I move: "That the Seanad do now adjourn."
I may be wrong, but to be on the proper side I would like to welcome the Minister. I am not sure if he has been here before in his present term of office. If he has, I do not think I met him. I met him in another forum in Cork a long way from Roscommon in which he has some very interesting things to say. I hope, in passing, that the things he had to say then have not got lost in the welter of chaos and confusion and upset that has descended on us, particularly in the area of children's legislation.
I do not think, a Cathaoirligh, that the words I used in seeking to have this matter discussed were an over statement in any way. It seems from week to week, and indeed from day to day, that crisis piles upon crisis in the health services. It is getting to the stage where I, or any Member of this House, could almost every week propose a motion under Standing Order 29 to adjourn the House to discuss a matter of urgent public importance. One week it is the closure of hospitals; another week it is the reduction in the number of beds; another week it is the appalling situation in my own home city where the victims of miscarriages are now consigned to the same ward as the women who are celebrating the births of their children; another week it is the return almost to 19th century custodial conditions in psychiatric hospitals; this week it happens to be the industrial action taken by junior hospital doctors or by non-consultant hospital doctors.
The term "junior" is a particularly unhappy and offensive phrase to people many of whom are senior to me. Whatever claims I make, and all politicians make extraordinary claims, I no longer qualify for either the minor or the junior team. In fact, I am probably too old for the senior team at this stage. They are not junior doctors by any means. Many of them are extremely well qualified. Many of them are at an advanced level of training and experience.
The best way to avoid accusations of special interests is to reveal them yourself. I am married to a member of the medical profession who was, until recently, a non-consultant hospital doctor and is now even more vulnerable because she is a temporary consultant and, therefore, comes under the gimlet eye of those who want to reduce the numbers in employment. She is not on strike. Therefore, I am not directly affected by this issue and that is why I felt happy to raise it.
Non-consultant hospital doctors are a particular breed within the medical profession. I have had many harsh things to say here about the medical profession even though, as I have said frequently, they are in large part constituents of mine and, therefore, I am not doing myself any great favour by some of the things I say about them. Within that category the conditions of work and the salaries paid to non-consultant hospital doctors are nothing that any respectable trade unionist would make a huge song and dance about. It is very easy for people to produce scales of salary for juvenile consultant hospital doctors, but the salary scales presuppose a number of years working at the job.
The actual minimum levels of payment for non-consultant hospital doctors are quite low and are not different from, and in some cases are less than, the salaries paid to people of comparable levels of qualification and education. I accept, of course, that there is a section among the consultants who are both ripping off the hospital service, ripping off the State and, indeed, ripping off patients. Very often patients are charged for the services of people who are called junior housemen who never see any of the fees paid to those junior non-consultant hospital doctors.
It is one of the peculiar ironies of the philosophy of the medical profession that intolerably long hours are apparently acceptable when they are being worked by the most junior, those who are least competent, least trained and least experienced. They are the ones who are expected to work extraordinarily long hours in extraordinary circumstances. I refer in particular to the interns, followed in their turn by the house officers, by the registrars, and by that rare specimen in Irish medical circles, the senior registrar, and then by the only permanent medical positions in the hospital services, the consultants. It is important that the public at large understand that there is only one grade of permanent employment within the hospital services on the medical side and that is of consultant. Every other grade is a temporary appointment for six months or a year, open to reappointment, renegotiation or dismissal and in many cases people are dismissed. That is why this industrial action took place so quickly because at the end of June all, or virtually all, of those on strike at present will be up for reappointment and they know, given the draconian measures that have been taken and are currently being taken, they are well and clearly targeted as being in a major area for cutbacks. That is not the only area for cutbacks.
If I have any criticisms of the doctors — and I have a number — one is the unfortunate refusal of the Irish Medical Association, which claims to be a trade union, to identify and affiliate with the campaign of the other health service trade unions to protect the health services. I am somewhat astonished that the journals which circulate amongst the medical profession. The Irish Medical Times and the Irish Medical News seem to have taken the most astonishing crisis in the health service totally in their stride and by and large confined it to the inner pages as if it were a minor hiccup in the continuing development of the services.
I have a distinct feeling that the action of the non-consultant hospital doctors and their hopes and intentions to extend their actions is not viewed with much enthusiasm by many of their senior colleagues in the medical profession, the consultants, or, indeed, by their own organisation. I await proof to the contrary. It appears that in many health boards the consultants, who are members of the health boards, voted for these cutbacks. The fact that their own organisation has kept its distance from the remaining groups campaigning to protect and vindicate the health services suggests that these non-consultant hospital doctors are the expendable commodity in the medical establishments' fight to defend not the health services but their own interests in the health services. It is true that those who are established as consultants in the health services will not lose as a result of these cutbacks. In fact, they are likely to get rich following these cutbacks because those who cannot get access to a reduced, if not entirely castrated, State health service will pay through insurance for what was up to then their entitlement.
It is important to remember that astonishing things are expected from non-consultant hospital doctors: hours of work, hours on call that defy description. People are on call for periods of 80, 90 and 100 hours a week. Many of them work a large part of that time and many work 24 hour days without sleep. I have never been able to understand how it was acceptable in a profession where judgment, understanding and proper rational analysis was so important that these sort of primeval conditions could be tolerated. I cannot, therefore, accept any suggestion of further cutbacks in this area, any more than I can accept cutbacks in any other area of frontline medical care in this country.
I was quite astonished to hear the Minister for Health referring to the number of acute case beds per head of population and comparing us with a number of other countries. One of the countries be compared us with was our nearest neighbour. What has emerged over the last three or four weeks in Britain is that the state of their health service is no model for anybody's health service. The idea that Thatcherite versions of the national health service would become acceptable models for our own seems to be reprehensible in principle and also reprehensible in terms of the philosophy that underlies it.
Some of the figures quoted about either the number of acute case beds we have, or the expenditure on our health services, are the sort of cosy figures that right wing economists, with their allies in the media, have foisted upon us for the past three or four years. One problem within the media is that the numbers of people who are actually constantly numerate are few and far between. Consequently, when an authority figure, masquerading as an independent economist, says, this figure is awful, this figure is unrepresentative or this figure shows poor levels of performance then of course newspapers accept this.
It would be invidious of me to name names, within the privilege of this House, but there is no doubt that a number of economists have contributed to a level of public acceptability in the area of cutbacks in the health services that is based as much on their politics as it is on their economics. For example, the alleged large proportion of our gross national product that we spend in the health services is in the region of 6.9 per cent to 7 per cent, which is as high as many countries with comprehensive health services. The truth is, as has been pointed out frequently, that if we were to run a comprehensive national health service the actual proportion of increase on what we currently expend would not be very large, because up until now a large proportion of the population had access to free hospital care, to both accommodation and to the hospital services, and 40 per cent of the population have medical cards and have access to full general practitioner service as well. The actual extra cost would not be very large.
Let us look at the figure of 7 per cent. We have talked about acute case hospital beds, for instance, and the alleged large numbers of them. This country has a birth rate which is virtually twice that of any other country in Europe. We also have one of the best standards of maternity care, or we used to have until recently, in the world. We have an infant mortality rate which is lower than that in the United States, which is four times as rich as we are. We have an infant mortality rate which rates with the most developed countries of Europe and of North America and we are not nearly as wealthy or not nearly as rich as any of those countries. We did it because we chose to do it and because we believed that it was a good thing. One cannot have the levels of maternity care of the wealthiest countries in the world proven and demonstrated by our impressively low infant mortality rate without putting the resources into it.
The idea of many of these economists which, unfortunately, both the alternative Government and the present Government have swallowed, that we are spending too much and therefore spending inefficiently on a large scale on our health services is palpable nonsense. The cost of health care will not vary between Ireland, Britain, the United States and Germany. You will have to pay for the equipment, for the buildings, for the medicines, for the technology and, in a free labour market, you will have to pay for the labour. Therefore, you cannot provide west European standards of health care on the cheap just because you happen to be a poorer country.
About 25 years ago we made a choice that in the area of maternity care we would provide a maternity service as good as any available anywhere else in Europe.
A great man, a man who was pilloried at the time, Noel Browne, was the initiator of much of that. Noel Browne did no more than work from the legislation that a Fianna Fáil Government had introduced in 1947, legislation which was described by one member of the hierarchy as reminding him of the worst excesses of Stalin and Hitler because it actually dreamed to suggest socialised medicine.
That was the history of this country and that is why we, a poor country in terms of the developed world, the 26th richest country in the world, have an infant mortality rate lower than that of the richest country in the world. When you bear in mind that we do not, and quite rightly so, allow abortion in this country and therefore high risk pregnancies and handicapped pregnancies cannot be terminated and that therefore the large number of pregnancies in this country which would be terminated in other countries go their full term, the achievement of such an astonishingly low level of infant mortality is a proud boast. You will not find any of our right wing economists referring to this when they write their detached, academic essays on the state of our health service.
If you are going to accept the ideology which stands behind the scale of cutbacks now being imposed upon us then you are effectively saying to mothers and children, "We can no longer afford that level of maternity care". We have already seen in the Erinville hospital in Cork that women who have had miscarriages and who need bereavement counselling and support have no longer got separate accommodation and now have to share accommodation with women who have just had babies. That is the direct antithesis of a caring service and that is what is being done in one hospital in Cork.
That is part of what we are doing. If you add on the fact that we have a huge young population and that children up to the age of five tend to need more medical care, the disproportionately large number of old people that we have, and that for reasons to do with history, isolation etc., we have significantly higher incidence of mental illness, then it is understandable that we have a large number of acute and long term hospital beds. When you understand as well that we actually believe in looking after our old people and that we cannot just abandon them because they have not made provisions for themselves, this allegedly excessive level of expenditure in the health services is put in perspective. It is in that context that this industrial dispute should be judged and deserves to be judged.
This industrial dispute is about the front line quality of care in our hospitals. We have had nurses dismissed, we have had other people dismissed and we will now have a large number of doctors dismissed. It is not my intention in any way to suggest that the doctors are more important than anybody else, it just happens to be this week's part of the savaging of the health services and this week's part is just one part of the continuing process. Because of that, it was most regrettable that the offers by these doctors to negotiate a different way of achieving the same savings which would not involve the same level of redundancies, to involve themselves in cost-cutting negotiations, in cost-cutting procedures, to accept some redundancies, were not accepted. The diktats of the gurus of the Stock Exchange have insisted that the Government must show no flexibility in the area of health care, no flexibility in the area of welfare, no flexibility in the area of education, not because the Government do not wish to and not because, unlike our friend in Britain, the Government actually do not believe in a health service.
This Government do. I know the history of Fianna Fáil. It is because economic absolutism of a particularly repulsive kind has dictated to the Government that they must be seen to be hard on the health services, they must be seen to be hard on social welfare, they must be seen to be hard on education or else the Stock Exchange will not wear it, interest rates will rise and the financial markets will turn downwards.
That is the motivating force behind these cuts. There are plenty of other areas in which expenditure could be reduced. It is astonishing, at a time when psychiatric patients in Cork are threatened with expulsion into a world that, in some case they have not seen for 40 years, that we spend nearly £5 million on the FCA every year. It seems astonishing that we can produce a 7 to 10 per cent increase on headage payments to produce more of a product that nobody wants to buy and spend £70 million on this in the current financial year and still tell women who have lost babies that, "You must share wards with people who have just had the joy of a healthy childbirth".
It seems astonishing that we can tell hundreds more of our young doctors, "You will have no job" while at the same time the old, the sick and the infirm will be confronted with longer and longer queues, longer and longer waiting lists and the glib assurance, "All you have to do is pay your few bob to the VHI and all these queues will miraculously disappear". It seems astonishing that we can pillory people who attempt to defend the health services as either unrealistic or worse. It seems astonishing that we are told that people will not die. Perhaps that is true because we will probably make sure people will not die. One of the convenient reasons for tackling the psychiatric service is that whatever happens to psychiatric patients they rarely die directly as a result of psychiatric illness. They may die as an indirect consequence of it but you can discharge psychiatric patients, you cannot admit psychiatric patients, you can give them poor treatment and, conveniently, the one thing they will not do, unless they commit suicide, is die. Therefore, it is easier to say that people will not die because of these things, particularly when you tackle the psychiatric service. People will suffer enormously; they will die as an indirect consequence of it; the incidence of suicide will increase.
There is evidence from medical literature that the disturbances in psychiatric hospitals, movements in wards, reductions in staffings, all have a profound effect on psychiatric patients and produce a significant increase in tendencies towards suicide. At the centre of what looks like yet another industrial dispute is another manifestation of the simple fact that there is not an enormous amount of fat on the areas of the health service that are being decimated in these cutbacks. Areas of waste have never been identified; areas of the cavalier use of public facilities by private consultants for their private gain have never been quantified. We still do not know what proportion of the time of our public hospitals, what proportion of the resources, what proportion of the capital costs, what proportion of the running costs are actually consumed in the interests of private patients paying private fees to private consultants.
How can we talk about reducing the burden on the State of the health services until we know what proportion of the State's expenditure on those services is actually directly or indirectly subsidising the incomes of some of the wealthiest people in our society? What do we do? We give them a common contract which must be unique in its terms. I have seen that contract and I have not seen any other contract between any State body and its employees that bears any comparison with it. I am a professional within the public service; I am on a salary scale, which is not as large as that of a consultant but it is comparable with it. My contract is quite specific about my duties, quite specific about what my employer is entitled to expect of me, quite specific about the limitations of the expenses I can claim, quite specific on the fact that I cannot carry out any additional work without the approval and permission of my employer. My employer is entitled to be satisfied that that work will not interfere with my first duty, which is to my employer, the City of Cork VEC.
In the case of consultants you have no such guarantees. You have escape holes and bolt holes written in in language that I have not seen in any other contract. That contract has been due for renegotiation, or for re-writing, for at least a year if not two years, and that still has not happened. It would have been a very healthy place to start if you wanted to win over public opinion that these health cuts were meant to apply fairly, to apply best to those who could most afford to carry them, to have started with those who have done best in terms of their own income. Instead we have a position where those who have benefited most will get richer because of the cutbacks and those who have benefited least, whether they be paramedics, junior doctors or the ordinary people, the domestics who cook the food, the people who clean the floors, the occupational therapists etc., because they are in temporary appointments, are easily let go. They have no contractual obligations which cause problems.
All the evidence in the area in which I live is that far from having a strategic plan based on an assessment of relative need and on an assessment of where cutbacks could be achieved with the least affect on ordinary people, what is being done is that the areas which are easiest to dispose of, the areas which are most likely not to answer back, are the ones which are being targeted. I do not understand why we have accepted with extraordinary fatalism the fact that these things must happen. It will be only in a year or two, if — I hope it is only an if — things like the infant mortality rate begin to go up that we will realise what we have given away, what we have thrown away.
If cutbacks in the health service were needed they should have been preceded by a proper analysis of expenditure in the health service, a public debate which identified where there was waste and excessive capacity and not on the basis of spurious international comparisons. Because of our unique demographic conditions we could not make a real, valid international comparison. If that identified areas of waste, I doubt if it would identify significant areas of waste, it would be easy to get public opinion to accept it. I do not accept that you can tell somebody in Bantry, "If you happen to be pregnant now you can take a 50-mile trip to the nearest maternity hospital in Cork."
Very often those who draft these plans and the economists who advocate these plans mostly live in Dublin where they have a choice of three maternity hospitals within a five or ten minute drive of where they live. It is only economists who can come up with these extraordinary notions and ideas that you can do a cost benefit analysis based on cash inputs and cash outputs and decide what is good health care. At the centre of health care are the feelings and needs of human beings. People who are told that because it is more efficient in terms of money they must now travel 50 miles where they previously travelled ten miles do not see it in terms of a saving to the State. They see it as an imposition on themselves.
The tragedy of what we are doing and what is going on, which seems to get worse from week to week, is not that we have largesse in the public health service which enables people to do very well out of it, or a kind of affluent national health service which spent money as if it was going out of style. We had a very limited health service in terms of what it could deliver but which delivered that which was minimally necessary to provide basic civilised standards of health care. We now have a health service which increasingly is a network of patches with gaps between the patches, with places which people can fall through, places where people can be missed, places where people will be without early diagnosis, proper treatment, proper after care etc.
We are actually allowing people whose interests are not in the area of health care, whose interests are not in the area of public health generally, who believe in a very crude, marketed, economic version of health services, to dictate to this State how we should look after our service. I reject that and I particularly reject the idea that money is not available. If international interest rates rose by 10 per cent next week we would find the money to pay the interest on our national debt and not one member of the Government or Opposition would say we cannot afford it, but when it comes to health services, to education and to welfare we can turn around and say of course we cannot afford it. We can afford it if we want to afford it, if we choose to afford it. The truth is that none of us who talk about this and take decisions about this will be affected by these cutbacks because we can pay for our medicine, we can pay for our education and we will not need welfare.
