide at present.

We should remember also that local hospitals will have the services of a wide range of health professionals. This is not confined to consultants and junior doctors, but extends to general prac titioners, specialist and staff nurses, radiographers, physiotherapists and occupational therapists. With this type of staffing and service provision, people will have access to a wider range of hospital services in their local hospital than ever before.

We have heard a number of calls recently to retain all services in all smaller hospitals, including 24-hour, seven-day accident and emergency departments. These calls are in spite of the medical evidence that I have described here. The case for change set out in the Hanly report is compelling because it is based on international evidence and is concerned with ensuring safe, high quality care for patients. Even if all this is rejected – a very unwise thing to do – we must remember the new realities about staffing and working hours.

Under the European working time directive, junior doctors will no longer be able to work the extremely long hours they do today. We have to reduce their working time from the current average of 75 hours per week to no more than 58 hours per week by next August and to a maximum of 48 hours by 2009. This affects how we provide services in local and major hospitals. We cannot just decide to keep every service in every hospital on a 24-hour, seven-day basis because we will not have the medical cover to provide it within a 48-hour working week.

It is clear that the solution must not be to employ more junior doctors. The Hanly report estimates that we would need an extra 2,500 non-consultant hospital doctors just to ensure that all of them worked no more than 48 hours a week. Even if we could recruit this number, it would be extremely undesirable to do so. Patients would have less access to senior clinicians and the junior doctors involved would have limited opportunities for formal training.

By contrast, the task force report argues for a consultant-provided service in which patients would be directly seen and treated by a doctor with the experience and expertise to make a decision without delay. This cannot happen if we disimprove even further the present ratio of consultants to NCHDs.

Those arguing that nothing should change in accident and emergency services must think about the practical staffing issues. They must answer the question of how to provide medical staff on a 24-hour basis in every local hospital when nobody can work more than 48 hours per week. The task force report has come up with the best solution. It is the only feasible solution I have heard so far which provides quality care for patients and ensures that doctors do not have to work excessive hours.

A number of Deputies have questioned whether we can reduce the working hours of junior doctors to an average of 58 by 1 August next. There is no doubt that this will be very challenging. However, it is important to bear in mind that, contrary to some claims, it will not be necessary to have recruited the additional consultants proposed in the Hanly report by then. The task force proposes a set of key measures which, if implemented on a national basis, will help significantly to achieve the reduction required by next August. These include a replacement of the present system of tiered or layered on-call, where a number of junior doctors are on call at once, use of cross-cover between specialties so that the number of doctors on call at once can safely be reduced, and revised working patterns for junior doctors.

These changes will have to be negotiated through the industrial relations process. I do not underestimate the task involved, but the results will be to the benefit of patients and doctors. For NCHDs, the changes will mean that they will no longer have to work the hours they currently do. This can only improve their quality of life as well as their ability to give the best possible care to their patients.

A key element of the Hanly proposals is the doubling of the number of consultants over the next ten years so that patients will have much more rapid access to senior clinical decision-making. Consultants would also participate, as required, in the provision of on-site cover in the hospital over the 24-hour period. The task force proposes that consultants should work together on a team basis, with a shared cohort of junior doctors for the whole team. This differs from the current practice where a single consultant and a group of NCHDs work together, but without necessarily any formal arrangements for co-operation between consultants. Effectively, then, consultants would share responsibility for patients with their consultant colleagues.

The benefits for patients of these changes are considerable. The increase in the number of consultants, together with a team-based approach and improved availability of consultant cover over the full 24-hour period, will give patients faster access to the doctors who are best placed to take decisions about their care.

We will need significant changes in the current consultant contract to make all this happen. I have asked the Health Services Employers Agency to press ahead with negotiations with the medical organisations as quickly as possible. A new contract will be vital to achieving the changes that we need.

Some concern has been expressed about the ability of hospitals to cope with new roles, especially where they are already very busy. I must stress that the changes proposed by the Hanly report should only be implemented on a phased basis, taking account of each hospital's facilities and ability to cope with the role it is being asked to play. There can be no question of asking any hospital to take on additional services until it is properly staffed and equipped for that role.

Some of the claims made recently would have us believe that hospitals will become overloaded and generally unable to treat the patients arriving. The Hanly report clearly states that we need to develop appropriate services before we transfer extra patients to them. This applies both in the case of moving services from major to local hospitals and the other way around. There will therefore be no question of the chaos that some people have claimed will ensue from implementing the Hanly recommendations.

In the regions looked at already, we will first analyse the detail of the services that should be provided in each hospital, together with the staffing and capital needs that arise from any change. There will be no question of transferring any services until the necessary facilities are in place.

I welcome the report of the task force on medical staffing. It is the only way forward. It will improve patient care, increase local access to services, reduce the working hours of junior doctors and give us a truly consultant-provided service. Those Deputies who oppose it must ask themselves these important questions: should we not improve our acute hospital services; should we not introduce a consultant-provided service; should we not double the number of consultants; should we not reduce the excessively long working hours of junior doctors; and should we not reform the way we train doctors.

Above all, if Deputies oppose the report, or key aspects of it, they must ask themselves what is the alternative. Can they suggest another realistic, substantive, workable way of improving services while also meeting the requirements of the European working time directive? So far I have not heard of such a single alternative to the Hanly report which would work.

I urge Deputies to consider the report carefully. I look forward to the debate about to take place and commend the report to the House.

Ms O. Mitchell:

I am a little annoyed that the Minister appears to suggest that it is somehow unpatriotic of us not to accept Hanly's report, and the Minister's endorsement of it, without question. As the Opposition, it is our job to question, dissect and ensure that all proposals, particularly those of this magnitude, are given the greatest scrutiny and not accepted at face value simply because the Minister says they are good. Any expression of opposition to the Hanly report by Fine Gael is not a knee-jerk reaction for the sake of opposition or for political expediency.

Fine Gael recognises much that is good in the report. While some of our criticism is about the Hanly report per se and its recommendations, much of it is political criticism. It is based on a lack of confidence in the Government's ability or willingness to fund all the necessary recommendations or to manage the major transformation in the health service envisaged in the report.

We recognise much that is good in the Hanly report and believe that many of the best practice principles underlying it are a necessary part of the reform of the health service and absolutely required to achieve a sustainable quality health care. We recognise also the value of a consultant-led service. If delivered, it will be infinitely better than the service available to many people presenting in hospitals at the moment.

We recognise the value of multidisciplinary teams. The lack of an integrated service, in hospitals, out-patient departments and throughout the health service, is one of the major deficiencies in the service. The synergies achievable from multidisciplinary teams are enormous in terms of the quality of the service and the cost savings that will be available through ensuring that the appropriate person gives the treatment.

I support the training and education recommendations contained in the report and hope they put an end to the scandal in many of our hospitals. Doctors, particularly those sent here from Third World countries, are given poor training and certainly no recognition whatsoever, yet in many cases they are here at great expense to their families and countries. We use them and abuse them merely to meet our service requirements, and I hope that practice will end.

Fine Gael also supports the increased regionalisation of specialties. It is totally unacceptable that people must travel long distances to Dublin to receive care in many of the specialties. That has repercussions for services in all hospitals, particularly the major hospitals around Dublin. I totally accept the notion of a population of 350,000 being the ideal one for the provision of many of the specialties. I accept other recommendations whereby we would have supraregional services and, indeed, national services.

I have no hesitation whatsoever in saying that Fine Gael does not support the slash and burn policy of closing all the smaller accident and emergency departments – I will return to that issue – but we support aspects of the Hanly report and we are acutely conscious of the urgent need for reform of the health service, not just the hospital sector with which Hanly deals almost exclusively.

The immediate context of the Hanly report was as a manpower study on how the European working time directive could be implemented. However, the broader context of it, and the reports of Prospectus and Brennan, was the urgent need for reform of the health service, not merely for the sake of change, but ideally to rethink fundamentally what it does, and to build in an automatically responding flexibility. Such flexibility will ensure that it can respond to changing circumstances in the future and be able to bear the pressures on the service so that we do not hear calls for fundamental reform and change to the structures every four or five years and wonder why in another five years we need to call for further reforms.

We need sustainable reforms which will carry us through all the pressures on the health service, such as the ageing population, improved technology and the more expensive better drugs. Those pressures cannot be sustained by the system as it is structured and there is a real danger that, starved of funds and subjected to all these pressures, together with the shortage of manpower, it will simply collapse. Therefore reform is vital and we recognise that.

I am convinced that these reforms do not go half far enough. I do not believe that getting rid of a few accident and emergency departments and the health boards is the whole answer. Certainly it will not provide long-term solutions. For instance, is there a proposal outlining how the abolition of the health boards will save money? Certainly it will get rid of the democratic accountability within the system. Replacing the health boards and the current system with a monolithic centralised one, with all the worst flaws of the Soviet Russian administration, hardly seems like progress or a way of providing a more efficient system.

Certainly there is a need for an overarching guiding hand to set policy, but that is the Minister's job. Abolishing all local administration is not the right way to go, and my colleague, Deputy Naughten, will make this point. Indeed, the Minister's colleagues in other Departments are going in the opposite direction. They are breaking up CIE and Aer Rianta, while the Minister, Deputy Martin, is going in the opposite direction and telling us that somehow this will be more efficient. It will not be more efficient. It will lack flexibility, it will lack local knowledge and it certainly will not enhance integration of the service and produce the kind of seamless service delivery which would allow patients access to the continuum of hospitals, community care services and nursing home services. It is hard to see how such a system, which was envisaged in the health strategy, can be provided under the new administrations. I will come back to these reforms, which I see as essential.

Everybody sees the need for good governance within the health service, which is absorbing much of the budget. The entire Exchequer budget is being absorbed by the health service, but just being in favour of good governance and making changes for the sake of change will not bring it about.

One of our criticisms of the report, which I outlined when Mr. Hanly came before the committee, is that he started from the premise of assuming a greenfield site and asking what is the ideal health service. The trouble is we do not start with a greenfield site. We have to move from a system where there are sick people to a sustainable one in the long-term and the Hanly report did not provide that road map. It provided a template for a health service if we were starting from day one, but it does not tell us how to get to that, and there is no confidence, even if the money was available, that the Government is capable of making that transformation safely.

The Government has given no reason for confidence. There has been inefficiency, incompetence, maladministration, stop-go decision-making and false promises, so people no longer have confidence in the Government's ability to deliver. We have seen people on trolleys and on waiting lists, not only to get into hospital but to see a consultant to get a diagnosis. As I stated previously, in many cases by the time people get a diagnosis it is too late for treatment.

We have seen community care services decimated. Throughout the country we have seen GPs totally disillusioned. People who had bought into the promise of the health strategy are completely disillusioned. The Hanly report does not offer any immediate solution – nor does the Minister – to any of these problems that exist in the health service and they do not offer a way forward either. Put simply, the public has lost confidence in the Government and will not believe that the Hanly report offers them a better service until they see it.

My second criticism relates to the lack of resources. Indeed, there is a lack of commitment from members of the Government to the Hanly report and we saw in the newspapers this morning that the report failed the political test at the first fence – the Ministers themselves cannot even support it.

The resources required for implementation of the Hanly recommendations are enormous, and that has been glossed over completely. I am not talking about consultants' salaries, which of course are considerable, but the huge infrastructural investment that would be required, both at local hospital level and particularly at the major hospitals. Acute beds, which were taken out of the local hospitals, must be replaced in these major hospitals before any dismantling of the local service takes place. GPs and ambulance personnel will require up-skilling and the regional hospital building programme, involving the provision of about 2,500 new beds, will be necessary to replace the emergency beds taken from local hospitals.

This is to say nothing of the huge investment required in ensuring access, which is a critical aspect of the Hanly report. Ensuring that people can access hospitals entails having a better road structure, perhaps having an air ambulance service, and the up-skilling and resourcing of GPs to ensure that they can provide many of the services provided currently by local hospitals.

We do not know the amount of money required. It has not been quantified. There is no commitment to it. The only thing we know for certain is that the Minister for Finance has said there will be no funds next year. Therefore we know that in year one of the ten years of the transformation there will be no funds, despite the fact that there are two pilot programmes which must be implemented by next August. Whatever chance there was of implementing aspects of the Hanly report or beginning the transformation during the years of the Celtic tiger, when it also would have been difficult and expensive, it is virtually impossible to do that now because it will be necessary to ensure that nothing is dismantled until replacement services are up and running and proof is provided vis-à-vis the system's capability of delivering a better service than that which exists now.

Or in full flight.

Mr. Gormley:

From whom will that time be recouped?

Mr. Martin:

The debate is open-ended.

Ms McManus:

Yesterday 37 patients were lying on trolleys at the accident and emergency department in Tallaght hospital, 19 of whom were placed in the corridors. There were 25 patients on trolleys in the Mater Hospital and 22 on trolleys in Beaumont Hospital. There were a further ten patients on trolleys at James Connolly Memorial Hospital, five at Cork University Hospital, 12 at Portiuncula Hospital and ten at St. Vincent's Hospital.

Those were the lucky patients. The unlucky ones were those who could not get a trolley and ended up sitting on chairs. An accident and emergency consultant at the Mater Hospital, Dr. Eamon Brazil, described the situation as being more or less constant for the past three years. He states that, in reality, however, it is worsening every month.

Yesterday Tallaght hospital had to go off call because the pressures there were so great. At the Mater, ambulances were immobilised because their trolleys were being used and they could not leave until they were returned. Ambulances were recently stranded at Beaumont Hospital for the same reason.

According to yesterday's newspaper reports, staff working in the Christmas rush in supermar kets are not under as much pressure as are the staff in Dublin hospitals at present. Today we are debating the Hanly report. Following its recommendations, the Government will close down hundreds of acute hospital beds, reduce dramatically the number of accident and emergency departments and divert thousands of patients away from local small hospitals. Patients who would normally attend their local hospital will be forced to go to major centres such as Tallaght hospital, the Mater, Cork University Hospital and Beaumont Hospital. At a time when these centres are tottering under the strain of demand, the idea for many of adding to their woes in this way smacks of madness.

The Minister's contribution was extremely soothing. However, it is not enough to soothe people's concerns in respect of the recommendations in the report. His contribution did not tell the full story. The closure of accident and emergency departments will end 24 hour emergency services at local hospitals which will be replaced by nurse-led small injuries units. There is already a shortage of nurses, with approximately 1,000 needed for Dublin alone. A further crisis is developing in that there is a shortage of general practitioners. The idea of closing down accident and emergency departments and expecting that there will be enough nurses and GPs to fill the gap does not reflect reality.

The Minister has not declared from where the money to facilitate this will come. No funding has been ring-fenced. We are aware that, next year, insufficient money will be provided to keep current services operating, not to mention providing for the additional facilities he states will be in place before any changes occur. If that is the case, the Minister ought to explain what will happen in the pilot areas. If nothing happens in those areas until facilities are provided, how will he ensure that the hundreds of acute hospital beds that are being closed in local hospitals will be provided at the major centres? The Minister should address that matter in his reply to the debate.

In presenting his report, Hanly explained that it was prepared in a vacuum without any political, financial or industrial relations considerations being taken into account. This is its greatest weakness. None of us, particularly the Minister for Health and Children, can afford to disregard these considerations. On the day of the publication of the Hanly report, the Minister warned that he would challenge any opposition. He stated: "I have no doubt that this will be manipulated and used for political purposes. I would say to anyone . . . listen very carefully in terms of what is being said. Anyone who opposes this needs to be challenged to produce a substantial and comprehensive alternative".

Last night, at a public meeting in Nenagh, County Tipperary, the Minister's Cabinet colleague, the Minister for Defence, Deputy Michael Smith, effectively tore up Hanly and stated that he refused to endorse the recommendations of the report. He also insisted that he would not stand over any downgrading of Nenagh Hospital. Where does this leave the Minister for Health and Children? What does he have to say in response to this outright rejection of his view? Where does this leave his much trumpeted programme of health reform? The Minister, Deputy Martin, should indicate whether he has the confidence of the Cabinet and whether Hanly has a future.

Since the smoking ban, which was to be the Minister's tour de force, has begun sinking under a welter of confusion, the question is increasingly being asked whether he has a future. What credibility can he have as he lectures us about his plans for the future of the health service while his Government colleagues openly reject them? Will this continue? Will the Minister for Finance oppose the closure of accident and emergency services at Naas hospital? What will the Minister for Foreign Affairs have to say? What will the Minister for Social and Family Affairs say about services in Donegal or the Minister for Arts, Sport and Tourism about services in Kerry? What will the Minister for Agriculture and Food say about the downgrading of Bantry hospital or the Ceann Comhairle about Monaghan hospital? The Minister should talk to them first before he comes to the House to debate with us.

While he is thinking about this, he might display a little courage and account for his record of gross mismanagement and incompetent use of resources, the failure to confront the core problems, the expectation that flinging money at the problems would bring results and the surfeit of political opportunism, hubris and false humility? Recently the Minster stated on RTE's "Morning Ireland" that the promise he made before the election to eliminate hospital waiting lists permanently by 2004 was a mistake. However, it was not a mistake because it was a cold, calculated ploy to fool people and it worked, but only temporarily. With 176 days to live up to the promise, the Government has lost all credibility on that score.

The Hanly report is the latest of three reports commissioned by the Government but, before our expectations become too high, I refer to what happened to the others. The Brennan and Prospectus reports were endorsed by the Taoiseach, the Tánaiste and the Minister and they all promised a swift response, which has not happened. The Minister promised he would announce the shadow HSE and the implementation body by mid-October, and we are still waiting. The process is bogged down because of lethargy and bureaucracy and because those who are part of the problem are taking charge of the process and delaying progress significantly.

The Hanly report is not like the others because it cannot be put on the shelf to gather dust. The report is fundamentally about an EU directive, which will be partly implemented next August. It is different from the others but it might be out of date already. I do not say this for political pur poses because I am concerned that we may yet again ape what is happening in Britain and we may be too late. Instead of learning from their mistakes, we are following the British. It is important to consider what is happening in Britain because a similar process has been in train there for some time whereby services are centralised in major hospitals and local hospitals are used as satellites.

The problems and pitfalls have led the NHS confederation and the Royal College of Physicians to set up a working group to review the system to see what can be done. An interesting article was published in the British Medical Journal in August 2001. It stated:

. . . the favoured model has been a large central hospital with associated local hospitals to which patients are discharged. But this model may make services worse rather than better, argues Andy Black, once chief executive of the Central Middlesex Hospital and now a consultant in the organisation of acute services.

Acute services can be thought of as a simple system that comprises a medical emergency that usually occurs in the patient's home, a journey to the hospital, assessment, admission, a treatment process, and then discharge. A large central hospital inevitably means longer journeys. This has immediate therapeutic implications: with many conditions minutes matter. Long journeys mean more ambulances –"and two fully crewed ambulances", said Black, "cost the same as the direct costs of a medical ward. Increased distance also creates problems for visiting families and weakens the links with primary care and social services, which are crucial for discharging the patient". Further problems then arise with assessment and admission. The large numbers of patients create logjams, with some patients spending hours on trolleys.

The worst problems come with discharge. The difficulty of discharging patients increases with their distance from home, so big hospitals tend to fill up with medical patients. Ironically this often means that patients who need elective operation – those who might benefit from larger hospitals – cannot be admitted because the beds are filled.

The Minister continually asks what is my alternative, and that is a fair question. I am not in a position to provide an alternative because I do not have resources. However, it is the Minister's job to set up a model. I can challenge presumptions made in the Hanly report and should not let them go unquestioned.

Andy Black proposed reversing the favoured model. The article states:

If the Minister wishes to change his line, he should do so in a coherent fashion. There should not be a little of this and a little of that.

I refer to the ambulance service. The Hanly report is predicated on the notion that there will be a massively enhanced ambulance service, which will replace accident and emergency departments in local hospitals. In view of difficulties in our current ambulance service, a huge amount of work would be involved in upgrading it. Under EU requirements, an ambulance can only carry one stretcher patient in future. I believe the training requirements which have been recognised in the Hanly report were also recognised in a report published in 1993, but it is only in 2004 that the training of trainers in specialised skills is envisaged. The situation augurs badly with regard to looking at the needs of the ambulance service and ensuring that, in taking emergency services away from local hospitals, notwithstanding what the Minister is now saying, as is clearly envisaged in the Hanly report, it can be replaced by a greatly enhanced ambulance service which will cost a great deal of money.

As Mr. Andy Black has stated, the cost of providing the type of ambulance service we are discussing may be equivalent to that of a medical ward. These are costly changes, but we have heard absolutely nothing from the Minister as to how he will fund those changes. It should be clearly understood that he is talking in terms of the removal of hundreds of acute hospital beds from local hospitals, ending accident and emergency departments and replacing them a with nurse-led, part-time service to deal with small injuries. That is not the same as the emergency services which people currently use at local hospitals. The current thinking in Britain in that regard appears to be that emergency treatment should be provided at local hospitals, which should act as a funnel into central hospitals, rather than the reverse, which is the logic of Hanly.

Dr. Twomey:

I wish to share my time with Deputies Gormley and Ó Caoláin.

An Leas-Cheann Comhairle:

Is that agreed? Agreed.

Dr. Twomey:

Unfortunately, due to time constraints, I must confine myself to negative points with regard to the Hanly report. In some respects, the report was summarised by a retired consult ant in Waterford, who said that one's response to Hanly depends on one's postal address. I regard that as a very good definition. For the people of Dublin, Cork and Galway cities, the Hanly report will have very little impact. Although we have heard a great deal about the accident and emergency crisis in this debate, that is a bed capacity and management problem as opposed to anything relating to consultant numbers. However, for patients and their public representatives in all other constituencies outside our major cities, the Hanly report, in its present form, would have very serious repercussions, unless major changes are envisaged in its roll-out.

For example, 22 million consultations are carried out each year in general practice and there is no remaining capacity in that system to take on an additional workload. As I expect the Minister has been informed, the services appear to be in slow melt-down. Unless there is some action in this regard, I do not see how GPs can take over any of the workload, regardless of fancy terms such as linkage and so on in the Hanly report – it just will not happen.

I am also aware of a report which highlights the weakness in ambulance response times across the country. The areas with the worst response times are also the areas which will have the worst outcome in so far as the Hanly report is concerned. The Minister and his Department officials should immediately have a look at this report, which examines the significant length of time it takes for an ambulance to deliver a patient to hospital from the time of the initial call.

To give some reassurance to those constituencies which could be significantly affected, there are some positive things the Minister could do right now. He could insist on an embargo on appointment of further consultants to the teaching hospitals in Dublin and Cork. At least that would give an opportunity to beef up the regional hospitals by increasing their numbers of patients so that they might begin to look like the type of institutions to which the Minister keeps referring. Perhaps if something of this nature was implemented, we might believe that the Government is concerned about more than just the people of Dublin, Cork and Galway.

In no way can any of the regional hospitals compare with the major hospitals in Dublin. It is easy for Dublin consultants to call for seven consultants in each specialty when that is already the situation in their own hospitals. However, that is not the case in the regional hospitals. The Hanly report identifies this bias which has existed for some time. The Limerick region, which is part of the pilot scheme, currently has 100 consultants, whereas the Dublin region, which is under review, has 177. However, they are both expected to have the same number of consultants when they reach the target population of 350,000. Clearly, a bias is already built into the system.

Part of the problem in the context of the Hanly report, as I have observed since I became a Mem ber of Dáil Éireann, is an over-reliance on the opinions of Dublin consultants whenever decisions are being made. The Government does not appear to take on board the views of other consultants – perhaps they have not the time to talk to the Minister – as to what is happening on the ground in smaller regional hospitals, which are not being looked after. There appears to be a fatalistic notion in Dublin that one can close accident and emergency departments across the south-east, leaving people to travel 70 miles to Waterford, but that one needs five accident and emergency departments in Dublin. There has been no reference to closure of two accident and emergency departments in Dublin. That situation compounds the bias I find in many reports.

The spin surrounding this debate is very annoying. It shows a lack of interest in the genuine concerns of patients, general practitioners, ambulance services and consultants in the hospitals which will be most affected by the Hanly report. That report needs much greater clarity in terms of what the Minister plans to do before the final deadline in 2008. We need exact timescales, rather than wishy-washy nonsense with regard to pilot schemes in Limerick, Dublin and the south-west. We need to beef up the regional centres to the status they are supposed to reach when the Hanly report is done and dusted. The report has to be implemented, although it is relatively easy to dismiss other reports. If the chairperson of the Brennan report group had not become so excited about its implementation, not very much would have been heard about that report.

With regard to negotiations on consultants' contracts, I will play the role of a politician rather than a doctor in this instance. The Minister should bear in mind that the consultants' representative organisations are comprised of over 70% of consultants who work in Cork, Dublin and Galway and have little interest in altering their contracts to suit the Minister's implementation of the Hanly report. That will be one of the major IR issues the Minister will have to face and he should give some consideration to how he will carry it out.

Health boards in some areas are already implementing their own version of the Hanly report – I regret that time does not allow me to expand further on this. The Department of Health and Children is digging itself a hole which is simply filled with patient expectations. There is more spin coming out than an industrial washing machine would generate. We need much greater clarity as to what is happening.

Mr. Gormley:

Faced with the ongoing accident and emergency crisis, it is appropriate to debate the Hanly report, although it has been covered extensively in discussion at the Joint Committee on Health and Children. On that occasion, Mr. Hanly was at pains to point out that the smaller hospitals were not being downgraded, a point which the Minister again stressed this evening. As I stated in the committee debate, this claim has been repeated so many times that it reminds one of the phrase "He doth protest too much." The claim is simply not credible. Withdrawing proper accident and emergency services from hospitals such as Ennis – I acknowledge Deputy Killeen's presence on the opposite benches – represents a downgrading – that is beyond question.

Hanly simply continues a trend established many years ago towards greater centralisation and more technology, which involved the amalgamation of the Adelaide and Meath hospitals in my constituency and their move to Tallaght. What has been the result? One has only to look at the situation in Tallaght, with up to 40 people on trolleys in the most degrading and humiliating circumstances. Overworked doctors and nurses are not to blame, as so many people have said, rightly pointing the finger at the Government. The ongoing accident and emergency crisis is indicative of a deep-seated crisis in our health service, caused by the incompetence and right wing ideology of the Government. The Green Party has argued that there should be a single waiting list, whether one is a public or private patient.

One may find oneself on a trolley, eating meals out of one's lap and using filthy toilets. One may be under harsh lighting all the time, with only occasional access to showers. This is the reality we have heard. The Minister speaks about the reality but this is the reality for patients in our accident and emergency units now. I am afraid the Hanly report is not going to make a blind bit of difference. One can carry out restructuring with the Brennan, Prospectus and Hanly reports, but none of them will deal with the central problem of capacity and years of underinvestment. The Minister and the Government may claim we have reached the Eurpean average in health spending but it is also true to say there is much ground to be made up.

There is a serious shortage of bed capacity in our major hospitals, particularly in the eastern region. In Ireland in 2001 we had three acute hospital beds for every 1,000 people. This contrasts with France, where there are four beds per 1,000, or Germany, where there are six beds. France has overcapacity built into the system; bed occupancy runs at approximately 75% there, compared to 95% in Dublin's acute hospitals. The Hanly report does not deal with this fundamental problem. There is also the failure to provide suitable step-down facilities, which means too many people spend too long in hospitals and not enough time in the community, where they ought to be.

One of the first things the Minister said was that we should deal with the reality of the Hanly report. The reality is that the Minister for Finance is not willing to invest further in the health service. Mr. Hanly told us at a meeting of the Joint Committee on Health and Children that the new contract for consultants and the greater need for consultants would not necessarily result in significant extra expenditure. That is extremely difficult to believe. The working time directive must be complied with, though we will not comply with it in time. We need more consultants, a finding in the report I welcome, but we probably need more than Hanly recommends and that will cost quite a bit of money. I recently saw the German figures for compliance with the working time directive and we have underestimated the costs involved by a great deal. Hanly continues a trend; look at what is happening in Peamount, where Dr. Luke Clancy has said the chest hospital option should continue. Look at the trend towards greater centralisation and the fact that in 1973 we had 108 maternity hospitals. Now we have 22, with a recommendation to close a further ten. This centralisation does not make sense. The Minister will have to listen to people. He will have to listen to the consumer.

Caoimhghín Ó Caoláin:

Despite a series of detailed reports analysing the state of the health service and an increased level of current spending above the EU average, our health services still suffer from the legacy of decades of underfunding and from the present day reality of gross inequality. The twin failures of successive Governments – the failure to reform and the failure to resource – continue in 2003 only in different guises.

The Brennan report exposed many of the economic inefficiencies in the system. The Prospectus report exposed the shortcomings of its organisation and management. The Hanly report has analysed some of the many complex problems of medical staffing. Each report proposed varying and sometimes conflicting solutions, some of which are positive and others negative. All the reports came in the wake of the Government's health strategy, most of which remains unimplemented, and now we have the anomaly raised in the Hanly report. Action to reduce the working hours of junior hospital doctors is welcome and essential, but the associated proposals to downgrade and slash services in hospitals throughout the State are wrong and should be resisted. Must we now depend on the Minister for Defence to defend in Cabinet the rights of communities to basic and essential services such as maternity and accident and emergency facilites?

We are repeatedly told that accident and emergency and maternity services should be centralised in regional and so-called national centres of excellence. However, the communities which are expected to bear the brunt of loss of services from their hospitals are witnessing crisis situations unfolding in existing centres of excellence such as the main Dublin hospitals. We learned this morning that there were over 100 patients on trolleys in accident and emergency units in the greater Dublin area yesterday. In Our Lady's Hospital for Sick Children, Crumlin, there are now fewer beds than when it was opened 50 years ago, despite a tenfold increase in patient numbers.

The Government's handling of the smoking ban has demonstrated an appalling lack of cohesion and political leadership. What hope, then, that it will deliver even on its own flawed health strategy? There is no evidence of that. The downgrading of hospitals under Hanly is being proposed while the initial 40 to 60 primary care teams and networks promised in the health strategy are not targeted to come on stream until the end of 2006.

The downgrading of hospitals under Hanly has long been signalled. The cause of the ongoing anguish visited on my home community of Monaghan is now set to visit a hospital near you, dear citizen. The Hanly report did not propose that all new consultant appointments be in the public system only, something it should have done, but the renegotiation of the consultants' contracts in the interest of public patients is essential. The weakness of the Government's position on this, even before negotiations begin in earnest, does not augur well.

Underlying all of this is the point blank refusal of the Government to confront the fundamental inequality of the two-tier public-private system. That system rumbles on in a week which sees the publication of figures for the various health boards and how they spent beyond their inadequate budgets for the first nine months of the year. The shortfall means real hardship for real people, including bed shortages in acute hospitals, patients on trolleys in accident and emergency, and cuts in home help and other services for the elderly. Funding to deal with the devastating health consequences of drug addiction and many other areas I mentioned today is also totally inadequate.

Hanly, Prospectus, Brennan and the Government's health strategy are all paper and ink in the final analysis. Without the political will to take action that makes a real difference to patients, without the political commitment to deliver and to mobilise public support and the support of those in the health service, any strategy will remain words and words alone. The Government has demonstrated its dismal failure on health again and again. I appeal to it not to compound those failures in the forthcoming budget and to free up the resources that are so desperately needed in order to have a comprehensive health service available to all our citizens, with equal access to care for all when they need it.

Debate adjourned.

Dáil Éireann díospóireacht - Tuesday, 11 Nov 2003