Dáil Éireann díospóireacht -
Tuesday, 18 Dec 2007

Vol. 644 No. 3

Health (Miscellaneous Provisions) Bill 2007: Committee and Remaining Stages.

SECTION 1.

Deputy Jan O’Sullivan

I move amendment No. 1:

In page 3, between lines 16 and 17, to insert the following subsections:

"(2) This Act, other than the provisions referred to in subsection (3), shall come into operation on its passing.

(3) Schedule 1, insofar as it inserts Article 4A in the St. James's Hospital Board (Establishment) Order 1971 and in the Beaumont Hospital Board (Establishment) Order 1977, shall come into operation on such date as may be specified by Order made by the Minister, provided that a draft of such Order is approved by both Houses of the Oireachtas by resolution.".

This amendment is to separate the main provisions of the Bill from those in the Schedule that relate specifically to co-location in St. James's and Beaumont hospitals. It allows the passage of most of the Bill's provisions but stipulates that the ministerial order on co-location must be discussed by both Houses of the Oireachtas. This will ensure that the Oireachtas will have the opportunity to debate and vote on the provisions on co-location.

Deputy Caoimhghín Ó Caoláin

I support Deputy Jan O'Sullivan, whose amendment is at the kernel of the Opposition's position on the Bill. We have indicated almost unanimously that we would accept the substantive body of the legislation for the reasons argued and on the basis of trust in respect of the advices received by the Minister, but we regard the section that seeks to facilitate the Minister's pet project, the further privatisation of our health service, as offensive. The first amendment seeks to delete the relevant references at the outset. This is the only sensible way to proceed.

There is no immediate and urgent reason to rush through the Bill by guillotine this evening at 10.30 p.m. It is incumbent on the Minister, if she really believes the rest of the legislation is as important and urgent as she suggests, to accept the amendment in this instance and allow the House to continue to address the remaining amendments on the substantive body of the Bill, as drafted.

I reiterate my objection in principle to the very notion of facilitating private, for-profit health facilities and acute hospital facilities on public land with public moneys. This is not a defensible notion and all public moneys should be vested wholly and solely in the public hospital and health delivery systems. If we are ever to confine the highly offensive two-tier system to the history books, we must grapple with the support of this and successive Governments for having a private, for-profit health care system piggybacking on the public health care system. Given the apartheid that operates between those who can afford access to health care and jump queues at will and those who are dependent on the public system and must suffer in lengthy queues even before being placed on waiting lists to see particular consultants, it is imperative that we oppose strongly the Minister's intent and the co-location scheme which, as I said, deepens the social divide and almost enshrines in our health care legislation the two-tier approach to the delivery of health care.

One should remember that we have never had a debate on the proposed co-location project of the Minister and her Government colleagues. There has never been legislation in this regard before the House for consideration yet, within a very short period, we have had foisted on us an underhand measure to facilitate co-location at two of the important hospitals in this city, St. James's Hospital and Beaumont Hospital. This is not acceptable under any circumstances. On behalf of the Sinn Féin Deputies, I fully support the Labour Party amendment, moved by Deputy Jan O'Sullivan. In the hope of a positive response from the Government benches, I appeal again for the abandonment of the project in question and ask that the Minister accept the amendment, as presented, and allow the rest of the Bill to be considered during the remainder of Committee Stage and Report Stage.

Deputy Pádraic McCormack

I am very much in favour of the amendment. The debate on co-location should take place in the House. If there is no consultation and debate, how can one arrive at a conclusion? I was very glad to put a question down last week that finally established that co-location is not proceeding at University College Hospital, Galway, not because the Minister did not want to proceed with it, but simply because nobody in the public sector would take on the co-location project there.

The location of some of these projects was crazy. One could not park a bicycle at University College Hospital, Galway at the moment. People come from all over the western region and they must queue up along the road to get in there. Therefore, if these problems were debated in the House, people with local knowledge of the situation in the various areas would be able to tease it out in this House. The amendment is sensible because it states that all of those matters should be discussed in the Dáil before they begin.

Deputy Alan Shatter

My objection to co-location is that we are finally copper-fastening and institutionalising, by legislative sanction, a two-tier health service. The Minister is likely to respond by telling us that we have private beds within our public hospitals. That has been part of the tradition of this country for many years. However, we are now going to have a private hospital and a public hospital on one site, with the State making tax concessions to those who build the private hospitals. The centres of excellence will be in the private hospitals, which will have the most modern and the best facilities available.

We should be striving for an excellent public health service. The Minister should be striving to persuade people that the public health service is so good it has the capacity truly to meet its health need in a manner that does not require the general population to take out health insurance. As the numbers within the community taking out health insurance increases, the credibility of the public hospital service decreases. People take out private health insurance because they lack confidence that they will get access to essential medical care when it is needed. They lack confidence that our public hospitals will have the most modern equipment available when required. They lack confidence that they will be given the same time and consideration on occasion by health professionals within the public system that they get within the private system.

We have fantastic doctors and nurses working throughout our health service, both in the public and private sector. Within the public sector, they are under pressure. The bureaucracy involved in recruiting additional consultants across a broad range of areas is astonishing. This is not the debate to go through all the deficiencies in our health system, but we can see the number of neurologists in this country per head of population compared to other countries. The people of Beaumont Hospital are crying out for additional neurologists to meet basic needs. There are people on waiting lists to see consultants across a broad spectrum of areas, but the Minister's focus and her primary health care philosophy is to get on with the construction on public hospital sites of private hospital facilities. I think that priority is wrong and there is no indication that when this policy is implemented, we will be any better off.

We are told that up to 1,000 public hospital beds made available by the provision of private hospitals in this way, and the Minister has asked how else can she free up beds. The dysfunctional nature of the health service is creating the log-jam within the bed structure of our hospitals. There has been a debate on whether we require more acute hospital beds. I believe we do and that there are strong reasons for additional bed facilities. We need more within our public hospitals' private bed facilities, not for private patients, but to tackle the problems we have with hospital diseases, such as MRSA. We do not have the isolation facilities within our public hospitals necessary to protect the health of those who require hospital care. My mother-in-law died in Tallaght Hospital of a serious illness which was compounded by contracting MRSA within a week of entering that hospital. How many other families have had the same experience? Patients are put in wards with other patients who have MRSA. We are not doing what is done in Scandinavia, which is to isolate patients with MRSA, because we do not have within our public hospitals the single bed facilities in private rooms to do that.

If the Minister wants to free up beds in public hospitals, rather than introducing co-location which is being copper-fastened by this Bill, she should be providing additional step-down and nursing home facilities. My colleague Deputy Mitchell recently highlighted the insanity of the HSE in keeping an elderly woman in a hospital bed for many months because it would have to spend €80 per week in providing her with nursing home care, even though the ultimate net expense of keeping her in hospital was far greater. This Minister should not be focusing on co-location to free up public hospital beds, but on the provision of step-down and nursing home facilities, so that many people currently occupying acute hospital beds could get the care they require that falls short of needing acute hospital care.

I appreciate that I was not in this House between 2002 and June 2007 when the co-location policy was adopted. However, I have listened to other Deputies saying it was never discussed or debated at any great length. It has been developed outside the House and this Bill is one of the few pieces of legislation relevant to the issue on which Members have any opportunity to debate it. It is entirely wrong that we deal with this issue as an adjunct to a Bill that we are told is necessary to copper-fasten the legal foundations of the variety of bodies detailed in the schedule which have been in place for many years. The co-location issue should not be part of this, but I suspect it is the co-location issue that has made it urgent. I suspect the Attorney General's report, which we are not allowed to see and which is being kept secret, detailed difficulties in entering into co-location contracts if this Bill was not passed.

I recall many years ago the formation of the Progressive Democrats and the sense of excitement they created about a new type of politics. They stood for more transparency in politics and more democracy in a Dáil that could truly operate its legislative function committed to Governments that would be truly accountable to it. Yet this evening the Minister insists on dragooning through a Bill based on the secret advice of the Attorney General that will not be revealed, and on which we are supposed simply to rely and trust. She is doing this in the same circumstances in which the Government, based on previous advice, was responsible for the Medical Practitioners Bill 2007, which was absolutely riddled with legal deficiencies and anomalies. Why should we accept on faith that the Minister's advice requires that we deal with this urgently? What on earth happened to the remnants of the Progressive Democrats that they regard it acceptable in a parliamentary democracy to keep secret legal advice that does not place the security of the State in jeopardy on which they claim emergency legislation is based and which forms the rationale for that legislation? That is a complete and utter disgrace and a total betrayal of any remaining principles to which that party was ever committed.

Deputy James Reilly

I will start by taking up where Deputy Shatter finished. The Minister did me the courtesy of sending me the letter from the Attorney General. He said the advice was privileged and should not be released. He did not say that it could not or cannot be released. It is at the discretion of the Government and it could have been released under certain restrictions to me and other members of the Opposition, but the Minister chose not to do so. This leads us to believe that there is little reference in the advice to co-location. From my conversation with the Minister at the briefing last week, the substantive advice was that this was to underpin the vires of 19 bodies; it had nothing to do with co-location, the Medical Practitioners Act or the HSE, per se.

How many co-located hospitals will not be for-profit? The Government failed to deliver 3,000 beds over a six-year period, as promised. However, the Minister wants us to believe that the public private partnership, the co-location plan, will deliver 1,000 beds and is the quickest, most effective and efficient way of doing so. What is the basis of that premise? Having listened to Deputy Shatter, and from what I and the Minister know, there is gross underuse and misuse of beds in the system because of inappropriate placement.

This policy tries to dislocate those who pay for the services with their taxes, the better off in society, from those who use it most, the elderly, many of whom do not have great income, and the chronically ill who, by dint of their illness, do not have great income. This will accelerate the demise of the public hospital service as the divide gets greater and greater and the funds are funnelled in. One of the reasons we have uproar about the accident and emergency crisis, which remains a crisis, is that every citizen must go through the doors of accident and emergency units. When the day comes that those who can afford it can go to the finery up the road, while Joe Bloggs, Johnny Murphy and Theresa Smith must use the public system, the divide will get greater and greater. We will end with the system of our American cousins' system, the most iniquitous. They spend 16% of GNP as opposed to our 8.5% on health care, yet 18,000 people die each year because of an inability to pay for health care. That is not a system we want, nor one that 56% of the population voted for in the general election. The Green Party must look at itself when it votes on this tonight. I wonder how the party can marry its words before the election with its actions tonight, when it vehemently opposed co-location.

Acting Chairman

I am loath to interrupt but I have let this run on.

Deputy James Reilly

Do I have a minute left or cúpla nóiméad?

Acting Chairman

I am trying to be helpful and I do not wish to curtail Deputy Reilly's contribution. The issue of co-location in its substantive form will arise under section 7. We might be better off discussing it then.

Deputy James Reilly

This section refers to the boards. Should I discuss that?

Acting Chairman

Please do.

Deputy James Reilly

Co-location is part of the boards issue. One of the major problems I have is that the Minister is responsible for these boards and I wish to remove her from that responsibility. It occurs in the documentation and I have made my objection to that clear. It is not my intention to speak to every section.

Acting Chairman

I am not stopping Deputy Reilly from speaking. I want to make that clear.

Deputy James Reilly

The Minister seeks to enshrine in law what has been the approach de facto, namely, disengaging and devolving responsibility from her to others who have not been found to be up to the mark, such as the HSE. There are now nine reviews. The Taoiseach, on 6 November, and the Minister, on 7 November, promised the report of Dr. Ann O’Doherty by the end of November. Tomorrow is the end of the Dáil session and there is no sign of it. The HIQA report was promised for 18 November and there is no sign of it. Is the Minister becoming the Minister for reviews in the same way as her predecessor became the Minister for committees and task forces, with 117 reports under his belt but no action taken after four years in the job? The Minister is three years in the job and there is an unhappy resemblance forming.

The major problem with beds is the lack of proper use, such as the unit lying idle in Mullingar or the 57,000 bed days lost between Beaumont Hospital and the Mater hospital last year. That is the equivalent of five 30-bed wards closed for an entire year because there are no facilities available in the community or for rehabilitation. It may cost €1,300 to keep a person in a bed in a public hospital such as Beaumont Hospital but when treatment is finished it would be much cheaper to keep the person in a nursing home at €1,000. Equally, there is a perverse incentive in that it could cost up to €7,000 per day if a person is being intensively investigated while acutely ill. That must be addressed.

The ambulance service cannot get people into hospitals because the ambulances are queued up outside and trolleys are locked in the accident and emergency unit. What about our primary health care plan and our rehabilitation and nursing home places? These are areas where we could free up beds quickly but we need staff and funding to do so. The Minister and particularly Professor Drumm have said they wish to see primary care developed, an idea to which I fully subscribe. As with the cancer strategy, the Hanly report and bringing people from psychiatric hospitals and long-term institutions into the community, the harsh reality is that the service must be maintained for those who need it now while we develop new services. It is not either-or, it is both. People are sick and in pain now and need treatment now, not three years hence.

I have no faith in the co-location plan. The devil will be in the detail. We have been through all this, being told that certain things would not happen, such as cutbacks not hurting patients. If the Minister wanted co-operation from this side of the House on the substantive issue of this Bill, she would have stuck to the substantial issue, namely, to underpin the vires of those 19 bodies and institutions on which the Attorney General advised the Minister.

Minister for Health and Children (Deputy Mary Harney)

The purpose of this Bill is to put beyond legal doubt the 19 bodies and the statutory bodies drafted and enacted by various Ministers to establish those bodies. Once legislation is passed we cannot amend those statutory instruments. The Minister's approval is required for Beaumont Hospital to lease land. Beaumont Hospital and St. James's Hospital are in a different position from the hospitals where the land is owned by the HSE. They do not have to undergo the same position as these two hospitals. Deputy Shatter acknowledged that there was no court decision to establish that these bodies are not legal. Once the doubt is raised by someone as powerful as the Attorney General and reinforced by independent advice, there is an obligation on me as Minister to take the advice. We want to proceed with the co-location proposals for Beaumont and St. James's. The boards of these hospitals are anxious to do so. Before the co-location policy was ever initiated, both of these institutions were developing plans for private hospitals on their grounds. Co-location is not being foisted on any hospital. Hospitals were free to either come forward with a proposal or not. As regards Galway, the reason it did not proceed is because there are an enormous number of private beds in the city, as Deputy McCormack knows, with the Bons Secours, Galway Clinic etc. There are a good many private beds in Galway.

Deputy Pádraic McCormack

That is not the answer the Minister gave me last week.

Deputy Mary Harney

That is a fact. There are a good many private beds in Galway and——

Deputy Pádraic McCormack

No contractor would take on the job.

Deputy Mary Harney

——there are proposals from doctors there to build an independent cancer centre on the grounds of Galway hospital. Many Deputies, however, are talking about public hospitals as if they were only accessible on the basis of medical need. The reality is that at the moment 20% of the beds, 100% funded by taxpayers, are only available to insured patients. I believe that is unfair.

Deputy Caoimhghín Ó Caoláin

Absolutely.

Deputy Mary Harney

I want a one for all system where the public facilities are accessed on the basis of medical need. These beds, in current terms raise for the hospitals €74 million from the insurers, and cost the hospitals €300 million——

Deputy Caoimhghín Ó Caoláin

A universal public system is the way to deal with it, to the highest standard.

Deputy Mary Harney

——in terms of staffing. It is a very bad deal for the public hospitals that these beds are subsidised to the tune of €226 million a year — to run and staff them — and that they are only available to some people. I do not believe that is fair or just. I want to make all the beds in public hospitals accessible on the basis of medical need, a one for all system. That has been at the heart of our negotiations with consultants. Deputy Reilly is a general practitioner and general practice works very well on the basis of one for all. If one goes to a doctor's surgery one can either be a medical card or a fee-paying patient, and I am sure most people there will not know who is what, and that is as it should be. That is the way hospital services should be accessed too. One should access the service on the basis of medical need.

Deputy James Reilly

The GP does not have a private co-located surgery beside his or her public surgery in order to achieve that.

Deputy Mary Harney

The GP is a private provider. Dr. Reilly and I have had discussions on this in his former role. He was a fan of tax breaks to develop primary care——

Deputy James Reilly

That is correct.

Deputy Mary Harney

——because it makes sense. Unfortunately, there was an EU dimension and we could not proceed with this, but the reality is that these initiatives which will create 1,000 public beds for all the patients of this country will be made available at less than half the capital cost of doing it the traditional way. Furthermore, we shall be staffing them for €74 million, instead of the €300 million it costs at the moment, because the staff are there.

Deputy Pádraic McCormack

The Minister will be giving away land to the private sector.

Deputy Mary Harney

No, we are leasing the land and we will get a return for the hospital from this. We shall also get a share of the profit. Some seek to justify income and others talk about profit. I was not aware that Fine Gael had a problem with profit. Earlier, Deputy Olivia Mitchell was complaining about co-location because she said we should keep the private beds in public hospitals, as she thought this was good for the ethos of hospitals, efficiency and so on. There seems to be some confusion there.

Deputy James Reilly

There is no confusion.

Deputy Mary Harney

I cannot understand a strategy that is in favour of private hospitals five miles away, but not if they are five minutes away.

I want to come to the Attorney General's advice. If the Attorney General tells me I should not release his advice, I have to accept that. I am obliged to take his advice under the Constitution. I should be a very irresponsible Minister if I did not take the advice of the Law Officer of this State. If the Law Officer of this State tells me we need primary legislation to put matters beyond legal doubt, that is what we should do.

Deputy Pádraic McCormack

Why did we not have it long ago?

Deputy Mary Harney

If the Law Officer of the State tells me not to release the advice, that is what we should do as well. He confirmed what he said to me on the telephone on Thursday afternoon, in writing, and I have made that letter available, although, no doubt my motives will be suspect. Legal advisers to both Beaumont and St. James's Hospitals did not believe there was an issue. We felt we could allow the lease to go ahead on the basis of amending the statutory instrument. We now know, as a result of 26 October, that it is not possible to give any more powers to bodies where a legal doubt exists. Therefore we are putting the legal doubt beyond doubt and using the opportunity in this legislation to amend a transitional loophole that emerged with the Medical Practitioners Act, to ensure there is no question but that these hospitals can lease their land. As regards the issue of disposal, as raised by Deputy Jan O'Sullivan, I am advised that is the legal term applied, whether it is a disposal in the form of sale or an actual lease. This is the legal terminology that is appropriate as regards this matter, and I can give her a note to that effect.

Deputy Jan O’Sullivan

Does this mean they will be able to sell the land, if they want to?

Deputy Mary Harney

No, they will be leasing the land.

Deputy Michael Woods

I want to support the Minister as regards what she has said. I have the privilege of coming from the north side and this is my local hospital. We must remove any doubt about the position now, as the Minister has suggested. We must proceed right away with the plans for Beaumont. There should not be any further delay. Already there has been 25 years of delay on this issue in Beaumont Hospital. In 1982, I was Minister for Health, when Jervis Street and the Richmond, St. Laurence's, combined to go into Beaumont Hospital. It was a very big change and a major development. At that time a site was made available on the hospital grounds for a new private hospital so that consultants could be located in and beside Beaumont all the time. This meant people would not have to cross the river and go out the other side to the Blackrock Clinic to get a consultant. All that was ready, the hospital was built, heated, equipped and ready to go. Then, this very argument was raised. The Government changed and in came Fine Gael and Labour who tore up the agreement that was there. The outcome of that was we now have 108 beds in the public hospital reserved for the private work of consultants.

That was the outcome of the delay at that time. There is always a danger in delay. The result was that the hospital actually sat idle for over four years. It was one of the greatest scandals ever in the history of the State and nobody every talks about that. A brand new hospital was left idle for over four years. The people on the north side of Dublin suffered and continue to suffer because of that, not those from Galway or people from the south side or anywhere else. Again and again we hear from the Opposition that there should be more beds, and that we do not have enough of them. It is very hypocritical and I find it hard to keep my patience when I hear people from Fine Gael and Labour saying things such as that about Beaumont Hospital. I do not know where they are living or what they are thinking of, because Beaumont Hospital already has purchased St. Joseph's Hospital in Raheny where it is building a massive community development. We do not have to wait for this in the future. It is happening now and it will be a major focal point attached to Beaumont Hospital.

Deputy James Reilly

Why were so many beds lost last year in Beaumont, if it is all so wonderful and working so well?

Deputy Michael Woods

I did not interrupt the Deputy. I do not intend to take much of his time, but this is my hospital and I have a great interest in it. I deeply regret what Fine Gael and Labour did to it the last time. It was a terrible scandal and that still exists in front of us today. We have seen that 20% of the beds in the hospital are now taken up with private beds. I should welcome very much the 180 beds that would come with this hospital in Beaumont; as far as I am concerned, they cannot come fast enough. That is what the Minister is trying to do. I know that situation, it is enormously important and I am totally opposed to any suggestion of delay. That is all there was in the amendment put on Second Stage. It declined to give a Second Reading to the Bill on the grounds that it bundles together urgent and uncontroversial matters with those the Opposition alleges are in no way urgent. This is politics. It is development for people and has been urgent for a long time. I am glad we are discussing it again. It was all set to go in 1982 but was stopped and the site was taken back. Fortunately, after 1987 when Fianna Fáil was back in government, it was proposed that consultants should have private clinics on the grounds in order that they could be near to the hospital in between times. This was also opposed. However, they are there now. Let us have the private hospital there also. It was due a long time ago. Let us not delay it any longer, or play around and let on there is another reason for it not being located there. There is a hardcore reason people are preventing it from being on the north side of Dublin. For approximately 25 years prior to Beaumont Hospital being built there was resistance to it being developed on the north side of Dublin. Eventually we broke this down and it was developed.

The theory of having wonderful hospitals for everybody which meet the highest possible standards is grand and we would all like to see it happen. However, the practice was not grand for people on the north side of Dublin, as can be seen. We must face the reality that almost half the population have health insurance and the reason is people want to have it. They contribute to it during their lifetime and want the service to be available. They are entitled to have provision made for this and to have it on a State-owned campus. There is no reason they should not have it.

I fully support the Minister and congratulate her on pressing ahead with the Bill.

Deputy Jan O’Sullivan

I had hoped the Minister would indicate whether she would accept this modest amendment. The more substantial amendments on co-location are amendments Nos. 4 to 7, inclusive. All this amendment does is ask for a Dáil debate on an order to provide for co-location at the two hospitals concerned. I would prefer if we had time to discuss the substantial amendments.

Deputy Caoimhghín Ó Caoláin

Once again, the Minister made reference to the advice of the Attorney General in her response to the contributions of Deputies who spoke in support of the amendment. She indicated outside independent advice had been received by the Attorney General. Is she willing to advise the House how this advice was triggered? Was it sought by her or the Attorney General? Was it advice presented independent of any lobby from within this institution? Will the Minister identify the advice? Will she indicate the basis on which advice received by the Attorney General is grounded?

Is the Minister serious when she states she wants to bring to an end the 20% private bed provision in the public hospital system by providing co-located private hospital facilities? Does she propose to provide these co-located facilities at every hospital and facility? Let us be sensible about this. We have a serious problem with which to grapple and the only point made by the Minister with which I can agree is that she wants to bring to an end the provision of a ring-fenced 20% of beds in public hospitals for private fee-paying patients. The problem arises with what she does after this. My belief is firmly in a public system of the highest standard in which every citizen will have confidence and will want to utilise as the need presents.

I have no objection to the development of private facilities. If people want to provide them and use them, let them do so. Where I draw the line is at the use of public moneys for the provision of private health care. Public moneys should be wholly and solely invested in what should be a state-of-the-art public health care delivery system which includes acute hospital facilities and services. Private facilities can be developed in an adjacent field but not in the field belonging to the health service. Such a facility could be needed for further expansion and the development of services by the public facility.

Questions must be answered. The Minister is not being up-front with Members about the advice received. She withheld the advice she could have shared with Members. With all respect, the letter from the Attorney General is but a fig-leaf. My earlier question applies equally at this point. Who triggered this line of inquiry with regard to Beaumont and St. James's Hospitals? Were they interested parties examining the opportunity to turn a buck from people's health care needs?

Deputy Alan Shatter

I will not speak again at great length. I do not accept what the Minister stated about the Attorney General's advice. I accept the Attorney General would have told the Government that advice given was privileged. It is privileged in that the Government is the Attorney General's client. However, it is open to the Government to decide to make this advice available. No law states one cannot do so. It is a political decision for the Government to make.

I had to restrain myself listening to Deputy Woods. I have known him for many years and he is a decent man. Many years ago when I first entered the House, I made life difficult for him when he was Minister with responsibility for health in the early 1980s. I have a great deal of time and respect for him. However, when he stated Beaumont Hospital had been discriminated against, that it was about time it received extra beds and described the problems of the hospital, I had to pinch myself to remind myself that Fianna Fáil had been in government for almost 18 of the past 20 years.

Deputy Woods is fortunate to have had the privilege to serve as a Minister for the largest portion of time during these 20 years. He was at the forefront of the decision-making processes in Cabinet. He was part of the Cabinet which cut the number of beds in the health service in 1987 and laid the foundations for some of the health crises we have witnessed within the public hospital system during the past two decades. In Cabinet he was able to see the difficulties, as he saw them, of the capacity of Beaumont Hospital not only to meet the needs of the local community but also as a centre for neurosurgery in Dublin and outside the Dublin region. He was in a position to get the Cabinet to focus on the difficulties of the hospital.

I know Beaumont Hospital intimately and people who work there. They have been crying out for years for additional neurosurgeons. I would be a great deal more impressed if we were being told the public service in the hospital would be provided with additional consultant neurosurgeons to provide the services which were so badly needed. It is pointless to provide the land to build a co-located hospital if we do not have the consultants. The timeframe for building it is such that lives will be lost because of the reality that we have too few neurosurgeons in Ireland and too few in Beaumont Hospital. The neurosurgeons have come together for a number of years to demand additional consultants be appointed. Will the Minister speak about this? It is a pity it is not regarded as much of a priority as the legislation before us.

Deputy Woods should not tell us about the difficulties of Beaumont Hospital, as he was in a unique position to address them, to have had them dealt with and ensure that whatever additional facilities were required by the hospital were made available. Beaumont Hospital requires additional beds for public and private patients.

I agree with the Minister on one issue, namely, that the health insurance system was advocated, formulated and established by Government and those covered by health insurance, which includes most Members, are entitled to proper hospital and medical facilities. Let us not play games, however. The problem is we are developing a two-tier system. The richer one is or the greater access one has to health insurance, the greater likelihood one will have speedy access to health care, which everyone should have when they need it. Creating co-located hospitals instead of having private facilities within a hospital will not make a difference or solve the problem of the badly run, ill-equipped, under-resourced public hospital system and it is fiction to believe otherwise.

The problems in Beaumont Hospital will not be resolved simpliciter by the proposal before us because there is a need to provide additional nursing staff, neurosurgeons, greater facilities and more modern equipment. As doctors working in the hospital are aware, some equipment breaks down regularly. It is time something was done to address this issue. These problems should be treated with the urgency and priority afforded this legislation.

Deputy James Reilly

Like my colleague, Deputy Shatter, I will raise the Minister's attitude to the legislation. For the Government to continue to behave as it has done with this Bill would be to tell the people that it will, in future, legislate in the dark and, in the event of legislation being urgent, as the Minister argued regarding this Bill, Deputies will not be given access to the relevant advice issued by the Attorney General. Such an approach is not a runner because democracy cannot function in this fashion. Ministers cannot inform Deputies for the next three, four or five years that having received the advice of the Attorney General on a specific issue, the House must act urgently to pass legislation without properly considering or debating the issues.

Why is 52% of the population insured? It is not because individuals choose to have health insurance but because they feel compelled to have it. They do not believe the public health service will deliver for them in a timely fashion. People are happy with the care they receive if they can access a service but the problem is that waiting lists prevent access to the health service. On five occasions this year, I have received letters from the ear, nose and throat department of one of our great health care facilities, Beaumont Hospital, stating that the hospital cannot offer an appointment within a year and suggesting the patient try a different service. No attempt was made to arrange an appointment for another time.

I remind Deputy Woods, for whom I also have a great deal of time, that since being returned to power in 1987, Fianna Fáil has held office for 18 of the 20 intervening years. Soon after I joined the Eastern Health Board in 1987 or 1988, the board discussed the establishment of a new psychiatric service in Beaumont Hospital to replace the services provided in St. Ita's Hospital, Portrane, which was considered an inappropriate location as it was housed in a 100 year old building on a relatively isolated peninsula that was difficult to access by public transport. In 2007, 20 years later, this service has still not been completed. It is clear that the problem in this area lies not with Fine Gael but with those who have been in a position to resource and fund services but have failed to do so.

Deputy Shatter referred to neurosurgery. Neurologists are in terribly short supply, with people waiting years to see a specialist. Many people with Parkinson's disease and other illnesses are in dire circumstances, with some of those living at home and facing the possibility of recurring brain tumours unable to access hospital services because beds are not available. Consultants are being asked to choose between admitting individuals who are unconscious and persons who, while conscious, have a condition which may erupt at any moment. That is no way to run a health service.

Where will serious trauma cases go in co-located hospitals? The Minister and I both know that road traffic accident victims suffering from serious complications will be admitted to the accident and emergency department of the public hospital, which will incur the full expense of treating the victim. Once the patient's condition has been stabilised, however, he or she will be transferred to the private hospital.

I do not understand the difficulty with having private beds in public hospitals. At least in those circumstances, training is available to junior hospital doctors and all the facilities are in one place and can be shared. It does not make sense to establish separate co-located hospitals on grounds which will no longer be available to the public hospital should it require them at a later date. This policy will result in cherry-picking of easier procedures which can be performed without any great infrastructural needs, leaving the more costly, difficult procedures to the public health service.

If the National Treatment Purchase Fund ceases to operate, how will the co-located private hospitals survive? Given that the VHI does not appear to believe these hospitals have a place, how will the Minister ensure an ongoing supply of prospective clients for these private hospitals?

Co-location is another case of the Minister distancing herself from her responsibility for health care by delegating the running of hospitals to the private sector. We have seen the problems this hands-off approach can cause. The lack of a proper inspectorate for private and public hospitals has resulted in members of the public, specifically women, having to endure the problems we have experienced in Barrington's Hospital, the Midlands Regional Hospital Portlaoise and other facilities. I repeat a question the Minister failed to answer. How many co-located private hospitals will be not-for-profit facilities?

Deputy Mary Harney

Does Deputy Reilly have a problem with someone making a profit? I presume the private nursing home in which he is involved is a for-profit arrangement. Irrespective of whether it is described as income or profit, I do not have a problem with it. Even if the House decided to legislate to prevent people from making a profit from private health care provision, it would be in breach of European Union and constitutional law

Deputy James Reilly

No one is asking the Minister to legislate against profit.

Deputy Mary Harney

General practitioners make a profit from their operations and I would not expect them to be in business if that were not the case. Bon Secours was the only not-for-profit operator selected but the hospital in question will not proceed and Bon Secours has withdrawn from the project. As a result, none of the eight proposals is in the not-for-profit category.

It would be amazing news to learn that Fine Gael has a difficulty with people making profit. I would not expect Deputy Reilly's practice or any of the other 2,000 general practices to continue operating if they did not make a profit. People will not be involved in providing a service unless they get a return on their labour or investment.

Deputy Reilly indicated he does not understand the problem of having private beds in a public hospital. Each site will have only one accident and emergency facility. I do not want anybody accessing a trauma or accident and emergency service on a preferential basis. An accident or emergency or trauma case should access service based on medical need rather than on a preferential basis. The issue is that 20% of the beds paid for by taxpayers are available to some people on a preferential basis. Staffing these beds costs the hospitals covered by the co-location programme €226 million more than they receive from the insurers. In other words, they receive €74 million per annum from the insurers for providing a service that costs €226 million.

In the case of Beaumont Hospital, which has been alluded to repeatedly, we will provide 180 private beds and the private beds in the public hospital will be converted to public beds and used on the basis of medical need. The hospital will gain in the region of 300 additional acute beds, which is a very good deal. The co-located facility will be involved in training and research and development because, under the medical practitioners legislation, we are extending training to the private providers as well as providing training in the public system. We live in a country where, as everybody has acknowledged, 53% of people have private health insurance. Why do they have it? It increased from 37% when the economy was a third of the size it is today. This economy has tripled in size during the past ten years. We have double the number of people at work. Private health insurance for many, including factory operatives, which would never have been the case previously, is paid for as part of their employment package. We have a new group of individuals involved, some of whom are quite young. I dealt with this issue in my previous job during the skills shortage. Part of the employment package included the provision of private health insurance for employees.

Deputy Caoimhghín Ó Caoláin

That is because of fear.

Deputy Mary Harney

That is the reason it has increased from 37% to 53%. If one can get into the public hospital, funded by taxpayers, on a preferential basis because one has private health insurance, that too is an incentive. I understand the late Susie Long was told by a doctor's secretary that if she had private health insurance she would be seen next week, but, if not, she would have to go on the list. I could not stand over that. It was wrong, and it is wrong. The publicly funded facilities are made available on the basis of preferential treatment. This is the fastest, most cost-effective way of providing additional capacity in these public hospitals and is also the most effective way of keeping the highly skilled consultants on the site. There are doctors in the city who work in Beaumont, Blackrock and, perhaps, other hospitals. That is not an efficient use of the time of those doctors who are highly skilled and highly trained. We want to see as many of them as possible only working on the single site——

Deputy Caoimhghín Ó Caoláin

Professor Tom Keane told us today that——

An Ceann Comhairle

I ask the Deputy not to intervene while the Minister is making her reply.

Deputy Caoimhghín Ó Caoláin

——the highest qualified consultants from this country are practising in British Columbia, Canada——

An Ceann Comhairle

I ask the Minister to proceed with her reply.

Deputy Mary Harney

That is true and my ambition is to get them. That is why we need a new consultants contract. I cannot break the current contract. We can do it but we would have to compensate people. There are 2,000 people on an existing contract, one third of whom can practise in several places because they are category two doctors. Some 650 of them are in the Dublin area. We want a new contract. At the heart of these negotiations, which hopefully will reach a successful conclusion later this year, has been a one for all system into our public hospitals so that we can get access for patients based on medical need. We are in the final hours of those talks.

On the issue of the resourcing of our public hospital system, we spend 8.9% of our national income on health, which is in line with the OECD spend in the world's 30 richest countries, yet 11% of our population is over the age of 65 while 17% of the OECD population is over the age of 75. The challenge for us is to change the way we perform the service and, in particular, to move more into community and primary care where 95% of health needs are met.

I was asked about isolation facilities. Recently I wrote to the HSE and asked, as a matter of priority, that in our public hospitals single rooms be made available to patients who need isolation before they are made available to private patients. It is not acceptable that if a patient is in need of isolation that a room cannot be made available to him or her because a private patient has preferential access. That is the policy we are implementing hospital by hospital. The hospital of the future will be one where everybody will have a single room. The new children's hospital will have single rooms for everybody and family accommodation. That is the hospital of the future but we are a long way from that here.

On the issue of the Attorney General and the advice, of his own volition the Attorney General got the advise of Mr. Maurice Collins, SC. It is normal practice for the Attorney General to seek outside advice in many cases. What happened was that the Attorney General felt there may be an issue with the 1961 Act and decided to get outside opinion to assist him in advising me. When he got that advice, he wrote to me on 26 October. It was not because some promoter, developer or somebody who is trying to build a co-located facility came forward with advice. It was in the context of funding the new paediatric hospital board that issues arose around the 1961 Act and the Attorney General got the outside advice and made me aware of it and the need to bring in legislation as quickly as possible.

Deputy James Reilly

The Minister makes the point that people are earning more and the economy has grown and this is the reason more people have VHI cover. I put it to her that 20 years ago there were 18,000 beds in the hospital system, which fell to 11,000 and now the number is at 13,000 while the population has increased by 700,000. It is the lack of access to public health care that makes people feel they must have health insurance in order to have any realistic chance of access to health care. The Minister mentioned the late Susie Long. Unfortunately, that was the reality for her. That is how many people feel. If they can afford health insurance, they will get it. Children are buying VHI cover for their parents to ensure they will access to hospital. That is the reality. It has nothing to do with our prosperity.

Deputy Mary Harney

That is not happening in many hospitals as the Deputy is aware.

Deputy James Reilly

It is perverse prosperity that leads us to a situation where more and more people consider they need health insurance to access health care which was freely available here 20 years ago.

Deputy Jan O’Sullivan

I have a problem with this debate. We are supposed to be debating the first amendment I tabled to this legislation. The content of that amendment has not been addressed by the Minister in her response. The substance of the amendment is that if an order is being made in regard to co-location in St. James's and Beaumont hospitals, it should first be debated and voted on in this House before being implemented.

Deputy Mary Harney

I apologise. No orders will be made on foot of this legislation. We cannot make orders.

Deputy Jan O’Sullivan

In other words, what the Minister is saying is that she is not accepting my amendment.

Deputy Mary Harney

I cannot because I will not make any orders. It will not be necessary.

Deputy Jan O’Sullivan

I would have appreciated it if the Minister had addressed that issue when replying.

Deputy Mary Harney

I apologise. I intended to address the issue. I am sorry I forgot to address it. The reality is that what we are doing here is putting beyond legal doubt the 19 bodies in question. If the Minister for Health and Children wishes to have power in the future to make orders, establish bodies or allow bodies to do certain things, we must have new primary legislation. I will not make any orders on foot of this legislation.

Deputy Caoimhghín Ó Caoláin

I wish to refer briefly to the point just mentioned by Deputy Reilly. The Minister was almost boastful in her contribution in relation to the numbers of people who are now signed on to the registers of VHI, Vivas, QUINN-Healthcare, etc. This is nothing to be proud of. When one gets to the bottom line with people, one will find that a huge swathe of those people, particularly those new people who have signed on in recent years, are doing it because they have lost faith in the public system. They see public moneys being diverted away from the public system. They have seen the reality of languishing on waiting lists and the difficulty of even getting on a waiting list. They do not want that for themselves or their children and that is very understandable.

Many are actually suffering the loss of something else important in their lives in order that they can have the assurance of that in the event of a need presenting. Many of these people would not see themselves as a part of a new poor in Ireland. The truth of the matter is that a greater number of them are obviously without medical card qualification. There is a body of people with medical cards and there are those who are much better off in society and for whom the matter of paying for access to health care is something they can take in their stride. There is then a huge group in the middle, the greater number of them couples, either married or in relationships with children, with both parents working to ensure they can cover the costs of the provision of a home and the needs of children in terms of child care and everything else. What they have got on top of it all is the forced reality of having to take out health insurance for peace of mind. I assure the Minister that a significant body of those people would never have taken that as a first course of choice.

The Minister's colleague, the Tánaiste and Minister for Finance, stood here on 5 December and announced the increased spending allocation for her Department for the coming year. People talk about the €16 billion allocated to the health budget. The reality is that the people are paying many millions more again. What is the true cost of the provision of health care in this State today? One must do the sums. The cost involves not only the monies expended through the Exchequer but what people also pay apart from their tax contributions that make up the Exchequer figures. They are also paying on the double through private health insurance, which is a fact of life. If one adds to that those paying cash for the direct delivery of services from their GP, access to medicine and all the rest, the total sum is huge.

I do not believe that sum has ever been computed because no-one has taken the time to do so. The Minister would be shocked by what it would be possible to do in the delivery of health care with the sum that actually comes from the pockets of our people, either through the Exchequer or directly into the health system through health insurance and all the rest.

If we were to have a state-of-the-art public health system in which every citizen would have confidence, it would cost a great number of people less than is currently the case. That is achievable and there are examples of this around the world that can be emulated. One of the real lessons that Professor Tom Keane can perhaps bring to his two-year tenure in this State is not any innovation, because he is on contract to implement the Minister's programme for the delivery of cancer care services, but that hopefully over the period of time some of the reality of the experience he has known in British Columbia and Canada might rub off on the Minister and others in the Department of Health and Children.

The lessons need to be learned. We need to get rid of the 20% allocation and the piggy-backing of private care on the public health system, but not in the way the Minister is going about it. The correct steps are for a universal system, free at the point of delivery for every citizen and on the basis of need alone. That is what we should be working towards and what every party in this House should be committed to achieving.

Our citizens, born equal, deserve equal treatment and respect throughout every stage of life until the end of life itself. I believe in nothing less.

Deputy James Reilly

It is 10.23 p.m. The debate ends shortly but we have not touched on the other two sections of the Bill which relate to the Medical Practitioners Act and the Health Act 2004, which dealt with the HSE. Do I have permission to comment on those sections?

An Ceann Comhairle

The Deputy must deal with this amendment.

Deputy James Reilly

In that case, we are leaving very little time for the other amendments.

An Ceann Comhairle

That is true, but it is the order of the House.

Deputy James Reilly

In that case, in my final comments on co-location I will focus on some of the other issues which arise due to the lack of investment in our hospitals. The Minister stated that those who need isolation rooms should have them but the reality is there are too few of them, particularly at Beaumont Hospital, which cannot deal with all the MRSA patients who should be in such rooms. That hospital certainly does not have the ability to isolate patients with cystic fibrosis, who have a ten-year shorter life expectancy in this country than patients in the United Kingdom because of that very fact. Other issues also have an influence, such as screening from birth, but the inability to isolate patients is a major issue.

Patients are afraid to go into hospitals because of the risk of infection and they stay at home longer than they should as a consequence. They are caught in a catch-22, damned if they do and damned if they do not. It is the State's responsibility to look after them. It is the State's and the Minister's failure in recent years, a time of unprecedented plenty, to put in place facilities for such people.

Deputy Dinny McGinley

In the past three hours I have been in different parts of Dublin, visiting some of my constituents in hospital. I visited St. Vincent's Hospital and St. Luke's Hospital, where I went to visit one constituent and found almost half of my county were there. I sat outside the radiotherapy unit for 25 minutes with a neighbour who was waiting for treatment. The staff of the unit are working hard and it seems to operate from early morning until late at night. Despite the question mark over St. Luke's, anyone I spoke to there had nothing but praise and admiration for the work carried out by the staff.

With regard to co-location and public and private medicine, I may be very naive in that I believe the country can tolerate both systems — we can have private medicine as well as public medicine. I confess I am a member of the VHI and pay my premium every year. If I must ever go to hospital, I have the choice of going to a private hospital. While I do not know whether this view accords with my party's policy, I believe the difficulty is not with public and private medicine but with mixing the two in the same hospital.

If people want to have private medical insurance, they are entitled to it and they should be allowed to go to private clinics. However, if people want public treatment, they should be allowed to access it. This is where the difficulty arises, in that every hospital has public and private beds. If one is fortunate enough to have private insurance, one can hop, skip and jump into one of the private beds ahead of people who may be more in need but who depend on the public system.

Why can we not have both? Why can we not have private hospitals for those paying VHI or other insurance? Public patients would then be able to access public beds because there would be no special beds in public hospitals and everyone would be treated the same.

Deputy Mary Harney

I agree. That is what we are doing.

Deputy Dinny McGinley

Why can we not have an agreement like that? When I go to a hospital, such as Letterkenny Hospital, some patients are private and some are public. If one wants to go private in a public hospital, one gets in immediately but if one wants to use the public system, one waits for a year or two. It is a mess.

I may be naive. I have been fortunate that the only time I was ever in hospital was when I had my tonsils removed at 12 years of age. I am not sure if it was public or private treatment, but I have needed no more hospitalisation since then. Why can we not differentiate between the public and private systems? It is a simple question. While it may not be solvable, if I were Minister, I would try to come up with a solution like that.

Deputy Mary Harney

That was a good contribution on which to end the debate because, Deputy McGinley will be pleased to hear, that is exactly what we are doing with co-location. However, it is not the view put forward by the Fine Gael spokesperson, who favours public and private service in public hospitals.

With regard to St. Luke's Hospital, all the expert advice is that there should not be stand-alone radiation facilities, so St. Luke's will move to the grounds of St. James's Hospital. However, we of course want to protect the ethos of St. Luke's, which is a fantastic place. I hope half of Donegal is not there — I would be worried if that was the case.

Deputy Dinny McGinley

It was an exaggeration but quite a few were there.

Deputy Mary Harney

I accept that, because those who live furthest away must stay in Dublin for the period of their treatment from Monday to Friday. St. Luke's does a fantastic job and I am just about to reappoint its board. I have told them on many occasions that we want to keep all that is best about the hospital when it moves to the grounds of St. James's Hospital.

An Ceann Comhairle

As it is now 10.30 p.m. I am required to put the following question in accordance with an order of the Dáil of this day: "That in respect of each of the sections undisposed of, the section is agreed to in Committee, the Schedules and Title are agreed to in Committee, the Bill is reported to the House without amendment, Report Stage is completed and the Bill is passed."

Question put.

The Dáil divided: Tá, 71; Níl, 61.

Tá

• Ahern, Michael.
• Ahern, Noel.
• Andrews, Barry.
• Andrews, Chris.
• Ardagh, Seán.
• Aylward, Bobby.
• Behan, Joe.
• Blaney, Niall.
• Brady, Áine.
• Brady, Cyprian.
• Brady, Johnny.
• Byrne, Thomas.
• Calleary, Dara.
• Carey, Pat.
• Collins, Niall.
• Conlon, Margaret.
• Connick, Seán.
• Cowen, Brian.
• Cregan, John.
• Cuffe, Ciarán.
• Cullen, Martin.
• Curran, John.
• Dempsey, Noel.
• Devins, Jimmy.
• Dooley, Timmy.
• Fahey, Frank.
• Fitzpatrick, Michael.
• Fleming, Seán.
• Flynn, Beverley.
• Gogarty, Paul.
• Gormley, John.
• Grealish, Noel.
• Hanafin, Mary.
• Harney, Mary.
• Haughey, Seán.
• Hoctor, Máire.
• Kelleher, Billy.
• Kelly, Peter.
• Kenneally, Brendan.
• Kennedy, Michael.
• Killeen, Tony.
• Kirk, Seamus.
• Kitt, Michael P.
• Kitt, Tom.
• Lenihan, Brian.
• Lenihan, Conor.
• Lowry, Michael.
• McGrath, Finian.
• McGrath, Mattie.
• McGrath, Michael.
• McGuinness, John.
• Mansergh, Martin.
• Moloney, John.
• Moynihan, Michael.
• Mulcahy, Michael.
• Nolan, M.J.
• Ó Cuív, Éamon.
• O’Brien, Darragh.
• O’Dea, Willie.
• O’Flynn, Noel.
• O’Hanlon, Rory.
• O’Keeffe, Batt.
• O’Sullivan, Christy.
• Roche, Dick.
• Ryan, Eamon.
• Sargent, Trevor.
• Scanlon, Eamon.
• Smith, Brendan.
• Treacy, Noel.
• White, Mary Alexandra.
• Woods, Michael.

Níl

• Allen, Bernard.
• Bannon, James.
• Barrett, Seán.
• Broughan, Thomas P.
• Bruton, Richard.
• Burke, Ulick.
• Burton, Joan.
• Byrne, Catherine.
• Carey, Joe.
• Clune, Deirdre.
• Connaughton, Paul.
• Coonan, Noel J.
• Costello, Joe.
• Coveney, Simon.
• Creed, Michael.
• Deenihan, Jimmy.
• Doyle, Andrew.
• Durkan, Bernard J.
• Enright, Olwyn.
• Feighan, Frank.
• Ferris, Martin.
• Flanagan, Charles.
• Flanagan, Terence.
• Gilmore, Eamon.
• Hayes, Tom.
• Higgins, Michael D.
• Hogan, Phil.
• Howlin, Brendan.
• Kehoe, Paul.
• Lynch, Kathleen.
• McCormack, Pádraic.
• McEntee, Shane.
• McGinley, Dinny.
• McManus, Liz.
• Mitchell, Olivia.
• Morgan, Arthur.
• Neville, Dan.
• Ó Caoláin, Caoimhghín.
• Ó Snodaigh, Aengus.
• O’Donnell, Kieran.
• O’Dowd, Fergus.
• O’Keeffe, Jim.
• O’Shea, Brian.
• O’Sullivan, Jan.
• Penrose, Willie.
• Perry, John.
• Rabbitte, Pat.
• Reilly, James.
• Ring, Michael.
• Shatter, Alan.
• Sheahan, Tom.
• Sheehan, P.J.
• Sherlock, Seán.
• Shortall, Róisín.
• Stagg, Emmet.
• Stanton, David.
• Timmins, Billy.
• Tuffy, Joanna.
• Upton, Mary.
• Varadkar, Leo.
• Wall, Jack.

Tellers: Tá, Deputies Tom Kitt and John Curran; Níl, Deputies Paul Kehoe and Emmet Stagg.

Question declared carried.