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JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Wednesday, 7 Dec 2005

Health Reform Programme: Ministerial Presentation.

We will proceed with our discussion on health reform and deal with correspondence later. I welcome the Tánaiste and Minister for Health and Children, Deputy Harney, and the senior officials from her Department. I invite the Tánaiste to make her opening statement.

It is always a pleasure to come before the Joint Committee on Health and Children. I am accompanied by Michael Scanlan, the Secretary General of the Department of Health and Children, and Dr. John Devlin, a member of the medical advisory team in the Department. I will make a short opening statement because members usually have many questions and find it more productive if they have the opportunity to ask them.

As the committee is well aware, we are now involved in a major programme of health reform which represents the most radical reform of the health service ever undertaken. At one level, it involves administrative and management reform. We now have a single entity, the Health Service Executive, which has responsibility for delivering health services and which is accountable for how the money is spent on the delivery of those services. The committee has engaged with Professor Drumm and some of his team from the executive. Next year we will be introducing legislation to establish another stool of the administrative reform process, that is, a new health information and quality authority. The role of this authority will be to produce quality information, set standards, etc.

We are also involved in reform at every other level, including reform of contracts of employment. Pivotal to this is the consultants' contract. The current contract has been in place for over 30 years. The last set of negotiations was concluded in 1997. Everybody acknowledges that reform of the contract is pivotal to our health reform programme and we have begun negotiations with the Irish Hospital Consultants Association and the Irish Medical Organisation in this regard. Clearly, we are anxious to ensure that these negotiations do not proceed forever. One need not have long meetings to get good results. We want to be in a position next year to recruit new consultants on the basis of a new contract that is more appropriate to the health care needs of 2005 and beyond. Issues such as the implementation of changes to mental health services will be very dependent on that new contract.

We are also involved in negotiations on a new contract of employment for the GMS. These are taking place under the auspices of the Labour Relations Commission. As part of the new contract, we want chronic illness to be managed in the community and to ensure that more initiatives can take place at primary care level. This is the level at which most engagement takes place between patients and their doctors. There are 18 million engagements, covering under 40% of the population, per year under the GMS alone, while there are approximately 4 million at hospital level. Hence, there are four and a half times more patient engagements at GMS level than at hospital level. The GMS represents a very important part of our health service and will represent a more central aspect of the provision of health care in the future.

We are also involved in negotiations with junior hospital doctors and the plan is to reduce dependency on them. The working time directive has an impact in this regard. However, if we did not have such a directive, our hospital system would be far more dependent on junior staff. We want consultant-led services and reform of the contract is central to achieving this.

There will also be reform in the pharmaceuticals sector. The supply chain consists of manufacturers who produce products, wholesalers who sell them into the retail market and pharmacists or retailers from whom we buy our drugs. The drugs bill at present is between €1.5 billion and €2 billion per year, accounting for approximately 15% plus of health spending. The bill is rising quite rapidly, as is the case in many other countries. We are concerned not so much about cost containment but about achieving value for money. Central to this is the contract and the Government will be engaging with the manufacturers in this regard. However, all the others involved in the supply chain are important. We want to maintain patient choice and clinicians' independence but we must also ensure that patients obtain the best possible value for money in terms of the treatments that will be available.

Among the priorities we have set ourselves in health reform is reforming the way we do business. This partly involves changing practices. We recently completed the cleanliness and hygiene audit in 54 hospitals. It has been very successful, not in terms of a name-and-shame process but rather in terms of acquiring benchmark data to allow us measure performance over time. The intention is that there will be two unannounced audits of our hospitals next year and thus we will be able to monitor improvements hospital by hospital. The results of the audit were surprising at one level but they bore out anecdotal evidence that our hospitals are not run to the standard we expect. Only 9% of hospitals received a good score of over 85%, which means there is much room for improvement. We expect to see this improvement during the spot-checks next year.

The audit identified the manner in which linen is handled in hospitals and drew attention to hand cleaning. Many of these are the basics. If, however, the basics are not right, one thing is certain: some of the more complex things are not right. As part of that audit and as a means of controlling infection and its spread, particularly within the hospital system, we have been involved in a fairly high profile hand cleaning exercise at hospital level. Guidelines have been in place for ten years and it is a question of ensuring that they are implemented.

Care of the elderly is a significant issue for our society. At the start of this year, the Minister for Social and Family Affairs, Deputy Brennan, and I gathered together an interdepartmental group of senior officials to examine the issues affecting ageing in Ireland. The group focused on two reports in respect of this area that were commissioned in recent years. The group completed its work, which will feed into some of the announcements being made by my colleague, the Minister for Finance, later this afternoon and on which I will elaborate tomorrow.

It is known that 11% of the population is over the age of 65 and this percentage is rising. International evidence suggests that approximately 4.5% to 5% of those over 65 require institutional care. This level has been reached in this country with 20,000 people in institutional care. However, approximately 28% of those currently in institutional care in Ireland could live in the community if alternative supports existed because they have a moderate or low level of dependency. Much of the Government's focus for next year and subsequent years is the establishment of community-based services for the elderly. The latter will include more home helps and more home supports but they will also include the provision of more community-based therapists to provide services such as chiropody, physiotherapy and the therapies required to allow people live healthy lives in the community. This will be a strong focus of what the Government will do next year. There will also be reform of the nursing home subvention scheme and other measures of that kind.

Much of the focus has been on the accident and emergency service. The accident and emergency departments deal with approximately 3,800 people every day, which is a large level of activity. Some of the activity is driven by the fact that in some parts of the country, particularly on the north side of Dublin, appropriate primary care facilities such as out-of-hours cover and weekend cover are not in place and, therefore, much of the activity that could be adequately dealt with at primary care level is feeding into the acute hospitals system.

The night-time cover for 500,000 people on the north side of Dublin is provided by a company with two available doctors. I understand that one third of calls, representing 10,000 people, to that service last year were referred to the Mater Hospital's accident and emergency department. It is clear that substantially more is needed to care for 500,000 people. Professor Drumm dealt with this issue when he came before this committee two weeks ago. A tender to recruit adequate out-of-hours primary care facilities on the north side of Dublin is in its final stages. Much of the focus in the Estimates published recently was on the expansion of primary care activity nationally and this is a priority. To put matters in perspective, of the €10 billion funding for the HSE last year, €3.5 billion was for hospitals and €6.5 billion was for primary, continuing and community care. I wish to emphasise that 65% of the HSE's budget is devoted to primary, continuing and community care.

There are issues to be dealt with regarding the appropriate use of accident and emergency departments, the flow of patients through accident and emergency and the delay from the time a person presents in an accident and emergency department until they are seen. Many people do not require hospitalisation but those who do are still obliged to wait far too long. That is the reason one of the current initiatives being carried out by the HSE is an examination of hospital processes. This examination includes everything from discharge policies, length of stay, timing of elective treatment, and so on. It was noted that much of the elective work is carried out on Mondays and Tuesdays. In the best hospitals in the world, however, such work is spread over five days. The elective work is not concentrated in the first two days of the week, when it must compete with much of the accident and emergency activity. The HSE is of the strong view that a change in hospital processes and more appropriate discharge policies, such as discharge plans made up on the day the person is admitted into the hospital system, will have a significant impact in ensuring the current cohort of hospital beds is used appropriately.

The total health funding in 1997 was 15% below the OECD average and in 2003 this was changed to 17% above the OECD average. To some extent, those figures are meaningless, except to say that the Government had increased funding by €8.6 billion in the period from 1997 to today's budget. The situation has changed from funding of just over €3 billion to €12.6 billion next year, an increase of 250% at a time when inflation has risen by 27% to 28%. I am not aware of any other country that has been able to consistently increase spending over that period and at that level. The increase in many mainland European countries is 2% or 3%. Funding and resources are always important factors in health care but the focus must now be on reform, which, along with innovation, will drive the radical change that will deliver better outcomes for patients and better services for the public.

Some Government innovations such as the doctor-only medical card introduce new concepts that can deliver services in a different way. Before this, the medical card system operated with a cut-off point whereby a person either qualified for a full medical card or else received nothing. I am a strong fan of graduated benefits. The purpose of the doctor-only medical card is to introduce a support, particularly to those with families, to allow them to at least see their general practitioners free of charge. It is a fact that one in three of those who visit their doctor never require any follow-up treatment or medication. However, it is important to have that reassurance, particularly for parents with young children.

A total of 45,000 new cards, not an additional number, have been issued this year. I was very disappointed that we were not able to introduce the card earlier because of difficulties with the IMO. Those cards are now being issued. We have changed the method of assessing entitlement to the card by basing it on net instead of gross income, allowing people deduct reasonable child care costs, reasonable mortgage and rent costs and reasonable travel to work costs before being assessed for entitlement to either the full medical card or the doctor-only card. This will have a significant impact on those who need it most.

I will be delighted to take questions on any matters that are of concern to members. I reiterate that I am pleased to be here.

I thank the Tánaiste. I remind members that Leaders' Questions will be at 10.30 a.m. for those who wish to attend. Nine members have indicated that they wish to contribute and I will take them in groups of three, beginning with Deputies Twomey, McManus and Devins.

Before we start, I reiterate what the Chairman said that rather than making Second Stage speeches, we should confine ourselves to questions so that all nine members will have an opportunity to speak.

We will try to make that effort.

It is a good idea.

My comment was not aimed at Deputy Twomey.

I will apologise before I start.

The NRA and the HSE are two Government agencies that both spend billions of euro but neither are very accountable to the taxpayer. In pub quizzes held over Christmas, the box of Cadbury's Roses will go to the people who can name the CEO of the NRA because he certainly does not make himself very available, even to public representatives, whereas Professor Drumm is almost becoming a household name and seems to be regarded as a de facto Minister for Health and Children in some circles. His comments on policy are totally divorced from the policy views of the Tánaiste. Will she explain how Professor Drumm operates within the system? He has contradicted many of the policy decisions made by the Tánaiste over the past year.

Last June, I highlighted the 2 million home help hours cut by the HSE national service plan for 2005 but I did not receive a clear answer from the Tánaiste until November. The HSE admitted that its own figures in the national service plan were inaccurate to the tune of 500,000. It is still unable to supply accurate figures in regard to disability, mental health and child care home help hours. I make the accusation that some of the home help packages announced by the Minister are nothing more than a case of robbing Peter to pay Paul; she is simply moving services, repackaging existing services and sending them back out again. I question the accuracy of the HSE financial report and I ask the Tánaiste to comment.

On the theme of robbing Peter to pay Paul, the National Treatment Purchase Fund is turning out to be just a privatised version of the waiting list initiative announced by Deputy Howlin as far back as 1992, particularly as half the work done under the fund is carried out in public hospitals. That contradicts the statement of the medical director of the National Treatment Purchase Fund in 2002, when he said that it was the only issue in town and that the majority of the work would be carried out in private hospitals. The latter has not been the case. That is why these home care practices are turning out to be a privatised version of home help services.

The home help services package that has been announced will be delivered by a private company. If recent press statements are correct, it seems that public health nurse services will also be privatised. I know that the Tánaiste is privatising the GP out-of-hours services in north Dublin and that the Minister of State, Deputy Tim O'Malley, is threatening to do the same in Limerick. I find it strange that the Tánaiste speaks about value for money for patients when she is opening private clinics that are happy to charge patients €85 for a first consultation. Whatever about the difficulties that may exist in primary care, we are fast approaching the advent of a consultation fee of €100 if this sort of behaviour is encouraged any further.

Last week, the national hospitals director poured cold water all over the Tánaiste's proposal to build private hospitals in public hospital car parks. I am concerned about this proposal because it could be her greatest folly yet. I would like to hear her views on this matter. The Tánaiste is correct to state that there are two important issues for the future, namely, the consultants' contract and how we treat tax incentives for privatisation. With regard to the consultants' contract, these private hospitals are a huge danger to patients and the taxpayer. At present, consultants are paid €165,000 per annum. It is well known that private practice, particularly in the Dublin area, can bring in anything from €400,000 to €1 million in private fees. We all know where people's loyalties would lie if their private income was between two and five times that which they could obtain from working in the public health service. Putting private hospitals in the middle of the car parks of public hospitals will make this problem worse, not better.

Many of the tax incentives brought forward by the Government as far back as 1997 will run out in 2006 and 2007, regardless of what the Minister for Finance declares today. Their time is up anyway. Hence, there will be a huge push to invest money somewhere else and I know the Tánaiste is trying to get private money into the health care services. However, there is not much equality in that because the ordinary taxpayer can only invest a maximum of €31,000 in these private hospitals. If someone owns a substantial amount of property and derives a huge income from it, he or she can invest as much as possible in these private hospitals. A large developer who is running out of places to shelter his money because the tax concessions are being abolished will be able to invest an unlimited amount of money in these private hospitals. That will cause difficulties within the service.

The Tánaiste promised between 70 and 100 primary care centres in the 2005 Estimates. Can she give the committee more information on that? It seems a substantial number of such centres, given the fact that we have not managed to get ten of them up and running in the past four years. Despite what the Tánaiste said about the IMO, we still have only 1,000 doctor-only medical cards in the system at present, even though funding was announced for 200,000 cards at the beginning of the year. What are her views on the concept of primary care centres with pharmacies? This will be a major debate among pharmacists, doctors and patients and the Tánaiste should also take an interest in it. Private companies are setting up primary care centres with pharmacies located downstairs and this drives the revenue for the entire enterprise. At the same time, the Tánaiste states that she is trying to keep drug costs down. The best way to do that would be to keep pharmacies and GP practices completely separate from each other and not to have a conflict of interest develop between either party.

In the enterprises to which I refer, pharmacists may be funding the entire primary care centre and, because their premises is located downstairs from the surgery, they fill most of the prescriptions written by the doctors. In other cases, doctors are requesting that pharmacists provide them with hello money in order that they can move their businesses into the primary care centres those doctors own. There are huge conflicts of interest developing in this area and millions of euro are at stake. Is this good for taxpayers? The latter pay most of the drugs bill in this country. They pay the total drugs bill for one third of the population and any expenditure greater than €85 per month. In the long term, these developments may cause problems.

The PPARs system has been discussed and it is a payroll system that costs too much and pays too much. However, the accountability issues surrounding the PPARs debate should also be examined. Why was the acting director of the ICT unit given a temporary contract for two years?

The Deputy has spoken for ten minutes and I would like to give everyone an opportunity to speak for that time.

The Tánaiste only comes before this committee once or twice a year, so we should ask her these questions.

The Tánaiste is very generous with her time.

I will just ask one more question and everyone will be happy.

There will not be time for answers if the Deputy continues.

Deputy Fiona O'Malley is like static on the radio on each occasion the Tánaiste comes before the committee. It seems she cannot stop interrupting.

The ICT unit in the Department of Health and Children is under the direct control of the Tánaiste. Why was the director of that unit moved just when the health services were being computerised? That man was highly respected by the health providers because he had been working closely with them for the past number of years. At a pivotal time when the iSOFT "Lorenzo" project was being set up, why did that unit seem to be run down?

In deference to my colleagues, I will withhold my questions on the care of the elderly until tomorrow.

I thank the Deputy. It is not a matter of curtailing anyone but we are trying to stick to ten minutes per member.

I can understand that the Deputies want to protect the Tánaiste as much as possible but this is the only forum we have available to us. There is an issue of public accountability that overrides any party political concerns.

We have the same concerns as the Deputy.

The Tánaiste is now in her second year as Minister for Health and Children. She came in with a grand ambition to provide a world class health service that would be available to all who need it. Does she not accept that her words sound very hollow now? There are severe problems that persist in the health service. Does the Tánaiste accept that it is difficult to comprehend how there is such a conflict, in policy terms, between herself and the CEO of the HSE, particularly in the context of the fundamental difference in their approaches?

One policy area she has initiated is the handing over of public property to investors to develop private hospitals throughout the country. How does she reconcile this with her commitment to provide greater equality of care? How does she reconcile it with the strong criticisms coming from experts such as Professor Muiris Fitzgerald, who seems to have nothing good to say about this proposal? Last week's presentation by Mr. Pat McLouglin, unlike that delivered earlier by the Tánaiste, informed us of the actual position. How does the Tánaiste justify the fact that despite her announcement of proposals to deal with the accident and emergency crisis and her promise of major improvements this autumn, most of the elements of the ten-point plan have not been delivered and a few have been delivered only in part? The evidence is clear. How does she justify the fact that last week, for example, 359 people were on trolleys in accident and emergency units across the country when nobody put her under pressure to make the commitment she did? She made it as a person taking an initiative who had a reputation for living up to her word. It is difficult to understand why the whole process has run into the sand.

I ask the Tánaiste to comment on value for money, which is another area where she has made her reputation. There is clearly an emerging scandal in health spending. While the Tánaiste says that a great deal more money is being invested, on the occasions we manage the difficult task of getting information we find the evaluation and monitoring of the spending of that money is almost non-existent. The most recent statistics we have seen relate to the national development plan and demonstrate that it is more than likely that overspending in the health sector will reach €1 billion. Furthermore, it is actually the Department of Transport which is responsible for health spending under the national development plan and it emerges that 55 major projects are still at the planning stage.

Fortunately, the media has been able to carry out some degree of assessment on the extent of overspending, which is quite scarifying. It has certainly added to the €170 million lost on PPARS in respect of which an evaluation system was supposedly in place in the form of a performance verification board that was granting benchmarking to people on the basis that they were developing PPARS. The latter has now been put entirely on ice until the Comptroller and Auditor General's report is produced. The Tánaiste must explain to the committee how such a great amount of money has been spent and how overspending to such an extent has been permitted in development plan funding. How is it that someone who has made such a reputation for ensuring value for money has been unable to come to terms with spending in the health service?

I agree with Deputy Twomey's point about primary care and the private developments the Tánaiste is encouraging as some kind of panacea. She has told general practitioners that there is no money for primary care development and that if they want primary care centres, they will have to approach the private sector. Surely she accepts that there are ethical considerations on tying general practice to promotion by developers who are themselves tied to the pharmaceutical industry. Does the Tánaiste have no concerns about the impact that might have on general practice and patient-doctor relationships, quite apart from the likely steep increase in the cost of drugs if this is allowed to proceed as she wishes?

What provision is the Tánaiste making for expansion in community care through increased recruitment of personnel to ensure quality of care for patients who are assisted to stay out of hospitals or nursing homes, which is one part of her policy? What support will be provided through nurses, chiropodists and other community services? Elderly people cannot access chiropody services without paying extra? Does the Tánaiste accept that if she is to maintain the standard of care equivalent to the care patients receive in secondary nursing homes and hospitals, she must invest in it and pay more people to do more work in the community? If she does not invest, the result will be poorer care for vulnerable people.

Commenting on the 500 home care packages the Tánaiste has promised, the vice president of the IMO said that we need 5,000. Will the Tánaiste comment on his view? Government policy is that 2,000 more acute public beds should be provided but what is the Tánaiste's policy? It is unclear what is going on in forward planning of high dependency and community nursing beds.

Much of the Tánaiste's contribution focused on what will happen in the future if things go right and she finally gets lucky. Referring to her experience on medical cards, she said it was a pity doctors did not co-operate and indicated that things might have been different had she known what would happen. She was well advised by the Opposition that there were issues of legislation and negotiation which had to be considered. Does the Tánaiste not accept that she has tunnel vision in depending on her own judgment, without reference to the fact that the health system is very complex and involves the provision of services by a great many people? To try to simply drive a policy through without acknowledging the need for partnership and agreement will delay a project further. She must have learned the lesson from her dealings in respect of medical cards, which we were promised would have been delivered by this time last year or in early January.

We still have significant difficulties with the information deficit and the accessing of data, which is an appalling state of affairs about which there is public concern. To be fair to the Tánaiste, she believes, as I do, that it is not a positive development for the health service to be a closed system in respect of which it is practically impossible to find out what is going on. We continue to experience delays in answers from the HSE. More importantly, there are no levels of accountability for the public or public representatives, which there were in the past. Even Professor Brennan argued for the maintenance of health boards in the reformed structures because she understood the need for accountability. The decision to wipe out those layers of accountability has had a very negative impact on the health service.

I welcome the Tánaiste, Mr. Scanlan and Dr. Devlin. The most important issue we will encounter over the next few months will be the negotiations of consultants' contracts. Does the Tánaiste have a rough timescale for the completion for discussions? The committee has considered health care in other jurisdictions, including Spain and France, and encountered the interesting fact that Spain spends approximately €1,000per capita on its health system whereas we spend €3,000 per capita on ours.

I welcome any innovative approach on the part of the Tánaiste regarding the use of hospital facilities. It has always struck me as strange that we have very expensive laboratories, X-ray facilities and theatres that lie idle for almost two thirds of each weekday and the entire weekend. Does the Tánaiste intend to propose in the contract negotiations the use of the facilities for longer hours from Monday to Friday and at weekends? I welcome the fact that industrial issues with general practitioners have been resolved and I urge the Tánaiste to engage in meaningful discussions with them going forward.

Does the Tánaiste have a timescale for the regional fora which were due to be established under the new HSE structures? How many people will serve as members of the fora and what areas will they represent?

I will begin by assuring people that I have no plan to turn any public health nurse or doctor into a private-type nurse or doctor. However, I am conscious that there are 2,500 private beds in the public hospital system and that is excessive. I want to see people treated in public hospitals on the basis of medical need. My plan is to move 1,000 of those private beds out of public hospitals and into a separate facility that will be privately funded. This will mean that 1,000 of those beds may be converted to public beds, which is supposed to be privatisation. I find that extraordinary.

At Tallaght General Hospital in Dublin, 46% of the elective work last year related to private patients. That does not reflect the catchment area of the hospital. Ironically, at St. Vincent's in Dublin, which is a private hospital, 20% of the elective work was for private patients. We can see clearly that if there is a private wing in conjunction with a public hospital, there is a higher throughput of public patients and many of the private patients can be dealt with in the private facility. That is the plan. Deputy McManus's party has encouraged investment in films, with accompanying tax reliefs, and I support that. However, if we want people to support films, surely we can give them the option of investing in the provision of health care facilities so that taxpayers do not have to provide anything. It is planned that 1,000 beds can be provided in the next few years in conjunction with public hospitals, where such projects are properly assessed and feasible.

I am not suggesting that private wings be built at every hospital. That would not make sense because the demand would not sustain such an initiative. However, it is Government policy, not just mine, to begin a process of assessing applications. A number of people have written to me. I am not in a position to assess the applications but I know, from discussions with its chairman and chief executive officer, that the HSE is putting in place a process for assessing those applications. As Mr. McLoughlin said, such applications must stand up to a business analysis. If it does not make sense to build a private facility in Waterford, one will not be built there or in Limerick or elsewhere. We want the HSE to examine proposals to decant up to 1,000 of the 1,500 private beds from the public hospital system. Central to all of this is the need to seek greater use of public hospital facilities for public patients in particular.

As regards general practice, this is a combination of private and public enterprise. Deputy Twomey's colleagues and the general practitioners who preceded them built up our current general practice infrastructure. That is the reality. They did not wait for the Government to build facilities. If they had waited, we would probably still be waiting because taxpayers' money is limited. In this year's Estimates, I have provided for 300 additional staff to supplement 75 to 100 primary care teams throughout the country. They include chiropodists, physiotherapists, nurses and staff of that nature. We have also provided in the Estimates for out-of-hours visits to be extended to an additional 375,000 people, bringing that form of coverage to approximately 70% of the population.

As regards whether doctors will over-prescribe if the pharmacy is located beside their premises, they are expected to adhere to Medical Council guidelines and only prescribe when it is appropriate. I grew up in a small village, Rathcoole, where the doctor's surgery and the pharmacy were situated across the road from each other. Effectively, they were side by side. They were not in the same building but were adjoining each other. From a convenience perspective and as is often the case, they were close together. If competition issues are involved, that is not my job but rather a matter for the Competition Authority. We are not allocating any money for these facilities but if people are providing them, I am delighted to support that. I recently visited such a facility in Mulhuddart that I had previously opened. A number of doctors who had been working separately in the area beforehand came together to offer services at the facility in question. They employ public health nurses, physiotherapists and dieticians. It is a fantastic facility. Instead of three people operating separately, they have come together to provide a better service for the community. I welcome that and if there are competition issues involved, that is a separate matter.

I wish to turn now to the National Treatment Purchase Fund, NTPF. Reference was made to the waiting list initiative. In the last year, 1996-97, of the waiting list initiative, the numbers rose a couple of thousand. The purpose of the NTPF was to use spare capacity in the private sector to treat those waiting longest. For 14 of the top 16 procedures, the waiting period is down to three or four months. That is the reality. However, all of it cannot be done in the private system because we do not have the capacity in, for example, paediatrics or some other complex areas. I have restricted the funds to no more than 10% of their expenditure in any public hospital, unless the circumstances are exceptional. Some 37,000 people have been treated and the feedback from them has been very good. This was simply a focused initiative to help those waiting longest for surgery or other procedures. The fund will receive €80 million next year, which, to put matters in perspective, is less than 2% of what is spent on hospitals. That is €80 million out of €12.6 billion. There is a good deal of focusing involved and it is a tiny amount of money relative to what it achieves. The general view is that it does a pretty good job.

As regards the per capita spend that was mentioned, it is true that Ireland spends €3,000, while in the UK just over €2,000 is spent. In Spain, as Deputy Devins indicated, €1,000 is spent. These are interesting statistics and I have used them but, to be fair, it is not possible, because of the economies of scale involved, to compare the spend on a small population base with that relating to a large population base.

I will not be provoked into responding to some of Deputy McManus's comments except to note that from my first week in the current job, she has been saying more or less the same thing. I want to repeat, however, that there are no quick fixes. Nobody was more aware of that than I. We need to change the practices in the way we do business, examine processing in hospitals as regards when they do elective work, discharge people, etc., whether they are focused on discharging patients and whether consultants are available 24 hours a day, covering for each other and discharging on Saturdays. If one takes Blanchardstown hospital in Dublin, where the consultants work together as a team——

Nobody is arguing about that.

These are the things we are doing but unfortunately one cannot press a switch and make matters happen now.

Nobody is saying that.

These are the things that will deliver the reforms. One does not hear of too many problems as regards James Connolly Memorial Hospital in Blanchardstown, either at accident and emergency or any other level. The consultants work together as a team. They discharge for each other, cover for each other and run the hospital very efficiently. There are many hospitals like that. Dr. Garry Courtney made a presentation at an event I attended last Friday. He said that for 25 years there were up to 27 people on trolleys in Kilkenny. This was never given any attention because it was seen as normal and people did not complain. For the past three years, not a single person there has been on a trolley. They have changed the way business is done in that hospital. It is from innovators such as these that we need to learn and to whom we should give support.

They are not getting the funding.

As the Senator is aware, they are getting the funding. He was present when I made the commitment. People such as that will receive more funding. We are going to reward the innovators. That brings me to the question raised by Deputy Devins about the greater use of expensive equipment. If surgeons cannot get into a theatre because there are no beds for patients, that is extraordinarily frustrating and very wasteful of resources. Equally, if equipment cannot be used as much as possible, that is a waste of a resource. Much of what we are trying to do, and what the current audit of process within hospitals involves, is reviewing capacity and staffing issues, equipment and how greater use of the resources can be achieved by doing business differently.

Deputy Twomey continually raises the issue of home helps. We increased expenditure on home helps to €120 million this year. It was £13 million eight years ago. That increased the number of home help hours to 8.9 million. Some 6.9 million of those hours relate to older people and the balance is accounted for by other categories of people who require home help. It is not a question of repackaging. Extra money is going into this area, including home care packages, which is not about repackaging home help. The home care package looks at the person requiring the care and devises a customised package around him or her. The average spend is somewhere between €350 and €400 per individual. Some of it is for a seven-day service. Some people require a higher level of support in the home than is on offer from home helps who just provide a basic service. An entire range of supports is being given by way of home care packages and there will be even greater emphasis on this next year.

I agree with Deputy McManus that we must move up in terms of the numbers and we must do that on a phased basis in the coming years. We have begun that process and, as I said earlier, there are probably 6,000 elderly people in institutional care who could be at home if appropriate supports were available. In conjunction with the home care packages, there is more emphasis on palliative care, the meals on wheels service and using day care centres and the other facilities that greatly help people elderly people to remain at home. We have also placed a heavy emphasis on changing nursing home subventions, which, as members are aware, had not changed since 1993. If someone's house was worth more than €95,000 — it would be difficult to find a house anywhere in the country worth less than that — they were disqualified. That is unrealistic and changing the subvention is one of the actions we intend to take in the context of next year.

On the question of value for money, the former health board system did fantastic work. I intend no criticism of its 157 former members but if there is anything that proved that having ten organisations — 11 if one includes the RHA — does not work for a population of 4.1 million, it is what has happened with PPARS. There is no doubt about that. There has never been a change process as large as the one in which we are engaging. The HSE is the biggest employer in Ireland. It is the largest change process ever undertaken in Ireland. We cannot complete that change without pain and there is no doubt that there will be pain and difficulties. As a matter of interest, this year there will be an underspend in the HSE's capital budget. There will not be an overspend. That money will not be lost to health care. It will be saved and can be used on health care next year or in subsequent years. It will not be returned to the Exchequer and remain unused. The money will be used. Among the reasons for the underspend are changes in the organisation and issues of timing such as those surrounding the equipping of St. Vincent's new accident and emergency department. We are not spending the money for the sake of doing so and to look good. If the money cannot be spent on what it was earmarked for, it will be carried forward and used in subsequent years. That is appropriate.

When the bed capacity analysis was carried out some years ago as part of the health strategy, it identified the need for 3,000 more acute beds. That policy has not changed. However, when that analysis was done, I understand that the private beds in the system were not calculated as part of the need and we all know that 53% of our population have private health care insurance. In examining the issue of acute beds, therefore, we must consider the entire stock of beds. We are making more beds available this year and have plans to put more in place next year but if we do not need the bed, we will not have them. It is about using what we have as effectively as possible but the policy of the Government remains until it is changed. When we began the process four years ago we needed 3,000 beds by 2011. To date, 1,100 of those beds have been put in place and a number of others are planned. Like everything else, whether it is increased numbers of beds or any other policy, it must be subject to constant review because something that may have been relevant a number of years ago may no longer be necessary due to changes in practices. We all know that more hospital activity is being carried out on a day basis. In fact, in some of our main hospitals the level of activity is slightly down, which proves that we must change the way we do business to ensure more effectiveness and efficiency.

As regards policy and the HSE, the Department of Health and Children and the Government, under the reform of the health service, the Department will have a policy, legislative and quality of standards role. The HSE's role will be to deliver the services and be accountable for the money spent but it is clear that there is a major crossover between policy and delivery. Many of the policies will come as a result of the delivery experience. We must work hand in glove with each other, which we do. It is not the case that the HSE has a different policy perspective and it would be unfair for anybody to suggest that. The HSE is very clear, as the Act specifies, that policy is dictated and where there are overlaps, differences or perhaps a difference of emphasis or need, those matters will be discussed and resolved in the normal way. The efforts of some to try to drive a wedge between the Department of Health and Children and the HSE or the Tánaiste and Minister for Health and Children and the CEO of the Health Service Executive will not succeed because health reform is too important. In my experience, if any two people attend the same event and give their perspective of the event afterwards, depending on how they emphasise certain aspects, listeners can often form a different impression. Forming impressions based on how people present would not be fair to Professor Drumm or me.

PPARS is under review within the HSE. In addition, the Comptroller and Auditor General will present a report to the Committee of Public Accounts shortly. As I informed the committee some months ago, we must learn from that experience and we are more likely to learn quickly and to put in place appropriate mechanisms for assessing expenditure, whether it is on technology or in other areas, if we have a single entity with clear lines of responsibility. We did not have that in the past and I hope the new organisation will greatly help to bring it about.

Professor Drumm and the board of the HSE asked Seán Hurley, who is the former CEO of the Southern Health Board, to carry out an assessment of PPARS. That process is under way. I am not certain when it will be completed but I am sure that he has the competence, expertise and experience to carry out a thorough evaluation. If PPARS is not appropriate to the HSE, it must be abandoned. It is currently suspended. If it is appropriate, it will be continued with but only if it is necessary and if it can deal with the payroll problems and the other issues a large organisation employing 100,000 people needs to address.

I have a difficulty in that seven members are offering but the Tánaiste is due to go to the Dáil. I will call Senators Glynn and Henry and Deputy O'Connor. Several members indicated at the same time and I took a note of their names as quickly as I could. I have a list and I will try to accommodate as many members as possible.

If people had listened to what we said at the outset, there would be no shortage of time.

Let us move on. I will try to accommodate everybody who offered. Senator Browne said he wanted to ask a brief question.

(Interruptions).

Will the Tánaiste be leaving at 10.30 a.m.?

Yes. The Tánaiste will make arrangements to come before the committee again.

I am not sure yet but it will not be today.

I welcome the Tánaiste.

Will the Chairman not just answer the question?

I submitted four concise questions to which I would like answers.

We will try to get to that point.

It was scheduled to be tomorrow. This was not explained to us——

I cannot discuss tomorrow's schedule. We are talking about today.

It was not explained to us that today's meeting would be cut short by one hour.

I call Senator Glynn.

Listening to the debate, I am surprised that the Tánaiste came here at all.

I flagged four issues with the Tánaiste, one of which is men's health. This is an issue I have tried to articulate in the Seanad for the past year and a half and I would like to hear the Tánaiste's view on it because it is an area that needs a great deal of attention.

Regarding type 2 diabetes, anybody who read the report on obesity will be concerned about that. What proposals does the Tánaiste have to address that problem and create increased public awareness of the condition? The most alarming aspect of this condition is the fact that many people have it but are unaware of it.

Regarding general practitioners, about whom I have been speaking to my colleague, Deputy Devins, and others, for the first time in my almost 27 years in politics, people are approaching me to see if I can get them on to doctors' panels. I am aware that there is a mechanism in place for that, either by way of community care or appointment to a doctor's panel by the relevant director, but the scarcity of GPs must be addressed. I am aware that the Fottrell report, which contains recommendations on the numbers, has been presented to Cabinet. There was an embargo in place from the mid-1970s. What are the Tánaiste's views on that and what proposals does she have in the meantime to address the shortage? I realise that we cannot pull GPs out of hats but there must be some mechanism we can put in place to address the problem.

Nurse training is another area in which I am interested. There will be a baby care unit in Mullingar which must be opened on a phased basis because we cannot get the appropriate trained paediatric nurses. That is the difficulty. Does the Tánaiste have any proposals she could bring forward, in consultation with An Bord Altranais, to see if this matter could be addressed? There are other nursing disciplines where there are difficulties in numbers, but I am sure that one will stand alone.

My colleague, Deputy Devins, referred to the health fora. There is a void between the service receiver and the service deliverer, which used to be filled by locally elected members on health boards. It is now almost a year since the health boards were abolished and that void has not been filled. Service receivers are frustrated that they have nobody though which to channel their views. That conduit no longer exists, so it should be reinstated as proposed, as soon as possible. I ask the Tánaiste to empower visiting committees from these fora to visit not only public facilities but also private ones. Any facility that is drawing down one cent of public money by way of subvention should be inspected. There are many examples as to why that should be so.

I am concerned about the issue of these private hospitals and the perception the Tánaiste seems to have about the 2,500 private beds. Some 70% of hospital admissions are emergencies. If private patients are brought into a public hospital, will they lose their entitlement to stay in the public hospital? If one manages to get into a public hospital one gets good treatment. Will people have to be transferred to these private hospitals, which may or may not have their own intensive care units, junior staff levels and nurses in training? If they do not have those sort of things, they are actually being subsidised by the public health care system.

The Tánaiste said that Tallaght Hospital has a higher percentage of private patients than public ones, while St. Vincent's Hospital has a lower percentage of private patients. From those catchment areas, one would expect the figures to be the reverse. The Tánaiste should remember, however, that hospital catchment areas are not necessarily geographic — they depend on the skills and disciplines that are being carried out in those hospitals. Tallaght is a major tertiary referral hospital for a large part of the country. I do not want to see people who are being encouraged to take out private health insurance and who, like myself, would prefer to stay in a public hospital, being put in a position where they must go to a private hospital. I am not asking for any preferential treatment in getting into a public hospital, but I just want to be allowed to stay there. Despite the fact that I have private health insurance, it seems that this entitlement is going to be removed and I feel that is a serious matter.

I went to Barcelona with Deputy Devins and Deputy Fiona O'Malley and we were impressed by the director of paediatric surgery we spoke to there concerning the way in which they organised their consultants' work. Targets were set by agreement among the consultants. In trying to resolve the common contract, I hope the Tánaiste will try to take into account the way in which consultants work in other jurisdictions, rather than just in the United Kingdom or America. I wish her good luck with that.

I wish to be associated with the warm welcome that has been extended to the Tánaiste. Normally in my contributions I would not mention Tallaght all that often, but seeing that it has mentioned by other speakers I probably will do so. Those of us sitting on the Government benches are just as worried and caring about the health service as anybody else. One does not have to sit on the Opposition benches, or be one of several would-be Ministers for Health and Children, to have a care.

Does the Deputy have a question, rather than an overview?

I do have a question.

This is not the Fianna Fáil Ard-Fheis.

I will not be afraid to speak up when I have to. Like other colleagues, I have also submitted questions to the Tánaiste so as not to put any of us under pressure this morning, but I would be happy to get the replies at some point. I raised a couple of local issues and I know the Tánaiste shares my concern over the need for the further development of health centre provision in the Tallaght area, particularly to sort out, at last, the Millbrook Lawns health centre, which is a big issue for me locally. I hope that, this close to Christmas, the Tánaiste might have some good news for me. There is also a need for such services in the Fettercairn area. Fettercairn is a local authority estate in Tallaght, which does not have any GP services or a health centre. If is was happening anywhere else, my colleagues on the left would be starving themselves to death against the railings outside.

I have also raised my concerns about orthodontic treatment, which need to be pressed home. My colleague, Deputy Fiona O'Malley, chaired a sub-committee on the matter. I was a member of the sub-committee and we did some good work on the issue. I hope there will be progress in providing orthodontic services.

The issue of equalisation keeps cropping up and I understand the Tánaiste will be making another decision on that at the end of December, which I presume will be same decision. There is some public interest in that issue.

Currently, there is much speculation about Our Lady's Hospital for Sick Children in Crumlin, where I used to live. That hospital has a relationship with Tallaght where I am now resident. There is much speculation and talk, some of it idle, about the decision the Tánaiste is going to make in respect of the hospital at Crumlin — where it will end up and whether it will move to Tallaght or elsewhere. I do not expect the Tánaiste to confirm anything now, but she should be aware that there is much interest concerning the issue. I wish the Tánaiste well and if she does not mind me being facetious, I would like to wish her a good day and a happy Christmas.

There were so few questions in that round that we could perhaps ask the next few questions. I call Senator Browne, Deputy Neville and Deputy Connolly in that order. Everybody will be brought in.

A report on sudden adult death syndrome has been due out for the last few months. When will it be published? I understand the Tánaiste has been briefed on it already. Many voluntary groups around the country are awaiting that report in order to proceed with the purchase of defibrillators, which will make a huge difference to rural communities. Therefore, the sooner the report can be published the better.

The national hygiene audit should be extended to nursing homes and non-acute hospitals. The Tánaiste said there will be two more unannounced audits next year, but they should be extended not just to acute hospitals but also to nursing homes.

I thank the Tánaiste for arranging a meeting last week about MRSA families. She heard about the disgrace over the lack of information on MRSA concerning patients who are discharged from hospitals to nursing homes and back into the community. I would like the Tánaiste to pursue that issue.

Senator Glynn referred to diabetes so I will not raise that matter, but I do want to refer to the disposal of clinical waste material at home. If one contracts MRSA in a hospital and is sent home, it can cause major problems. I understand that public health nurses called to patients at home to change dressings and do whatever else is required before taking waste material away with them. Those nurses were told, in turn, that they could not do that without a licence from the Environmental Protection Agency because the waste was hazardous material. The problem is that families do not know what to do with the material. Should they put it out with the ordinary domestic rubbish? No guidelines had been drawn up when I asked the Tánaiste that question in July. It should get priority within the Department.

I wish to make a final plea on behalf of the Cystic Fibrosis Association of Ireland, which made a powerful presentation to the joint committee. Funding has been promised in this respect, which is encouraging. However, I met someone yesterday who told me that their daughter had been discharged from hospital, but had to go back to hospital and was referred to the accident and emergency department. The person concerned spent another night on a trolley, which is not good enough in this day and age, especially for people with cystic fibrosis who have terrible medical cases. For many years, they have been promised funding by successive Governments, but I hope the Tánaiste will deliver on the commitment that has been given. It is not acceptable that an 18-year-old girl with cystic fibrosis should have to spend days on hospital trolleys, as is happening at present.

I also welcome the Tánaiste and Minister for Health and Children. I want to give her the opportunity to clear up a matter that has been hanging around during the past ten days. I refer to the issue the Leader of Fine Gael, Deputy Kenny, raised about the €2 million paid to a shelf company, Blackmore Group Assets Limited, in Guernsey for staff working on PPARS. To date, the HSE has refused to adequately reply to any of the issues raised by Deputy Kenny. The HSE is insisting that Blackmore is a UK-based recruitment company, when all the evidence is to the contrary. Based on the assertion that Blackmore is a UK recruitment firm, no withholding tax was deducted from the €2 million payment. Is there something wrong here? The HSE is either incompetent in dealing with this issue or it is simply covering up. Based on the HSE's response last week, is it fair to say that it cannot be trusted to investigate this matter properly? Has the Tánaiste and Minister for Health and Children been briefed on the issue? Perhaps she would inform us in respect of that matter. Is she satisfied that there are no tax issues involved? She will be familiar with the use of the Cayman Islands in the past for tax evasion. I hope this matter is not comparable and perhaps she will clarify the position.

The Tánaiste announced that she will be providing further funding for mental health services in the Estimates. Perhaps she will elaborate on where it is proposed to spend that funding and the improved services that will ensue as a result.

I will raise a few specific issues. Many general issues have been dealt with and I do not want to revisit them.

Many elderly people have been illegally charged nursing home fees. Some of them will not live to see a penny of the money that has been taken from them illegally. Is there any possibility that the Tánaiste could authorise a substantial ex gratia payment prior to Christmas? There are many people with bona fide cases and they would be known as such. Has the Tánaiste given consideration to paying them a bonus prior to Christmas, as a gesture of goodwill, and wrapping up the final details later? In light of the way legislation is being dealt with at present, it will be more than two years before any money becomes available. People cannot stomach the fact that when legislation was needed to legalise these nursing home charges, it was rushed through the Dáil in a short period. I seek a response from the Tánaiste on that matter.

The second issue, to which reference has already been made, is whether the Tánaiste and Minister for Health and Children has any plans to introduce risk equalisation within the private health insurance market. She could experience major problems in that regard, with the fees for specific elderly groups rising by possibly several hundred per cent. I would like her views on that.

On the possible arrival of avian influenza and the likelihood, if it does strike, that Roche in Switzerland will find it difficult to supply the world market with Tamiflu injections, has the Department considered granting a compulsory licence? I understand that under World Health Organisation rules such a licence can be granted to pharmaceutical companies here to make their own supply of Tamiflu injections. Has any consideration been given to that?

The Tánaiste and Minister for Health and Children may possibly be surprised to hear me raise the issue of Monaghan General Hospital. The Royal College of Surgeons in Ireland recently issued a set of recommendations. This was despite the fact that no reports or recommendations on Cavan General Hospital or Monaghan General Hospital were meant to be issued prior to the report into Mr. Pat Joe Walsh's death.

A related matter concerns the fact that the Royal College of Surgeons in Ireland issued this set of recommendations. It appears that the college must not have been in contact with its colleagues in Cavan and Monaghan because on 15 September last every consultant surgeon in Cavan and Monaghan sent a letter to the HSE requesting that Monaghan General Hospital go back on call for acute surgical services. If every surgeon in both of these hospitals stated that Monaghan General Hospital should, for a period, go back on call in respect of acute surgical services, that should not be ignored. These are the professionals who are expected to deliver surgical services in Cavan and Monaghan. However, their parent body, the Royal College of Surgeons in Ireland, has issued recommendations about sending all the consultant surgeons to one base in Cavan and then, on a daily basis, asking a surgeon to spend part of his time driving from Cavan General Hospital to Monaghan General Hospital and to be followed down the road by his registrar. If a surgeon enters his or her office in the morning and opens his or her books or whatever, then he or she must get into a car and drive to Monaghan. Quite a lot of valuable time, in fact two thirds of one session, is wasted driving in a car between Cavan and Monaghan, particularly when one considers it would take one third of a session to drive from Cavan to Monaghan and another third to drive back. This is a serious waste of resources.

Will the Tánaiste consider listening to the distress signals that these consultant surgeons in Cavan and Monaghan are sending out? They are flagging the fact that there will be problems. A small country hospital such as Cavan General Hospital is holding as many as 10% of its accident and emergency patients on trolleys on any given weekend. That is a serious problem and it is causing severe knock-on effects within the hospital in terms of the cancellation of elective surgery. I want to know whether the consultant surgeons who are expected to deliver this service will be listened to and whether the Health Service Executive will meet with them and take their views on board.

Could the Tánaiste and Minister for Health and Children let us know the timeframe for the restructuring of the VHI in the interests of delivering competition in the private health insurance market in Ireland?

Will the Department be formulating a sexual health strategy, given the incidence of sexually transmitted diseases in the country? In particular, we have a HIV-AIDs problem and it is not going away. Public awareness of the matter is not really being addressed.

I would also be interested in the Tánaiste's views about the Crisis Pregnancy Agency and Cura. The latter is in receipt of public money and is no longer honouring a service agreement. The public is entitled to clear information. Does the Tánaiste have any contribution to make on this? It is appalling that Cura is getting away with using public money without doing what was intended.

I welcome the Tánaiste and Minister for Health and Children. I apologise for being late; I was delayed at another meeting.

These are two areas which I raised with the Tánaiste previously. These concern two excellent groups that came before the committee. Can the Tánaiste see her way to granting the Post Polio Support Group the small amount of funding it requires? The group's presentation was impressive.

The group representing women's refuges throughout the country also made an excellent presentation to the committee. This is not only a matter for the Tánaiste's Department, as it spans approximately five or six Departments. With the day that is in it, I wonder if there will be any increase in that group's budget.

The Medical Practitioners Act has been in existence for 27 years and those governed by it are crying out for change. I understand that this matter is constantly in the forefront of the Tánaiste's thinking.

In support of my colleague, Deputy Fiona O'Malley, I also would ask about the sexual health strategy, particularly in light knowledge to the effect that sexually transmitted diseases among young people of all ages, some of whom are quite young, is on the increase. We need to take our heads out of the sand and talk about issues such as sexually transmitted diseases, particularly as they affect teenage children.

I apologise for being late; I was obliged to attend a meeting in my constituency.

I want to ask the Tánaiste and Minister for Health and Children two questions, the first of which concerns the alcohol products Bill. This Bill mysteriously disappeared off the list of promised legislation. Does she agree that alcohol is the most damaging, albeit legal, drug in Irish society? Knowing from much experience that self-regulation does not work, why has she allowed the industry to regulate itself? She has stated that if it does not work, she will introduce the Bill. What period of time is involved? For how long will the Minister provide for self-regulation? On the one hand, the Department is running advertisements on television telling people to drink sensibly but, on the other, they are outweighed by the number glamourising alcohol and encouraging people to drink.

I refer to water fluoridation. Ireland is the only country in the world that experiences mass fluoridation of water. The last time the Minister appeared before the committee, she stated the jury was still out on the issue. Has it come in to give its verdict? Has the Minister changed her mind, given that the latest evidence from a study conducted by a US university links water fluoridation with cancer?

I will try to deal with as many questions as possible. I apologise to Deputy Devins because I forgot to deal with the issue of the regional fora. The regulations have been drafted and I forwarded them to my colleague, the Minister for the Environment, Heritage and Local Government, as I am required to do under the Act. I expect them to be returned in a number of days. The fora will be established early next year. We will also have in place by the end of this year new regulations governing how the HSE interfaces with the Oireachtas. This will be useful, given the issues raised about the supply of information and connections between the two. The HSE is putting in place a parliamentary affairs division, the purpose of which will be to provide early responses for Members.

In response to Senator Henry, there is no question of somebody with health insurance being prevented from attending a public hospital. That will not happen and I do not know how that impression was created. I want to ensure nobody in a public hospital is given preference because he or she has insurance because that would be unfair. I accept the Senator's assertion that Tallaght and St. Vincent's Hospitals are tertiary referral centres. While tertiary services can only be provided on a national basis, the HSE is concerned that many people feeding into the Dublin hospital system could be appropriately cared for in their own region. We want to provide for regional self-sufficiency as much as possible. This is adding to the burden in a number of Dublin hospitals, in particular. Professor Drumm and HSE will introduce an initiative on the matter shortly, the purpose of which will be to provide, where appropriate, additional services for patients in facilities which are funded privately. For example, 40% of open heart surgery is performed in two private hospitals. A great deal of other complex work does not take place in private hospitals because of insurance-related issues and so on but much of the private work done in public hospitals is not charged to insurers on a commercial basis. The work involved and even the drugs used are heavily subsidised by the taxpayer. If we are to reach a point where access is on the basis of medical need and equality of treatment for every citizen — that is my ambition — I do not want to embed the current activities relating to private activity in public hospitals. I do not want to make the position worse. It cannot be changed overnight but over time some of this activity must be decamped to a more appropriate setting.

I refer to the status of VHI. I will bring proposals to the Cabinet shortly in this regard. This refers to its commercial status, not its ownership. VHI does not have a commercial focus. For example, it does not have to meet the reserve requirements of its competitors. This is not fair. If we want an active and dynamic health insurance market, it must be ensured all players are treated equally.

I am required before 26 December to make a decision on risk equalisation. Nobody should assume the same decision will be made as last time. It is not an automatic process. I am required by law to take into account the circumstances that have arisen in the market. Internal and external advisers advise me in this regard. We are involved in the consultation process required under the Act. We wrote to the players in the market to ask why risk equalisation should not be introduced. They have a timeframe within which they can respond and I must consider all those responses. I am a fan of risk equalisation which provides intergenerational support. It means young people with premiums in the main support older people in receipt of care. If we did not have risk equalisation, intergenerational support and community rating, which means everybody pays the same for the same products, regardless of age, health condition or usage, the health insurance market would be similar to that in the United Kingdom where only 11% of the population has health insurance because it is not affordable. I do not want a scenario where if one does not have health insurance in Ireland, one might not be covered by the public system. Only those at the bottom and with private health insurance would be covered and, similar to the United States, a group in the middle would not be entitled to care. I do not want that to happen in Ireland. The public system must provide health care for all our citizens on the basis of medical need.

I refer to men's health. When I took office, I thought there was a great deal of emphasis on women's health and wondered whether we should consider issues such as prostate screening. Having taken the advice of medical experts, the jury is very much out the issue. There is no evidence to suggest such screening would have a positive impact. I do not mean there are not major issues regarding how men access services but men are less likely to access health care and counselling services than women. During the past year six seminars on men's health and how we can ensure services meet their needs and are supportive of men coming forward were held. I very much share the views expressed by Senator Glynn.

Senator Glynn also asked about nurse training. I recently decided, for example, to introduce graduate education in paediatrics and general nursing which will comprise a four and a half year programme commencing next year. Midwifery training will also be transferred to the university sector through a four year programme. The two programmes will offer 240 places at seven centres. This was recommended by the Commission on Nursing and is the final piece in moving all nursing education courses to the third level sector. To date, the Department has invested €240 million in capital developments in the third level sector to provide for nursing education. The ongoing financial commitment is approximately €110million per year.

Diabetes was mentioned by the Senator. A major challenge for health systems globally — ours is no exception — is how to manage chronic illness in the community. The HSE feels strongly about this for a host of reasons. In 2000 a total of 3,000 people entered the acute hospital system suffering from diabetes. Two years later this number had increased to 4,000, a 33% increase. The most appropriate way to manage such illnesses is at community level. Therefore, a strong focus of the GMS negotiations and negotiations with doctors generally is on the management of chronic illness at primary care level but much more needs to be done. Podiatry services, for example, are necessary and particularly important for diabetics. The outcome of deliberations chaired by the chief medical officer of the Department, Dr. Jim Kiely, on the diabetes agenda is with the HSE for implementation. Lifestyle and preventive strategies are very important in this regard.

Deputy O'Connor asked a number of questions about his constituency which I represented previously. Planning permission has been granted for the Millbrook Lawn health care centre. The project is at tender stage and the Deputy can take it the Estimates and the plans of the HSE will advance it. Approximately 6,000 people live in Fettercairn. It has no GP services and is an area of huge disadvantage. The HSE has not yet identified that area as a location for a health centre. However, it is assessing the need in the area and I would be surprised if that is not the outcome. If there are innovative ways of providing that quickly, I will be delighted to support them.

Tallaght Hospital got €190 million this year and it may get more next year. However, that will be based on the hospital performing to the standard expected by the HSE. The HSE is in discussions with all the major hospitals, particularly, but not exclusively, with those in Dublin regarding their practices. Money will be given to them next year on the basis of performance and I hope Tallaght Hospital will do well in that regard. It is important that it should.

Senator Browne asked about sudden adult death syndrome. I recently had a discussion with Professor Brian Maurer who chairs the group. He gave me an outline of what the group will suggest. The report is almost complete and we will publish it in January. It is very important to train people to use defibrillators, and make sure people have access to them and know where they are. I know the Senator and his colleague, Deputy Timmins, along with other Deputies have a strong interest in this matter.

The Senator also asked about clinical waste. We have guidelines in this regard. He is correct in what he said about the group I met last week regarding MRSA. We learnt a number of things. Only their doctors should tell people that they have MRSA. The group we met mentioned that in one case the cleaning lady in the hospital advised people not to enter a particular room. That is not acceptable and I have asked the chief medical officer to get legal advice on what role we might have in asking doctors to inform their patients. This does not mean the infection is acquired necessarily in the hospital. In approximately 50% of cases the infection is acquired in the community. However, if a doctor becomes aware that a patient is suffering from an infection of that kind he or she should be told. When a patient is discharged back into the community, as the guidelines require, his or her general practitioner should be informed. We want to establish whether that aspect of the guidelines is being enforced, as there is some doubt in this regard.

I understand staff have been trained and informed regarding the handling of waste, for which guidelines exist. The public health nurse is required to take the waste back so that it can be disposed of safely. If there are issues in this regard, I will raise them with the HSE. That is the practice we expect should be followed for clinical waste, which should not be placed with domestic household waste.

In response to Deputy Neville, as the Taoiseach said in the Dáil yesterday, we have asked the HSE to report on the company which got the €2 million contract. I have no more information than the Deputy has at the moment. The Secretary General and I had a discussion with the chairman and the CEO of the HSE. They are endeavouring to establish the facts. I know there is no cover-up on the part of Professor Drumm, or the board or chairman of the HSE. We want all the facts on the matter brought into the public domain. I do not know the tax situation of the company in question. I know very little about the matter other than what the Deputy knows. We are trying to establish the facts.

On mental health services, one of the big disappointments this year and one of the reasons for extra money in the Department Vote was that we could not establish the tribunals. This goes back to what I said earlier about reform of the consultant's contract. This is pivotal to even implementing health services. We all know we are in breach of our international obligations regarding people who are involuntarily detained in psychiatric hospitals. The Oireachtas has passed legislation to establish tribunals to assess all these cases. Heretofore the psychiatrists were not willing to participate. It is a dreadful indictment on our society that the most vulnerable group should be ignored in this fashion. If we cannot get participation we will need to find alternative ways to establish these tribunals. They will be established next year.

In January we expect Professor Joyce O'Connor to publish her report, which will inform how the money is spent on mental health services next year. Essentially, as the Deputy knows, it is about developing services at a community level. On a recent visit to Castlebar I was happy to see that the old psychiatric hospital, which incredibly even in 1977 had 1,200 patients, is closing. It may have closed by now, as it was due to close in the autumn. Deputies from the west may be more familiar with this. Approximately 45 patients are in a psychiatric wing of the acute hospital there. The reduction from 1,200 to 45 represents an incredible improvement. This is the story in many places and it is a good story. The sooner we can make the story a reality for more people the better.

The savings that ensued from that programme were not transferred to community-based services and went back into the Exchequer.

The HSE is anxious that moneys realised from the sale of properties or land be used in the region of the sale. It is not possible to earmark all of it, as occasionally different priorities might exist. However, as far as possible mental health services represent a priority. It has been one of the areas of the health service that traditionally got least attention.

Deputy Connolly mentioned a number of issues including the elderly. We are very anxious to make those payments as quickly as possible. From a legislative point of view it has proved to be extraordinarily difficult owing to issues regarding wards of court and how moneys are handled on behalf of such people. We are in consultation with the Attorney General. We will introduce that legislation next year. Some €400 million will be provided next year to make payments, which will be made over a period of 18 months to two years. Clearly we would like it to happen more quickly. No payment will be made before Christmas. Many of the nurses working in long-stay institutions have said that in many cases the €2,000ex-gratia payment given last year is in the bank account. I am not certain that the elderly people are spending it. I hope that the elderly people who get this money will get an opportunity to spend it on themselves. Perhaps elderly people do not do this as much as they should.

They cannot if they do not have the option.

There is no issue regarding the anti-virals being manufactured in Ireland. Many pharmaceutical companies, including some of the world's major players, make drugs here and they employ 24,000 people. However, only a limited number of companies make these products. Next week we will take delivery of a substantial number, approximately 400,000 anti-virals. The big issue regarding a pandemic is a vaccine. The vaccine cannot be developed until the strain is known. Apparently development takes between four and six months from the time the strain is determined. We have what I believe is called a silent agreement to purchase a particular quantity of the vaccines in the event of a pandemic.

Ireland was asked to become involved in a European-wide pandemic planning exercise in which I participated on 23 November. All countries participated to ascertain whether our plans were up to date, how we should work with each other and what lessons we could learn. The exercise was carried on the basis that we had a real pandemic and how we would react in certain situations. An evaluation of the exercise will take place on 9 December at the European Council meeting that I will attend. It was a valuable exercise from which I learnt an enormous amount. Among the issues arising was the question of whether the schools should be closed. If schools are closed many of the health care staff with young children might stay at home. Huge issues arise. We are establishing an interdepartmental group as those issues are not simply a matter for the Minister for Health and Children. There are matters for the Minister for Education and Science and other members of the Government. The wider group will consider these issues and in so far as we can we will make decisions in advance.

I want to repeat what I said in the House some time ago about the hospitals in Cavan and Monaghan. We talk about patient-centred health care and the focus on patients, which mean that the patients must come first. Even when discussing IR issues the patients should come first. Unfortunately very often they do not. Ten years ago Northern Ireland had 41 surgeons operating in the cancer area and this has now been reduced to ten. Cancer surgery took place in 19 locations and this has been reduced to six. This has happened for patient safety reasons. We must learn from that experience. We have 35 hospitals that carry out some form of cancer surgery. While the Deputy did not ask me about cancer surgery, I use that as an example.

Patient safety must be paramount. However, the issue cannot be decided on by me because I am not competent to make such a decision. It has to be decided on by the experts available to us. If the Royal College of Surgeons in Ireland, the accreditation body for surgeons in this country, decides it is not safe to perform surgery in a particular hospital out of hours, for example, in the evening or over the weekend, I have to listen to it, even if it is unpopular to do so. I cannot second-guess the college's decisions. I do not doubt the eminence, experience and expertise of the surgeons in counties Cavan and Monaghan, but the reality is that the opinions of the professional body which accredits them have to be paramount. The decision in respect of counties Cavan and Monaghan was made on that basis. No long-term decision will be made until the outcome of the inquiry into the death of the late Mr. Pat Joe Walsh is known. We want to ensure there will be no other deaths. People are entitled to rely on the Minister for Health and Children to guarantee, at least, that patient safety will come first. I know it is difficult, but I expect Deputies to buy into this, notwithstanding the pressures they face from time to time. It is not me who makes the decision. It is a question of safety, rather than of resources, money or staff.

Who knows more about patient safety than the consultants expected to deliver care? They have said they have difficulties and want to their voices to be heard. They should be listened to by the HSE as they know more about the health and safety of patients than anyone else. The safety of their patients is the primary interest of those expected to deliver care.

The body which accredits surgeons and dictates where surgery should or should not be performed——

The word "dictates" is very appropriate.

I have mentioned Northern Ireland.

The body in question is not liaising with consultants.

I am certain that the decision to reduce the number of places in Northern Ireland was not taken because it was popular — it was most unpopular — but because patient safety had to be considered. Patient safety has to be paramount. I attended a discussion last Friday, at which Sir Liam Donaldson, the United Kingdom's chief medical officer, spoke about patient safety. I would love if Sir Liam who is a world expert on patient safety had an opportunity to address this committee at some stage. When I heard about what could go wrong in the best hospitals — I do not refer specifically to Monaghan General Hospital, Cavan General Hospital or any other — my view that patient safety had to be paramount was reinforced.

The Tánaiste should mention that the cancer treatment service in Northern Ireland is getting better results than we are in the South. This should be taken into account.

I agree with the Senator.

It appears there will be more than 30 patients on trolleys at Cavan General Hospital every weekend. That cannot be in the interests of patient safety. It is not right that 10% of all patients in the country are being treated in the way patients are being treated at Cavan General Hospital.

The Deputy is talking about a different issue. There are five hospitals in the north-east region, serving a population of 300,000. That is a very high hospital-population ratio. We need to organise services in such a way that makes it clear to people what is delivered and where. In my experience, most would prefer all facilities to be as close to them as possible. If one of one's loved ones is ill, one will want him or her to get to the best place with the best doctors, as quickly as possible, in order that the best results can be achieved. Senator Henry is right to state this country's cancer care outcomes do not compare favourably with those in the rest of Europe, mainly as a result of the manner in which we have organised our services. It is not fair or good enough.

It is important for patients to be able to access treatment in order that their lives can be saved and condition stabilised. I refer to the concept of the "golden hour". It is understood in all parts of the world that the sooner one treats one's patients, the better and more successful the treatment outcomes will be.

I accept that, but it is also important to treat patients in the most appropriate place.

Deputy Gormley asked me about the alcohol products legislation. It has been decided to make progress in that regard by means of a code of practice as a single Bill will not alter the fact that alcohol abuse is a major problem in Irish society. The cultural patterns endemic in our society need to be changed by means of increased educational awareness, for example, although that will take quite some time. One of the frightening aspects of the drinking patterns of the young people of today, as opposed to my generation, is that they seem to engage in binge drinking in order that they can be out of their minds within a short period of time. I am not certain about the role of advertising in that regard. As somebody said to me recently about a different issue, it is difficult to target campaigns at young people because they do not read the newspapers we read and do not listen to the radio programmes to which we listen. We need to be innovative in our use of forms of technology such as texting, for example.

Young people watch television.

The Government has decided to initiate a voluntary code of practice in the first instance. I was asked about a timeframe. I expect it will take a code of practice of this nature at least two years to have any impact.

At least two years, to be fair. I am a fan of the philosophy of "if it ain't broke, don't fix it".

It is broken.

If we want this to work, we need to give it a chance. I agree we have a great deal to do if we are to combat alcohol abuse as the lifestyles of every generation have been associated with alcohol. We have a long way to go — it will take much longer than many of us anticipate to develop a healthy attitude to alcohol in this country. Such an attitude does not necessitate encouraging people not to drink alcoholic products, as it can involve drinking in moderation and responsible drinking, which I favour.

The medical experts who have advised me at departmental, EU and WHO level take a contrary view to that of the Green Party on water fluoridation. That is a fact, although I accept there is an alternative view. I would like to think I am open-minded. If something needs to be changed because it makes good medical sense, I will agree to change it. If it does not, I have to maintain the status quo. That is the position on the fluoridation of water.

Deputy O'Malley asked about the status of VHI Healthcare, an issue with which I have dealt. She also raised the issue of sexually transmitted diseases.

I referred to the sexual health strategy.

The Deputy also mentioned CURA and the need for public information. The moneys which are provided through the Crisis Pregnancy Agency should be used for the transmission of information in a non-judgmental way. That is the intention. Perhaps I will raise the issue highlighted by the Deputy which has been in the public domain with the agency's officials when I next meet them. It is obvious that there is a need for a focus on sexual health and safe sexual practices. A great deal of the population health strategy being pursued by the Department of Health and Children's health promotion unit and the HSE relates to promoting good practice and safe and appropriate behaviour.

Senator Feeney mentioned the post-polio group which was seeking to be included in the long-term illness scheme, as I understand it. Nothing has been added to the scheme since 1975. Perhaps the matter could be usefully examined by the joint committee. I might examine this area myself. If something has not changed for 30 years, there is something wrong with it or what we are doing. I assume this area is governed by cost considerations. I have been informed that the extension of the scheme to cover asthma alone would cost €244 million. I know many individuals who suffer from general long-term illnesses and feel such illnesses should be included in the scheme. Perhaps the Department should examine it to ascertain how it can be targeted at those who need it most in a more relevant way. If it has not been altered in 30 years, it needs to be re-examined.

The Senator also mentioned the need for a medical practitioners Bill, which is a priority. When I attended the recent Irish Pharmaceutical Union dinner, the incoming president of the union informed me that on the night his father was made president of the union 25 or 26 years ago, the Minister of the day announced that legislation would be introduced in this regard. The new president of the union is hoping the Bill will be published in his term of office 25 years on. It is 27 years since the last medical practitioners Bill was introduced. I intend to introduce both Bills next year. They are at an advanced stage of the legislative process. To be fair to the Department of Health and Children, a substantial legislative burden has been placed on its officials in recent times, not only by issues relating to long-term stay such as the fall-out from the charges system, but also by the need for a great deal of reform legislation such as the Health Act 2004 and the forthcoming health information and quality authority Bill. While I accept matters have slipped slightly, I hope we are not too far behind. We will definitely have the legislation in question next year.

I asked two questions. I asked about the establishment of the representational forum which is long overdue and the shortage of general practitioners which presents a major problem in my area.

On the forum, I stated that the regulations are drafted and I have sent them, as required, to the Minister for the Environment, Heritage and Local Government, Deputy Roche, for comment. I expect to have them back from the Minister in a couple of days. The regulations will then be signed and the forum will be established early next year.

With regard to general practitioners, the annual intake to medical school was capped at 305, presumably for cost reasons. In this year's Estimates, we began the process of doubling the intake to medical school and increasing the number of doctors on the GP training programme. The most effective way of ensuring we meet our manpower needs in the future is to produce more medical students and graduates. However, wider issues arise due to lifestyle and, for example, the trend broadly known as the feminisation of medicine. The Minister for Education and Science, Deputy Hanafin, has a considerable responsibility in this regard, whereas the role of the Minister for Health and Children is to fund clinical practice and placement. Much of the responsibility for addressing this matter, therefore, lies with the education system. The Minister for Education and Science and I will shortly bring a joint memorandum to Government on the Fottrell and Buttimer reports, which we have already discussed. It is proposed to double the numbers in medical school and provide for graduate entry. It is then a matter for the Government to decide whether we go down this route. I am an enthusiastic supporter of the proposition to double numbers and have graduate entry into medical school.

Has the Minister given any thought to the requests I made to her regarding the representational forums and the question of visiting committees? These proposal would be extremely important in ensuring service recipients receive appropriate treatment in private and public institutions. I have spoken privately to the Minister on the matter.

Yes, the Senator has spoken to me about this issue. It is important the forum has a clear focus. Inspectorates, however, are the statutory duty of the State, rather than a political group. In saying this, I mean no disrespect to the forums which will be nominated by local authorities. As the Senator will be aware, we are expanding the social services inspectorate and placing it on a statutory footing. It will have a role in public and private sectors.

There is an assumption that public institutions do not need to be inspected. Major issues will arise with regard to some long-stay institutions, not in terms of the level of care but as regards the quality of the facilities. Many of these institutions are former workhouses and some have large numbers of patients in one ward. This year we provided some money for minor capital refurbishment of many of these facilities and more funding will be provided next year. Capital investment in many of these institutions will be required on an ongoing basis to bring them up to acceptable standards. The social services inspectorate will have this remit and it is not envisaged that the forums will have a role in this matter, nor would such a role be desirable.

If I were the Minister I would not close the door on that option.

I ask Senator Browne to confine his questions to the issue raised in his previous question.

On the shortage of general practitioners, a significant group of people, for example, patients with heart disease and blood clotting disorders, including those taking warfarin, must have their blood tested regularly. They seek to have anti-coagulant strips provided on the medical card scheme. Would this proposal not make sense in that it would free up doctors' surgeries as patients could test the thinness or thickness of their blood at home? This group of patients has been waiting since July 2004 for a response from the Department.

The GPs are waiting.

No, the patients are waiting.

This is the first time the issue has been raised with me. The Senator's suggestion sounds sensible but I would like to find out if GPs are a factor in this. The doctor-only medical card was enthusiastically welcomed by the president of the Irish Medical Organisation on "Morning Ireland" on the day after it was announced. However, we were not prepared to pay a large amount of money to have it implemented, even if this could have been done the following day. If doctors are in a position to implement the Senator's proposal, it will not come without significant cost, whereas if it is something patients can do——

No, this is——

The many doctors present will understand what I mean.

The suggestion is that patients would check their blood in the same way as other patients check their glucose at home. The instrument required for the procedure is similar to a glucometer. Patients carry out a small test which involves making a minor skin prick.

Is the procedure not available on the medical card?

How much does it cost? The Deputy should know. It sounds like a good idea and one on which the joint committee could make progress.

Each test should cost approximately €5. Patients would usually test their blood about once per week but some might do so only once a fortnight or once a month. The procedure is required more often if a patient changes medication and the machine costs about €400 or €500.

The proposal seems sensible to me.

As regards the doctor-only medical cards, the Minister had an opportunity to introduce 30,000 full medical cards but failed to do so.

The Deputy announced that the Fine Gael Party, in Government, would introduce the doctor-only medical card to every child aged under five years. At least his party has bought into the concept, which I welcome although I do not agree with the specific proposal.

The Tánaiste also knows that I announced that I considered a doctor-only medical card a good idea before she announced it in the Estimates last year.

Yes, the Deputy announced it in the same week I did. While I was delighted he supported the idea, I have not noticed his support over the past year.

I thank the Tánaiste and Minister for Health and Children, Deputy Harney, and her officials.

The joint committee went into private session at 11.25 a.m. and adjourned at 11.50 a.m. until 9.30 a.m. on Wednesday, 19 January 2005.

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