Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 6 Feb 2007

Vol. 630 No. 5

Private Members’ Business.

Health Service Reform: Motion.

I move:

"That Dáil Éireann,

aware of:

the fall in the number of acute hospital beds in Ireland up to 2001;

the fact that over 40,000 elective operations have been cancelled in the past two and a half years;

the cancellation of emergency surgery due to lack of ICU and HDU bed capacity at St. James's Hospital;

the fall in the percentage of people eligible for medical cards;

the shortage of consultant, specialist and general practice doctors; and

deploring the Government's failure to reform the health service to enhance the quality of services and achieve better value for money;

calls on the Government to commit to excellence in the quality of care, fair access on the basis of medical need, and efficient use of resources by inter alia:

beginning immediate planning for an additional 2,300 hospital beds;

scrapping the Ministers plan to build private hospitals on public land;

extending medical card coverage to 40% of the population; extending GP-only cards to all children under five, who are not covered by a medical card;

introducing health insurance for all children up to the age of 16 — including an element of free GP care for children from 5 years upwards;

beginning reform of health funding so that the money follows the patient;

making progress on the appointment of 1,500 new consultants, with a corresponding reduction in the number of junior doctors in general specialties, until a better balance is achieved;

implementing the Fottrell report on medical training to expand the number of doctors in training;

expanding community support services for elderly people to live independent lives as far as is practicable;

providing at least 1,500 additional convalescence, rehabilitation and long stay community beds to meet current and future needs with 600 of these beds based in Dublin; and

increasing the number of home help hours."

I wish to share time with Deputies McManus, Crawford and Enright.

Is that agreed? Agreed.

As the Dáil will sit for just eight more weeks before the general election, it is important that the Opposition should continue to highlight its concerns about the health service, while outlining its solutions to such problems. The Government's failure to reform the health service, after ten years in office, has landed us with an awful legacy. As I said last week, the Government has no clear policies for the future of the health service. It is clear that the policies published by the Government in the past have not been implemented to any significant degree. The Government's amendment to the motion before the House demonstrates that the health service continues to be poorly structured, after ten years of this Fianna Fáil-Progressive Democrats Administration. The national review of acute hospital bed needs under way will identify the number of acute beds which will be needed up to 2020. That the review will tell us the number of beds we will require in 13 years' time is a demonstration of the Government's crazy attitude to the health service.

Another part of the amendment that deserves comment states: "regrets that some patients have their operations postponed when priority is necessarily given to emergency cases; recognises that postponements cause upset and inconvenience for patients and their families...". "Inconvenience" is not a word I would apply to Rosie. This postponement did not cause inconvenience but a delayed diagnosis of her cancer. As a result of the delayed diagnosis, she has more or less been handed a death sentence by the Government.

During the debate on Private Members' Business last week the Minister said the HSE had been instructed to provide an urgent colonoscopy within two weeks for those who require it. I asked the Minister to define what was meant by an "urgent colonoscopy". If a patient presents to me with signs and symptoms of what could possibly be bowel cancer, an urgent colonoscopy is required. A number of my patients had procedures cancelled and they were subsequently diagnosed with bowel cancer. They do not have the disease to the extent suffered by Rosie and received treatment within a certain timeframe but it had a significant effect on their quality of life because they required more aggressive treatment because of the significant delay in receiving it. I am a qualified doctor and do not send a patient for a colonoscopy unless I consider it urgent. Every person who needs a colonoscopy should be seen as urgently as possible. In Britain a great deal was made of the fact that in the NHS patients had to wait six weeks. In this country one would not even get on the waiting list for a colonoscopy in six weeks.

The amendment "notes the significant increase in intensive care and general bed capacity at St. James's Hospital". This gets around the comments by the Tánaiste about crises being taken down from a shelf. His insensitive remarks about the way patients are treated in St. James's Hospital shows an unbelievable arrogance. When commentators from the back benches try to spin their way out of this problem, they say there has been a 50% increase in the number of intensive care beds in St. James's Hospital. In actual numbers, one new intensive care bed has been provided in St. James's Hospital in every year for the last five. In a hospital which carries out such complex surgery one new intensive care bed per year can hardly be considered a record achievement by the Government. It is time to put real doctors in our hospitals, get rid of the spin doctors from the Government benches and deliver these services. It is a 50% increase on very little. St. James's Hospital should have a massive intensive care unit in view of the complex surgery carried out there.

There is also the Minister's co-location plan to provide new facilities on the campuses of public hospitals. It was interesting to hear on the news this evening that she intends to sign these contracts in May but that she will also insist that the consultants' contract is renegotiated in the next seven weeks. I am glad there is some reality in the Department. An investor would be mad to sign a contract for the new private hospitals without seeing what the new consultants' contract will offer. The success of these hospitals depends on a new private consultants' contract, and there is none.

Patient care is another issue, and the Minister has been extremely evasive when I have asked questions about it. If consultants are taken out of the public hospitals, patients will be exposed to the care of less senior doctors. The Minister will make the current situation worse. In the private hospital one will see the consultants going home at 5 p.m. and the patients there will be under the care of doctors who are not in training and are unsupervised. Both private and public patients, therefore, will get an extremely raw deal from what the Minister is offering.

The amendment asks us to support the Minister in negotiating the consultants' contract. This time last year I offered her my full support when she said she would introduce public-only contracts if the negotiations did not get under way quickly. At the time I asked her to put a timeframe on the negotiations and suggested that it be the end of March. Nothing was done. Why did the Minister do nothing throughout 2006 to push the consultants' contract talks forward? There are eight weeks of the Dáil session remaining. If there is any delay, we will be in the middle of an election campaign with no new consultants' contract. The Minister should be more honest about why this process fell apart.

The best way forward is for the Minister to chair the talks. At least then we would know whether the talks collapsed because of what the consultants or the Department and the HSE were doing. The consultants' contract talks of the last three years have been the most unbelievable nonsense and I am surprised the Minister allowed it to continue under her stewardship of the Department. I would not mind if it was the former Minister, Deputy Martin, given his failure to act in a number of other crises. The Taoiseach should have fired him or one of his Ministers of State for what happened with the illegal nursing home charges.

As a result of the Taoiseach blinking on that issue, political accountability in the Government has gone into freefall. One need only consider the issues that have arisen in the past 12 months. There was the failure to act in the Leas Cross crisis, for which we still do not know if anybody will bear responsibility. Tonight we saw on the "Six One News" that a lady who worked in the blood laboratory will become a scapegoat for the huge hepatitis C crisis. We have seen what happened in Leas Cross and to a number of patients in the nursing home sector during the Minister's term of office but nobody is taking responsibility for it. What will happen in that case? Will a junior clerk in some department in north County Dublin take the rap in five or six years? It is a shocking disgrace in respect of how the health service is being run.

What happened with BUPA and with regard to the loophole that will impact on the private patients of VHI? A total of 1.6 million customers of VHI will see their premiums go through the roof. Much of this is related to Government policy and the fact that the Minister is trying to build co-location hospitals and increasing charges for private beds. A former colleague of the Minister, Mr. Charlie McCreevy, is trying to impose sanctions from elsewhere in Europe. In addition, the usual health inflation issues will impact on premiums. What happened with regard to the BUPA loophole, of which the Minister was informed a year ago?

I was not. That is not correct, as the HIA has confirmed.

The Minister has failed to deliver an implementation plan for the cancer strategy. This means the policy guiding Government cancer services is the one produced by Deputy Noonan in 1996. I studied the Minister's response to the Private Members' motion last week. Of the eight issues she raised, five related to what she would do in the future. Only three related to what had been done over ten years in power. That is a hopeless record.

It is difficult to find out the truth. The Minister, for example, says a sum of €44 million has been provided for primary care teams. There are no such teams in County Wexford. I welcome the Minister's visit to the county next week and hope that, like the Scarlet Pimpernel, she might——

The Deputy is welcome to attend the conference.

——be able to find some of these primary care teams.

The Deputy, with Deputy McManus, could listen to the health debate.

I have searched high and low across County Wexford and still cannot find them. There should be at least three in the county by now.

The Government gave a commitment to provide 800 long-term beds in the public sector this year. However, in a response to a parliamentary question about the programme for additional publicly-owned extended care beds, the Minister said an additional 446 beds would be provided this year. The other 400 will be provided in 2008. This is simply spin that she is doing something for the health service. The reality is different. For that reason it is difficult to know whether the €400 million provided for care of the elderly services is actually spent there.

The former director of primary care services in the HSE once attended a meeting of the health committee. When he was questioned about the number of home help hours being provided by the HSE, he said he did not know the number, as the HSE had no way of measuring the total number. We do not know if the services the Minister says are being provided for care of the elderly in the community are being delivered by the HSE.

It is not the only area of the health service where everything appears to be disjointed and out of kilter. It is possible the nurses will go on strike, although the Minister and the Taoiseach do not have much to say about it. The Minister places a great deal of emphasis on what the general practitioner and primary care can do in the community.

From next year no doctors will be trained in Cork because all those who train young doctors there have pulled out owing to the protracted negotiations with the HSE. A successful training system for young doctors has collapsed and is imploding. Significant numbers of qualifying physiotherapists are not being employed by the HSE, even though they are badly needed. Occupational therapists play a significant and important role in defining services for those with disabilities and the elderly who need facilities to make it possible for them to live in their own home. The Minister constantly refers to people living in their own home and the care of people with disabilities, yet one of the key factors in the delivery of such services — occupational therapists — are not available. It is unacceptable that the waiting time to see an occupational therapist is six months.

The sham report on radiotherapy services produced in July 2005 shows that the Minister has contempt for those who require radiotherapy. It is also a sign of arrogance and a pointer to the way the HSE works. I stated I have my own concerns about political accountability and political interference in the HSE and stated I would like to see the HSE reined in. The report demonstrates what I mean by the need to rein it in. In the days of the former health boards there was political interference but also political responsibility to some degree. Now we are left with the political interference and no political responsibility. The Minister constantly tells us that these are issues for the HSE to deal with but there is evidence of significant political interference in the health service, a matter about which we will question Professor Drumm in time to come. The response of the board of the HSE to this allegation is a clear indication of how it occurs.

Fine Gael will improve access to primary care for both young and old. We will provide a doctor-only medical card for every child under the age of five years. Both my wife and I are general practitioners but we have often had to weigh up whether to give one of our children an antibiotic. We have three young children under the age of six years. The financial element in a parent's decision on whether his or her young child requires a medical opinion needs to be taken away. This is the reason for the Fine Gael proposal. It proposes to provide health insurance for every child under the age of 16 as a way of making all children equal, rather than simply paying lip service by means of a referendum on children's rights as proposed by the Government.

I will allow other colleagues to speak on the other Fine Gael policy proposals. Reform is about matching resources such as manpower, beds, theatre space and occupational therapy services and dealing with industrial relations issues. It is about time the Government showed real leadership in delivering services for the people.

I thank Fine Gael for ensuring this motion was jointly proposed by the Labour Party and Fine Gael. The motion sets out a road map for a Government that has lost its way. Instead of consistency, Fianna Fáil and the Progressive Democrats have lurched alarmingly in different directions on health policy. Instead of commitments made honourably, the two Government parties spewed out promises that were dishonoured within months of the last election. There were to be no cutbacks, an end to waiting lists, 200,000 medical cards, 200,000 GP-only cards and 3,000 acute hospital beds. The reality is a shameful record. In 2002 the Government health strategy promised "immediate benefits for substantial numbers of people and the construction of a health system which in little more than half a decade will be immeasurably improved". I remind the Minister that we have reached that half decade and no one believes that the promised improvements have materialised.

On the contrary there is a low level of morale among staff and a high level of anxiety among patients about many aspects of the health service. More than anything there is an aching need for reassurance in the public psyche. Many people have simply lost faith that the immeasurable improvements will ever be made. The Government has clearly failed in the task it set itself but those on this side of the House have not. For the first time well in advance of an election, two major political parties in opposition have engaged in the preparation of a major health plan. It is a significant initiative which provides the springboard for a new and better Government capable of meeting the needs of patients and those who care for them.

I remind the House of the record: of Our Lady of Lourdes Hospital inquiry report, the report on the death of Mr. Pat Joe Walsh, the report on the death of Mr. Peter McKenna, the report on the death of Róisín Ruddle and the Leas Cross report. These are only some of the reports that have examined the institutional abuse of elderly, frail people, the surgical mutilation of young women and the death of a middle-aged man who bled to death in a ward of a modern Irish hospital.

There is also the anecdotal evidence that arrives on our desks on a regular basis. I refer to the patient who was not informed he had contracted MRSA and whose family only discovered the fact when it appeared on the death certificate, the patient who had been waiting more than five months for open heart surgery because he did not have private health insurance and the case with which we are all familiar, the tragic case of Rosie from Kilkenny whose life has been so tragically foreshortened. The evening news today was full of stories about health. One of the issues not referred to by Deputy Twomey is the problem of nursing shortages in Our Lady of Lourdes Hospital. I refer to paediatric nurses not in place, accident and emergency patients on trolleys and staff members concerned about the risk to patients.

Last March, the Minister was forced into declaring a national emergency with regard to the accident and emergency departments around the country when it emerged that 500 people were on trolleys. There has been ongoing disagreement about the accurate and exact number of people on trolleys. Last night I telephoned the person in charge of the accident and emergency department in a major Dublin hospital. She painted a picture which is radically different from the bulletins issued by the HSE on a regular basis which state that things are getting much better. A manager of an accident and emergency department is under fierce pressure because some patients on trolleys never appear in the HSE statements as they have not been seen by a doctor. I refer to the case of one old lady who was there from morning to night, with no food and sitting in a wheelchair, and at 11 p.m. she still had not been seen by a doctor. That woman will never appear on a HSE bulletin because only people who have been seen by a doctor and are waiting for a bed will be counted on the trolley watch.

Those working in accident and emergency departments face considerable pressures. Speaking on "Prime Time" last month, Dr. John McInerney, emergency medicine consultant at the Mater hospital, said, "Over recent months there has been a regression to the same problem as last year". A new trend has emerged as a result of the concentration on shortening the time of accident and emergency patients on trolleys. The cancellation of elective procedures is escalating. The Taoiseach, when asked, refuses to countenance the word "cancellation", but for anybody being told to wait for cancer care or a heart operation there is no other description that matches their experience of finding that all the intensive care beds are full. At a time when St. James's Hospital did not have enough intensive care beds to meet its needs and major procedures were cancelled, intensive care beds in another Dublin hospital were lying idle. They had not been commissioned owing to a lack of staff and resources.

To which hospital is the Deputy referring?

I will tell the Minister afterwards. I am more cautious than the Minister when I make statements but I am quite happy to give that information to her.

Is it a public hospital?

Yes, it is a public hospital. I would have thought the Minister would have heard about it. However, I will be happy to give her the information.

With regard to the situation in Our Lady of Lourdes Hospital, we hear from the Minister that we have too many nurses but time and again facilities cannot be used because there is a shortage of nurses. This raises issues regarding the consultants' contract. While I want the contract renegotiated — it is a scandal that it has persisted for so long — I also want to ensure it does not become inoperable and the current nonsensical problem, whereby hospital consultants are unable to work due to shortages of staff, beds or operating theatres, is not prolonged. Regardless of what one thinks of hospital consultants, most of them work hard, like to work and feel frustrated when prevented from performing operations or procedures because the Government, despite the unprecedented level of resources at its disposal, has failed to provide the necessary infrastructure. Overlaying this scenario with additional consultants without first providing an infrastructure will create problems. The Minister must be honest about what she proposes.

While it is popular to take on the consultants, what does it mean in reality? Resolving problems in the health service requires much more explanation, thought, investment and reform. While it is easy to have a populist catch cry, it is difficult to rectify the problem. The Minister will have my party's support if she takes the correct approach but we will be quick to point out any flimflam should she engage in it on this issue.

It is worth reiterating the proposals outlined in the motion because they address a number of the core problems in the health service, not all of which occur at hospital level. The Labour Party recognises that a rebalancing towards primary care is critical because too many of those who end up in hospital do not need to be there. We must shift many patients towards accessing care at community and primary care levels. Serious reform of health service management is also required. We propose a major drive towards preventative medicine and children's health through the provision of medical cards to 40% of the population and free general practitioner cards for all children under five years of age. The development of an insurance-based system for those aged under 16 years is a first step towards a truly integrated service, to which both the Labour Party and Fine Gael Party are committed.

The Government side has produced a daft proposal to build private, for-profit hospitals on public lands. It tries to sell the notion that these facilities will result in the delivery of 1,000 additional public beds. The Government's approach will not deliver 1,000 beds because it is not a case of substituting like for like. In addition, the proposal does not enjoy broad support either on the medical side or at political level.

Interestingly, Professor Drumm implied criticism of the Minister's proposal when he expressed the fear that, having entered a hospital's grounds through the same gate, private and public patients will go their separate ways, with the former accessing a nice hospital with hanging baskets and the latter accessing an under-resourced and inadequate public hospital. Anyone examining the Minister's approach of developing for-profit hospitals at the expense of building public capacity would have major concerns. I sincerely hope the Minister, who has no mandate to go down this route, will fail in her endeavour and will not reach her target of signing a large number of contracts. Parties on this side are committed to ending this policy, which is bad for the health service, to ensure we secure best value for money and optimum patient care in future.

It is important to consider the content of the Government amendment. While amendments tabled by all Governments are self-congratulatory in tone, the amendment before us is dishonest. It states, for example, that there are more medical cards now than in 1997. Given that the proportion of the population with a medical card has declined from approximately 34% to roughly 29% since 1997, this statement is not true. The rules of the game require that the Official Record reflect the truth.

The GP-only medical card, of which 38,000 have been issued, is a joke.

The figure is 60,000.

On 17 January I received a reply from the Minister indicating that 38,000 GP-only cards had been delivered. She now claims the figure is 60,000.

I am pleased to note the figure has increased rapidly. The publicity campaign is working.

I ask the Minister to provide accurate information in her replies to parliamentary questions. In many cases, Deputies do not receive any information. I am perfectly justified in citing information included in a reply to a parliamentary question, dated 17 January, which indicated that 38,000 GP-only medical cards had been delivered.

The House was in recess on 17 January.

That is correct.

The Health Service Executive rather than the Minister replies to parliamentary questions.

The correct figure is 60,000.

Let us not quibble about a difference of a few thousand. The figure will undoubtedly continue to increase but I must depend on the latest information provided in reply to parliamentary questions. Even if the Minister's figure is correct, she gave a commitment that 200,000 GP-only medical cards would be issued.

The programme for Government does not include any such commitment.

In that case, the Minister's word is not her bond.

A different party made a commitment in its election manifesto. The Deputy should get the facts right.

I find it odd that a senior Cabinet Minister should continually interrupt during Private Members' business. She promised 200,000 GP-only medical cards.

I am sorry, I thought the Deputy was referring to medical cards.

I suggest the Minister thinks before she speaks and I will try to do likewise. We are approaching the end of the Government's term in office. Its failure to meet a commitment it made on GP-only medical cards is but one example from a litany of broken promises with which patients must cope daily.

I welcome the opportunity to speak on this vital motion on the health service. Once again, people living in the Cavan-Monaghan region are the victims of bed shortages in the main Dublin hospitals. In one case a patient has been waiting in Monaghan General Hospital since before Christmas to have urgent, life-saving heart surgery. If it were not for the high care unit in the hospital, which the Health Service Executive wants to close, I have no doubt the man in question would not be alive today. He was ready to travel yesterday morning but it transpired that a bed was not available. This morning he was given special medication to prepare him for the operation but, again, a bed was not available. Others are clearly being given priority.

It is unacceptable to right-thinking people that a state-of-the-art theatre in Monaghan General Hospital is lying idle when more than 40,000 elective operations have been cancelled in the past two and half years. Only this week, I received a six-page report detailing the trauma a man from County Monaghan experienced in a private hospital on the outskirts of Mullingar. Although its services are covered by the VHI and the Government's National Treatment Purchase Fund, it has not been inspected or subject to the same type of reports or inquiries as Monaghan General Hospital or other hospitals in the north east. The private hospital answered in writing the litany of complaints received without any denial, accepting that the complaints were justified. Surely, the first thing the Health Service Executive should do is fully to utilise the equipment, facilities and personnel it has in place in its own units before throwing away money to services that are unacceptable. I know the Minister got that six-page letter.

For the past ten years, it has been clearly accepted that we have a shortage of consultants, specialists and general practitioners. It is nothing short of a joke, however, to see the present Government and especially the Minister for Health and Children, becoming so active in an effort to solve, or be seen to solve, all these problems weeks before an election.

Patients who desperately need physiotherapy cannot obtain such services in the south Monaghan region because none is available in Drogheda. However, none of the physiotherapists who finished their final examinations last year got employment in the HSE.

People in the north-east will not forget that the Minister and her Fianna Fáil colleagues have failed to deliver the services they guaranteed five years ago. They knew in their hearts that they had no intention of getting involved. I was glad to hear the Minister is going to Wexford this week. We would be glad to see her coming up to Monaghan also. I know it is a long journey of 80 miles but it would be worthwhile.

Would I be welcome?

The Minister would have been welcome if she had come on time.

And the Ceann Comhairle.

Fine Gael played a major role in getting services brought back on stream at Monaghan General Hospital. Both our party leader and Deputy Twomey were up there two days in a row trying to do something about the situation. No doubt, they will provide the extra beds, extra medical cards, the 1,500 consultants needed and an additional 1,500 convalescent beds. In their short two and a half years in Government, Fine Gael and Labour left a proud record of achievement in the health services and the economy generally. I have no doubt that they will do the same again, if given the mandate.

We hear a great deal about primary care teams and home help packages, but when one seeks such services in the Cavan-Monaghan region one does not find them. All areas have a right to fair play and no services, including hospital services, should be withdrawn from a region until a workable alternative is available. That is not happening, however, and it is a disgrace.

I welcome the opportunity to speak on this motion, which has been proposed by my colleagues Deputies Twomey and McManus. I am disappointed by the Taoiseach's remarks earlier in response to questions posed by Deputy Kenny concerning the roll-out of the BreastCheck service and cervical screening. The Taoiseach deliberately tried to throw sand in our faces by attempting to give the House the impression that Deputy Kenny was mixing up the issues of diagnosis and treatment. It is clear that both BreastCheck and cervical screening are designed to see if there are difficulties and to make diagnoses. There is no disagreement on the fact that treatment is the next issue that comes into play. I do not believe these services will be rolled out by the end of this year, which is the new time-frame that has been announced. The slow pace of delivery on these services has been evident to women around the country. It is nothing short of disgraceful. I raised this matter in the House last week. Some 16 nurses in the midlands area have been trained for the past two years to carry out cervical screening. They are ready, willing and able to do it but they must get the HSE's consent to proceed. There is no good excuse as to why this has not happened.

Last year, 1,199 operations were cancelled in the Midlands Regional Hospital in Tullamore. The Minister for Health and Children's colleague in my constituency tried to say that if we have a problem with this we are just against the staff involved, but that is not the case. That this number of operations was cancelled in one year is symptomatic of the serious problems facing the entire health service. The hospital services only four counties so that indicates a huge number of cancelled operations for that region. It proves that we need urgent investment in step-down facilities and the establishment of urgent care centres to free up extra beds.

Hospitals should operate on a full-time basis. At weekends, one sees empty beds in hospitals and in my constituency I frequently hear of people being sent home on Friday evenings and asked to return on Monday mornings. That should not happen. I realise that extra capacity is required for emergencies but hospitals should not send sick people home at weekends, as is often the case. That matter needs to be addressed.

I wish to highlight the dangers faced by hospital staff in accident and emergency units. I have spoken to nursing staff and the Garda about an incident in Tullamore last week. Gardaí had to be called to put somebody into an ambulance and then had to follow the patient to the hospital's accident and emergency room where they spent much of the evening keeping a woman under control at great risk to others, including themselves. Had those gardaí not been available due to another crisis in the town, with the limited number of gardaí on duty, hospital staff would have suffered the consequences. We should examine others proposals and in this context I support my colleague's idea of wet rooms to ensure that safety for hospital staff and other patients is a priority.

I reiterate my opposition to the Minister's proposals to build private hospitals on public hospital sites. It is accepted that, by their very nature, private hospitals want to make money, so they will cherrypick the most profitable and least care-intensive procedures. They are there to make money. However, public hospitals' land is a diminishing resource, especially in our major towns, so it should be kept for public use.

I also question the facilities available in the community because they are putting pressure on our hospital system. For example, Edenderry with a population of 9,000 has only four GPs. Over one weekend last year, two of the GPs were sick and a third was on holidays so one GP was left to cover 9,000 people. There is still no out-of-hours patient service in the midlands, so the only alternative for such people is to attend an accident and emergency unit. The lack of an ambulance service in a town such as Edenderry causes its own difficulties. These matters have to be examined.

The Deputy's time has concluded.

On the issue of therapies, some of which were mentioned by Deputy Twomey, while some physiotherapists, speech and language therapists, occupational therapists and psychologists can gain employment, they are still not available locally, particularly for children who need such services. The waiting lists for the vast majority of those therapies are disgraceful, if people can get on them at all. Giving a child a few hours of speech and language therapy for a year is insufficient.

I move amendment No. 1:

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

welcomes the increase of 1,200 in the number of in-patient beds and day treatment places since the publication of the Health Strategy in 2001 and the plans to open new acute hospital units;

welcomes the unprecedented rate of expansion of acute hospital bed capacity since 1997;

notes the national review of acute hospital bed needs currently under way which will identify the number of acute hospital beds needed up to 2020;

notes the annual increase in acute hospital activity with the result that in excess of 1 million patients receive treatment in public hospitals each year;

supports management actions to improve the efficiency of use of acute hospital beds in order to shorten lengths of stay for patients and bring average length of stay closer to international norms;

regrets that some patients have their operations postponed when priority is necessarily given to emergency cases; recognises that postponement causes upset and inconvenience for patients and their families; and supports all management actions to free up hospital beds and keep postponement to a minimum;

notes the significant increase in intensive care and general bed capacity at St. James's Hospital;

supports the success of the National Treatment Purchase Fund in providing treatment for 55,000 patients, achieving major reductions in waiting times for public patients and providing a service that is directly responsive to patients;

supports the initiative to encourage private investment in new facilities on the campuses of public hospitals with the central purpose of freeing 1,000 beds currently reserved for private patients for use by public patients in a most cost effective way;

commends the Minister for:

the fact that there are now more medical cards in issue than in 1997;

the fact that substantially more people can now visit their GP free of charge than in 1997 due to the introduction of the GP visit card;

the substantial increases in the medical card and GP visit card assessment guidelines;

the considerable easing in the means test income assessment now based on disposable income after tax and certain living expenses;

the investment in the development of GP out of hours services and the recent commencement in GP out of hours service in north Dublin city; and

funding additional GP vocational training places;

commends the Government on the funding of €44 million provided to date for the establishment of primary care teams and networks and acknowledges the commitment in the Towards 2016 partnership agreement to the further expansion of the primary care system;

strongly commends the Government for the largest expansion in services for older people over the two recent budgets, with additional funding of €400 million provided, bringing in major expansions in home help packages, home help hours, palliative care and nursing home subventions;

commends the Government and the Health Service Executive for securing 1,000 new long-term care beds in 2006 and for the planned addition of 800 long-term beds this year, the majority in the public sector;

commends the Government on publishing and accepting the broad thrust of the recommendations from the Working Group on Undergraduate Medical Education and Training (Fottrell) and the Postgraduate Medical Education and Training Group (Buttimer);

acknowledges the measures taken by the Government to provide funding and support for the integrated implementation of the reforms in medical education and training across the health and education sectors from undergraduate through to specialist training;

supports the Government's proposals to increase the numbers of EU student places in medicine at undergraduate level; introduce a graduate entry stream into medical education; reform the entry mechanisms into medical education; strengthen governance and accountability, improve graduate retention and phase out non-consultant hospital doctor (NCHD) posts of limited training value;

acknowledges the significant increase of 66% in both the number of consultants and junior hospital doctors over the past ten years; and

supports the Minister in the conduct of negotiations with medical consultants on a new contract within a specific, urgent timeframe, to allow for the beginning of the recruitment of 1,500 new consultants on new contractual terms and a corresponding reduction in NCHD numbers.

I wish to share time with the Minister of State, Deputy Tim O'Malley.

Is that agreed? Agreed.

It would be a good idea if I were to respond to the Opposition's arguments, rather than delivering any prepared comments. It would be a more useful debate from every perspective. I do not think that anyone in the House is more motivated than anyone else concerning health care. Everybody here, on both sides of the House, is motivated by trying to have the best possible health care system for all our citizens. We may differ on some matters as to how that should be provided, but that is the motivation. Arguments about who may be more outraged do not serve any purpose. It is important to put some facts on the record and to confront some myths that are constantly being peddled. First, in relation to——

I wonder if we could have——

Please allow the Minister to continue. It is too early in her contribution for the Minister to give way.

I want to know if we are going to get a copy of the Minister's speech. It might be useful for us and I am sure we would learn from it.

I am not going to deliver a script.

So there is no script.

There is a script but I am not going to deliver it.

That is great.

I will respond to what was said.

I am asking if we can have the script anyway. It might be useful to us to have it.

I am not going to deliver a script. I want to respond to the arguments that have been made, rather than making prepared comments which may be out of context, given what was said.

We all acknowledge that, from the taxpayer's perspective, expenditure on health has increased four-fold in ten years. We also know that in 2006, more than 1 million patients were treated in our public hospitals, either on an inpatient or day-case basis. We know 2.5 million patients were seen in our outpatient departments, 1.3 million arrived at accident and emergency units and there were 65,000 births. By any standards, for a country with population of 4.3 million, that is a considerable output of activity, which was performed by the approximately 120,000 staff working in the health services, not including those working in primary care, community care or continuing care.

The purpose of the health reform agenda is to ensure that as we invest more money in new facilities and treatments, we also change the way we do business so we can have a better and speedier experience for patients. Many of the initiatives pursued by Government in the past ten years had this aim, in particular the establishment of the National Treatment Purchase Fund, which sought to use the facilities available in this jurisdiction or, in the case of some treatments, in other jurisdictions to treat those waiting longest on the public hospital waiting lists. I am happy to say almost 60,000 patients have been treated to date. Instead of people waiting two to five years for 17 of the top 20 procedures, they wait on average two to five months, which is a huge improvement.

That is not correct.

For the top 17 procedures, it is a fact.

I am speaking from my experience and it is not the case. There is no way any of my patients are being seen in two to five months for procedures.

Allow the Minister to speak without interruption.

It is the case.

That is false.

Sorry, Deputy——

It is not true. What goes on the record should be true.

There is no provision for interruptions.

People do not get on the waiting lists.

That is the data verified by the National Treatment Purchase Fund and it is fact.

There is great debate about hospital beds. Since the health strategy was introduced, 1,200 hospital beds, both day and inpatient beds, have been put into the public hospital system. On average, we have invested in 170 new beds per year whereas in the three years preceding 1997, there were 30 new beds per year. The debate is not about the number of beds; it is about ensuring we use whatever beds we have as effectively and efficiently as possible.

Patients in this country spend 50% more time in an acute hospital bed for the top 20 procedures than they do in Australia, for example. They spend between 3.5 and 5.5 days in an acute bed for an appendix operation whereas in many countries they would go home the day after such a procedure. For a hip replacement, the period in hospital is 11.5 days. There is no point in having the taxpayer constantly invest in more facilities if we do not also deal with the length of stay of patients in the acute hospital system. Central to the length of stay is the new consultant contract of employment.

That is wrong.

The Deputy will have an opportunity to reply.

I am talking about the average stay in Irish hospitals in 2005. Central to appropriate discharge policy is having a consultant in the hospital whenever one is required, and certainly to have 24-7 cover for the main specialties. The reality is that if this does not happen, daily ward rounds and daily discharges cannot happen. We all know that doctors who are not at consultant level tend to admit people more frequently and do not tend to make decisions on discharges except when the consultant is away on holidays or otherwise.

Above all else, with this new consultant contract we want to ensure consultants work on a 24-7 basis and as part of a team, not as single operators. We want to ensure a clinical director is in charge of that team because everybody will acknowledge that having administration and management interface with clinicians does not deliver positive outcomes as far as best practice is concerned. That is how the best hospitals in the world are organised — indeed, Ireland has some small examples of hospitals organised on the clinical directorate model. That is the essence of the contract of employment the Government wants for new consultants, hopefully with as many of the current consultants as possible working in our health care system.

With regard to the public private mix, the Deputies opposite talk about co-location as if we had no private activity in our public hospitals. Governments for many years, certainly since the 1970s, have ensured that when a hospital is built, 20% of the beds are private beds. In our major hospitals, the situation is as outlined by Deputy McManus, namely, there is a private wing or private wards and the beds in those wards are only available to private patients, insured patients. No matter what public patient case arrives, no matter how urgent, the patient cannot access those beds, and that is wrong.

That is not true.

I beg the Deputy's pardon. Private patients——

Emergency patients have access to private beds.

The Minister, without interruption.

The private beds are ring-fenced for private patients. There may be an occasional exception, but that is the reality.

It is not true.

Furthermore, if a private patient, insured patient arrives in a public hospital, no matter what bed that patient is in, the consultant gets a fee for that patient. I have described it previously as being akin to having an airline where the pilots got paid for all the business class passengers, even if they sat in the economy seats. It is ludicrous.

Who gave them that contract?

These are the factors that mitigate against public patients getting access to services in the public hospital system when they require them. It is not good enough and must end.

There are 2,500 private beds out of 13,500 beds in our public hospitals. I want to move 1,000 of those beds from the private system to the public system. I want to convert them into public beds so all patients can have access to them so the nurses, the administration, the management and all of the radiology and pathology facilities, which are paid for by the taxpayers, are available to all patients, not just some. I want to replace those beds by having a private facility built, invested in and managed by private individuals and companies. The land will not be given away, it will be either sold or leased.

Does the Minister foresee any problems?

Deputy Twomey suggests there will be clinical issues. Is he suggesting there are clinical issues at St. Vincent's hospital in Dublin, which is a co-location hospital, or at the Mater hospital? I do not believe that is the case.

The Minister is making a bigger issue. Significantly sicker patients are being moved out of a hospital. Serious clinical issues could arise.

I am simply converting private beds to public beds, a policy I would have thought would win fairly universal support in this country. It is not correct to suggest there is not much support. For example, the medical teams in eight of our biggest hospitals are involved in co-location projects throughout the country.

They make money from them.

There is huge interest in co-location because people see it as an effective way of achieving additional capacity. It is effective because we will get the beds for no more than 48% of the cost of providing them in the traditional way. That is a fact. They will be provided quicker and cheaper through this model than through any other. I do not believe a private facility within a public hospital should have nurses and all other facilities paid for by the taxpayers. No company would tolerate a situation where a core group of its workers were working within its operations for one of its competitors, using its computers, diagnostics and equipment.

The Minister gave them that contract. That is the problem.

The current contract was finalised in the mid-1990s and I was not around for it.

The Minister's partners in government were around.

Deputy McManus raised the issue of medical cards. For the Deputy to compare the number of medical cards in terms of a percentage of the population given the situation in 1997 does not stand up. In 1997 there was 11% unemployment and 6% long-term unemployment and take-home pay was 45% lower. There is no comparison.

People could afford to buy a house.

I understand the Labour Party used to have a policy to provide medical cards and universal insurance to the whole population.

That is not true. The Minister would want to get her facts right. We did not suggest medical cards for the entire population. The Minister does not even do her homework before she comes to the House.

The Deputy will have an opportunity to reply. We must have an orderly debate.

She hides her script so we cannot read it and then she tells us——

I am not using a script.

The Minister should get her facts right.

I want to answer the points made by the Deputy. Any target set must be for X% of the population, regardless of prosperity or income. These are not appropriate to target setting.

With regard to children under five, the Government has often been criticised by the Opposition for universal coverage for the over-70s on the basis that well-off people ——

No it has not; that is a lie.

Deputy Twomey said to me that well-off people were getting medical cards, but now he suggests that children under five, regardless of the circumstances of their parents, should be covered. What should happen when the child is six, seven or eight?

Get it from health insurance. In the lifetime of a Fine Gael-Labour Government, they would be much better off than the Minister thinks.

Allow the Minister, without interruption. The Minister should address her remarks through the Chair.

There are 900,000 young people under the age of 16, 400,000 of whom are covered by health insurance taken out by their parents, but Deputy Twomey now proposes that taxpayers should pay for that.

I am looking after the children.

Please allow the Minister continue.

Will those young people be able to access private hospitals or what hospitals and services will they be able to access? What will happen when they are 17? Will Deputy Twomey's proposal be compulsory and will the service be provided free to all of them? These are significant issues.

I must be honest about this. Twenty years ago, it was Progressive Democrats policy to ensure universal insurance for everybody. However, when analysed and studied, the proposal caused serious problems. First, it is a compulsory tax on some and second, the insurance companies decide what health facilities are kept open and what hospitals to do business with depending on whether they like their rates. In such a scenario, the insurers drive where the activity happens. In a system like ours, where we are committed to paying the salaries of those we have employed for the rest of their working lives and their pensions, there are serious issues with universal coverage.

That is an interesting issue I will take up with the Minister any time.

Deputy, please allow the Minister, without interruption. The Deputy will have an opportunity tomorrow evening.

Let the Deputy look at what insurers are doing all over the world with regard to closing hospitals.

We are talking about the system for which the Minister is responsible tonight.

I am dealing with that.

The people of Monaghan would enjoy listening to this.

On the issue of nurses, they make up the largest number in the health care system at 35% of the workforce. We have the highest ratio of nurses in the health system, not just registered nurses, with 15.5 per 1,000, the highest in the OECD. In the workforce there are 12.2 nurses per 1,000. In Canada that figure is seven, across the EU it is approximately 8.5 and in the UK it is eight. We have a lot of nurses in the health care system.

As I have said previously and not just with regard to nurses and other allied professions, we need different patterns of working and different skill mixes. We need people working as part of teams and longer days from some of the allied professionals because patients do not just get sick between the hours of 9 a.m. and 5 p.m. All of these issues must be addressed in the context of reform of work practices in the health care system. Otherwise the reform will not work.

When will the Minister address them?

We know the problems, we want answers.

Within the health system I meet well motivated individuals from different specialties and each one tells me we need so many beds for each specialty. If I added them all up, we would need to double the number of beds we have in the system. We cannot adopt a piecemeal approach. We must work on the basis that everybody works together to deliver the service and that the system responds to patients when needed. This is particularly the case at weekends, for example, with regard to care of the elderly.

The focus now is on trying to strengthen primary, community and continuing care, which gets 65% of the health budget, despite the fact that hospitals tend to form the biggest part of public debate. Primary, community and continuing care must remain the emphasis as we move forward. I am pleased that the new out-of-hours service on the northside of Dublin, which serves 500,000 people, has been successful. There has been a positive response to the service and it is incredible we did not have it until recently and that three doctors were expected to cover the on-call service for that population base. It is for that reason significant pressures were placed on hospitals on the northside of Dublin.

I accept there are gaps in the out-of-hours service — Deputy Enright mentioned Tullamore — but over 80% of the population is covered by an out-of-hours service. Generally, where the service operates, it works well and is responsive to the needs of patients. The service has experienced doctors, general practitioners, dealing with patients that require services after 5 p.m. and over the weekend.

I want to deal with the issue of the cancer report and radiotherapy strategy. On behalf of the Government I issued a policy directive to the HSE to provide this facility in a number of centres around the country and two satellite centres in Waterford and Limerick, and to do so on the basis of a public private partnership by 2011. The management of the HSE felt this was not deliverable, but the board of the HSE did not accept that and neither do I. When we see the facilities that sprang up over a two-year period in Whitfield in Waterford, I cannot accept that we cannot roll out radiotherapy facilities over the next four years. Last week, the board of the HSE confirmed the facilities will be provided in that kind of timeframe. We must all, myself included, think outside the box to find speedier responses to issues confronting patients in our health care system.

Patient safety must govern where services happen at hospital level. Up to recently, 35 hospitals in the country performed breast surgery. This number has been reduced and must be reduced further. International evidence, which has been backed up by what I have been told here, shows that where surgery is performed by a unit that does not carry out at least 100 similar surgical procedures a year the outcome is not good. Our outcomes across a number of cancers do not compare favourably with other European countries.

The one area where we perform extraordinarily well is that of children's cancer. When we moved children's cancer haematology from Tallaght Hospital to Crumlin Hospital and centralised it, the outcomes improved by 70%, which proves when we bring the expertise together and centralise the planning of the service for delivery on a more localised basis, we get better outcomes. We must have the courage to do the same in other areas throughout the country where international evidence and best practice dictate this should be the case.

I would like to deal with a number of issues raised in the motion before the House.

The development of primary care services is an essential component of the health service reform process. In a developed primary care system, 90% to 95% of people's day-to-day health and social care needs can be met in the primary care setting. The emphasis is on keeping people well and supporting them so they can live in the community rather than in institutional care.

The key objective is to give people direct access to integrated multidisciplinary teams of general practitioners, nurses, physiotherapists, occupational therapists, speech and language therapists, home helps and others. These teams will be able to provide people with integrated, comprehensive services to meet their health and social care needs in the communities where they live. This has been characterised as providing the right care, in the right place, at the right time.

Funding totalling €32 million has been provided in 2006 and 2007 for the establishment of 200 primary care teams involving 600 new frontline professionals. Approximately 450 general practitioners are currently involved in teams, with a further 700 projected to join teams in 2007.

In November 2004, as part of the health Estimate the Government set a number of priorities including the provision of an additional 30,000 medical cards and the introduction of a new benefit, the GP visit card which would be available for up to a further 200,000 people. The Government provided the HSE with an additional €60 million for these measures. Last month 1.221 million people held a medical card, almost 77,000 more people than two years ago. On 25 January, almost 58,000 people held GP visit cards. Since their introduction, an average of 4,000 people have received a GP visit card each month. Approximately 30% of the population now has free access to the services of a GP under the general medical services scheme.

The Minister for Health and Children introduced the GP visit card as an innovative measure to provide a graduated benefit so that people on moderate incomes, and especially parents with young children who do not qualify for a medical card, would not be deterred from visiting their GP on cost grounds.

Significant changes have been made to the way in which people's eligibility is assessed. Those measures now mean that income is assessed after income tax and PRSI. The income guidelines, including allowances made for children, were increased by a cumulative 29% in 2005. In addition, allowance is now made for reasonable expenses incurred in respect of mortgage or rent, child care and cost of travelling to work. In June 2006, the Minister agreed to a further adjustment in the assessment guidelines for GP visit cards. They are now 50% higher than those in respect of ordinary medical cards.

With the increased number of people in employment, the continuing bright economic situation nationally, and people on higher wages, a greater proportion of the population can access services using their own means.

In making policy changes, the Minister sought to address the needs of people on low and moderate incomes by ensuring that they were not deterred on cost grounds from accessing GP services.

Between 2000 and 2006, approximately €139 million was allocated to the HSE to develop out-of-hours GP co-operatives. Those figures do not include the fees of participating doctors. In 2007, the Government provided a further €3 million to meet the full-year cost of co-operative developments commenced in 2006. GP co-operative services are now available in all HSE areas, providing part or full coverage in all counties. In late November 2006, the north Dublin GP out-of-hours service commenced providing services to a population of approximately 500,000 people. As with other GP out-of-hours co-operative services, patients can contact the service using a lo-call telephone number to receive medical advice and, as required, be seen at a treatment centre or at home by a GP.

The Government accepts that we must ensure that sufficient general practitioners are trained to meet the future needs of the population. Agreement has been reached with the Irish College of General Practitioners, ICGP, and the HSE on an increase of 66 GP vocational trainee places, on a phased basis. To date the Government has funded 44 such places in line with that phasing.

I now come to the vexed topic of postponed operations. The public acute hospital system admits over 1 million patients overnight or as day cases annually. The number of operations postponed represents a small percentage of the overall activity of acute hospitals.

It was 40,000.

I stress that it is a very small percentage of the total.

It is a great many people.

It is regrettable that some patients have their operations postponed, and everyone recognises that it can cause upset and inconvenience to them and their families. The public hospital system endeavours to keep postponements to a minimum and to have postponed operations rescheduled as soon as possible. However, owing to the nature of the demands on the acute hospital system, in some instances it is necessary to reschedule planned treatment when priority must be given to emergency cases or for a variety of other reasons, such as infection control.

The issue of postponing elective admissions to hospital was highlighted last week in the case of St. James's Hospital. The HSE, having been made aware of recent pressure on ICU capacity at St. James's Hospital, has offered full support to hospital management to fast-track post-acute patients to other settings and free ICU beds. Discussions have also begun with hospital management with a view to increasing the number of high-dependency beds at St. James's Hospital.

The HSE has advised me that intensive care capacity at the hospital has increased over the past three years, with an additional five intensive care beds now available on top of the existing nine. It is also worth noting that overall bed numbers at St. James's Hospital have increased by 140 in recent years.

The Minister has already mentioned the increase in consultant numbers in 2006. Of the 125 additional consultants approved in 2006, the greatest number last year was in psychiatry, owing in part to the implementation of the Mental Health Act 2001. In 2006, as part of the growth in mental health services to improve capacity and fulfil the requirements of the Mental Health Act 2001, the HSE established an additional 18 multidisciplinary teams in adult psychiatry. In 2006, some 383 new posts were created in mental health. This year, the HSE will have 254 extra posts. An additional 1,800 posts are envisaged during the seven-year lifetime of A Vision for Change.

The Government is taking measures to ensure that Ireland produces enough suitably trained doctors to meet the needs of the Irish health service by implementing the reforms in medical education and training outlined in the Fottrell and Buttimer reports.

A co-ordinated approach to policy-making undertaken in the area across the education and health sectors includes stronger workforce planning. A legislative and structural framework will also be put in place to improve the governance and delivery of medical education and training. Associated initiatives include curriculum reform, doubling the number of medical places for Irish and EU students, the introduction of a new graduate entry system and implementation of graduate retention policies.

The Government is committed to investment and reform in the health services. We are confident that there are gains to be made from a radical restructuring of the system in efficiency, effectiveness and value for money. I will not understate the scale of the task before us. There are no quick fixes, and many challenges lie ahead. However, the system's potential will be realised only through a combination of continuing investment and reform.

I wish to share time with Deputies Naughten, McEntee and Deenihan.

There is no doubt that the Minister of State can talk the good talk with regard to health issues. If talking were all that was required, we would probably have the best service in the world, with more consultants, more beds, more doctors in training, and public-only contracts for doctors and consultants. Owing to that good talk, we all bought into this agenda, which we have now supported for ten years. The problem is that we never got anything promised regarding the health service, and that is why this motion has been tabled.

On the other hand, we are getting things not promised to us, which have emerged like rabbits pulled from a hat, for instance, the use of land adjacent to public hospitals for private hospitals. Where did that originate? Why, if the Minister for Health and Children is as serious as she says about doing away with public private contracts and moving to public-only ones, do we need private hospitals beside the public ones? A consultant's working life is roughly 15 to 20 years. By the time the hospitals have been built, all those consultants will have retired, and we will have only public consultants in them.

Surely the best use of that land would be for community beds, which do not exist in Dublin. That way, people in acute hospitals, when they are ready to leave, could receive relevant therapies, medical care, rehabilitation and opportunities to convalesce before returning home. That facility simply does not exist in Dublin, and it would certainly relieve pressure on the expensive acute beds from which the Minister is so anxious to move people, not to mention delivering better care to patients.

If private beds are taken out of public hospitals, as the Minister is promising, all she will achieve is a two-tier system. Perhaps this is what the Minister wants but it is not in anybody's interest to do this, be they private or public patients. Insurance costs for private patients will go through the roof, whether VHI, Vivas or anybody else provides it. Money will be taken from public hospitals and such action will ultimately result in lower standards in public hospitals. There will be one service for private patients and a lesser service for public patients. This is the only result from that type of two-tier system. I believe in and support private hospitals, but only when services are being provided to both public patients paid for by the State and private patients through health insurance. If we create a two-tier system we will live to regret it, and I ask the Minister to go back to the drawing board on that matter.

In the short time available, I want to raise another matter against the backdrop of the Minister's promise to provide additional beds within the system. There is a gross and widely-accepted shortage of beds throughout the system. I refer to the plan to close the paediatric beds in Tallaght Hospital and concentrate a tertiary service in the Mater Hospital. I support the development of a tertiary paediatric hospital but I do not support the removal of beds from Tallaght, where expertise and experience has been built up over many years. There is also a very large catchment area of children.

Last year, some 65,000 children passed through accident and emergency departments in Tallaght and Crumlin, which is also to close. The vast majority of these were not acute cases from around the country requiring tertiary services for very complex illnesses. They were children local to the Minister's constituency, from my constituency and the burgeoning adjoining constituencies in Kildare, Wicklow and in south and west Dublin. These children had normal childhood illnesses or injuries from accidents.

If the Mater plan goes ahead these children will have nowhere to go, despite the Minister's claims they will go to a quality hospital. There are issues surrounding access and it is hard to see anywhere more difficult to physically access than the Mater site. My problem is with the medical access. Where will these children end up? The Mater Hospital is smaller than the hospitals being closed, so there will be fewer beds. However, it will have to deal with the really complex medical cases from around the country.

Inevitably, a tertiary hospital must deal with the more acute and complex cases first, which is correct. This leaves local children competing at the bottom of the queue for beds and facilities. I ask the Minister to rethink the matter as it is folly against the background of a burgeoning population. In other cases we have seen hospitals closing because we do not have the population to sustain them or the critical mass, but it is certainly there in Dublin.

I thank Deputy Olivia Mitchell for sharing time. The health service changes by the day so, like the Minister, I will not be speaking from a script. I have been in this House for a year and a half in which we have had many debates on the health service. The Minister correctly stated there is no Deputy in the Dáil for whom the health issue is not the biggest one on the doorsteps or in the office.

In my time in the House, GPs and nurses have been blamed for the problems in the health services and cleaning staff have been blamed for the diseases within hospitals. Last week was the final straw when consultants were being blamed. Tonight the Minister has stated that patients are staying in hospitals too long, so it is now the patients' fault.

The issue was simpler 20 years ago when every area had its own hospital, and 95% of sickness could be dealt with therein. Complications have set in and now 95% of incidents cannot be dealt with in a local hospital like that in Navan now, from where a person would have to be transferred to Drogheda or Dublin and then go on a waiting list.

In my time in the House, I have heard how we spent billions on the health service but people feel they are worse off. Nobody in this House would disagree that people are worse off.

Hear, hear.

I do not know why the issue cannot be kept simple. Last week one of my constituents, married to a Lithuanian girl, had a serious sinus problem. He went to a consultant and was told he needed an operation. The procedure could not happen for three weeks because no bed was available, and the man would have to give up work. His wife booked a flight and brought her husband to Lithuania. He had an operation that evening, paid a fee of €30 and was given medicines worth €65. He was sent back to Ireland and was back to work within a week. He received treatment in a basic hospital with a top-class operating service.

I checked this again today as I thought I might have dreamed that an Irish citizen had to get on an aeroplane and fly to Lithuania, paying €30 for an operation before being able to go back to work. That is what is wrong with this country's health service. When I was growing up, the hospital in Navan was one of the finest hospitals in the country. I was a patient several times myself, sometimes through my own fault and sometimes when I could do nothing about it. One could access basic services and almost any operation could be performed.

I spent 17 hours in the same hospital two weeks ago with my own child and I eventually had to take her out of it at 8.30 a.m. because nobody could provide a diagnosis for her. Monaghan General Hospital has an operating table and there are hospitals in Cavan and Drogheda. It is like a refugee camp in Our Lady of Lourdes Hospital in Drogheda because it is the only bit of comfort we have.

This has nothing to do with consultants, most of whom are finished work at 2.30 p.m. because there are no operating tables or beds available. I blame nobody but this Government. Why did it not assess what was going on? It had the necessary money and people, and it knows how many extra people are entering the country on a daily basis. We now have a system where if a person is sick, he or she does not know where to turn. It will not be sorted out in two or three months.

Blaming others will not help and we must go back to the basics, where every Deputy will look after his own hospital, ensure the operating tables are opened again and that consultants — Irish or otherwise — are put in place. There is no point in putting in place 1,500 extra consultants and paying them over €30 million a year if they are finished work at 11 a.m. Under this Government's plan that will happen.

Every hospital and operating room in Ireland should be reopened. The issue should not be complicated as too much money is already being spent on consulting on what should not be done. I realise elections are approaching but it is not time for playing politics with people's lives. The Minister for Health and Children did so last week and I am glad that the proper answer will be given by the people in three months.

I welcome the opportunity to speak in this debate. Over the past ten years we have seen significant spending on our health service, yet last year the then Tánaiste and Minister for Health and Children, Deputy Harney, handed back €300 million to the Department of Finance because she could not spend the money. That money could have been used to provide additional home-help hours, operations, medical cards or orthodontic treatment.

The €300 million, on a per capita basis in my own constituency, would have had a serious impact on problems we have to deal with every day. It would have provided an extra 4,300 families with a medical card, an extra 400 inpatient elective surgeries in local hospitals and an extra 76,000 home-help hours could have been provided in every parish in the Longford-Roscommon or Sligo-Leitrim constituencies. Some 400 additional children could have been called for orthodontic treatment rather than being bullied in school because they have low self-esteem and cannot get access to treatment.

Last week the Taoiseach stated that operations were not being cancelled; they were being postponed. There were 8,300 operations cancelled in the past two and a half years in the west. It is a serious symptom of what is happening in the health service, where it is failing to deliver for patients. We need significant investment in step-down facilities and urgent care centres which would provide extra beds and take pressure off accident and emergency services.

On emergency services, a decision was taken in the dying days of the last millennium to locate a ambulance base in west Roscommon, the single biggest blackspot in ambulance services in the west. For some reason that base was moved from west Roscommon to Knock, County Mayo. Tenders are being sought for that ambulance base. I plead with the Minister at this late stage to postpone that decision and re-evaluate the location of that ambulance base. When I questioned the Minister in the House on a number of occasions about the timetable for the delivery of the ambulance base to west Roscommon, she always responded on the development of the service in west Roscommon, not east Mayo, but for political reasons it was diverted to Knock, County Mayo which happens to be the home town of one of the Members on the far side of the House. That is disgraceful. Last summer when the Government spoke of taking the surgery services out of the county hospital in Roscommon, the Health Service Executive stated it would evaluate relocating that proposed ambulance base to west Roscommon. When it suited them they could move it to west Roscommon and when it did not they could move it to Knock.

There has been a stay of execution in the closure of the surgery services in the county hospital in Roscommon. The Health Service Executive is still not prepared to give clarity on where the surgeons will be based in the new reconfigured hospital service between Roscommon hospital and Portiuncula Hospital in Ballinasloe. If the surgeons are based in Portiuncula Hospital, that is where the surgery will take place and, in effect, the surgery services will be closed in Roscommon. It will be the same as what happened in Monaghan Hospital. That is what is being planned. The decision is being postponed until after the general election. If the services are based in Ballinasloe, that is where the surgery will be carried out and that involves the effective closure of the county hospital in Roscommon. The threat looming over the people of Roscommon is that if they do not agree to this, the HSE will not appoint the third consultant physician on a permanent basis. We are seeing smoke and mirrors used on this issue. There is a lack of clarity from the Government, which wants to postpone its inevitable plan under the Hanly report to close small effective hospitals like the county hospital in Roscommon.

The hospice service is also affected. There has been a state-of-the-art hospice bed in Boyle in County Roscommon for the past number of years. The nurses have been appointed to run that service, and yet that bed has not been in use due to industrial relations difficulties. Anyone who saw the television programme about St. Francis's Hospice in Raheny during the week would understand the importance of providing such a base in the community of north Roscommon, and yet due to industrial relations problems that bed still remains closed.

The Government will be leaving office in a few months having presided over the greatest chaos in the health service since the foundation of the State. When people look back on the legacy of the Government, it will stand indicted for not providing the people with a decent health service, spanning both the public and private sectors.

What is happening at Tralee General Hospital, or Kerry General Hospital as it is now called, is a microcosm of the rest of the country and I will refer to it briefly. Kerry General Hospital is seriously understaffed by comparison with hospitals of its size in the rest of the country. It is now regarded as a band 1 hospital and it is really staffed and equipped to meet the needs of people 25 years ago. The population of Kerry is growing, people are getting older, there are more cases of cancer and more bones broken, and there are less services available for those people.

Kerry General Hospital depends considerably on student nurses. As a result the regular staff are suffering from stress and losing time through sickness etc., and they are very fed up at this point.

I am informed that in the ongoing review the nursing staffing levels of Tralee hospital will be found to be down by between 60 and 80 nurses. That is a really serious indictment. It is affecting the service that the hospital and the nurses themselves would like to provide the population of Kerry.

The accident and emergency department in Tralee hospital was built to provide for a throughput of approximately 15,000 patients and currently the throughput is approximately 31,000. It has a temporary locum consultant. He will be leaving at the end of March and there will be no consultant left. There is no registrar in the accident and emergency department in Tralee hospital. There are five senior house doctors who are trainees. The locum is there for only 33 hours a week. There is no one present to guide these young trainees, who are making serious decisions. If there is not a consultant upstairs, they have no one with whom to consult. As a result, I understand that one of the senior house doctors has written to the Health Service Executive outlining his concern for his position in case anything should go wrong.

Tullamore Hospital, which is the same size as Kerry General Hospital, has an accident and emergency consultant, who left Kerry to take up that post, and six registrars. In Kerry General Hospital, there are five senior house doctors. That speaks for itself. The service can not be given in Kerry as it is given in other parts of the country. In any case there should be two consultants in Kerry General Hospital. I understand an accident and emergency department was opened recently in Cashel, where two consultants were appointed.

I refer to the cleaning staff issue in the accident and emergency department at Kerry General Hospital. Currently the department has a temporary cleaner who works three hours a day. She is shared with other departments in the hospital. With the MRSA bug, it is not acceptable that the accident and emergency department has a cleaner for just three hours a day. If there is a spillage or somebody gets sick overnight, they call on staff from the rest of the hospital and the nurses themselves do the cleaning. Morale is low at present.

Debate adjourned.