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Seanad Éireann díospóireacht -
Wednesday, 24 Oct 2001

Vol. 168 No. 8

Health Services: Motion.

Mr. Ryan

I move:

That Seanad Éireann condemns the present Fianna Fáil/Progressive Democrats Coalition Government for its gross mismanagement of the health services, thereby causing untold suf fering to the weakest and most vulnerable of our people.

Much as I like the Minister of State, Deputy Moffatt, I am intrigued that the Minister, Deputy Martin, who has found many opportunities to criticise the Labour Party's policies on health care and, in many cases, to make outrageous claims such as that we are going to close hospitals and so forth, declined the invitation to discuss this matter. Instead, he sent a likeable but junior Minister to deal with it. It probably reflects the Minister's view of Seanad Éireann; it clearly reflects his view of the Labour Party and might reflect his continuing despair at his inability to have any significant influence on Government on this issue. No doubt he is otherwise engaged in yet another stunt to secure publicity, perhaps for sponsoring a sporting occasion or the like or making nice rhetorical flourishes about under-age drinking. However, he is not in the Seanad to discuss the health services.

Perhaps the Government does not think there is a problem. It is only five months since the Taoiseach was quoted in The Irish Times as saying that there was no crisis in the health services. That is bad, although it is the type of rhetorical phrase one expects from politicians. However, he went on to say that it was an “excellent, well resourced health service” on which more than £5 billion was spent each year for a population of almost four million. I will wait to hear the Members on the other side of the House make their contributions. I do not expect them to say that little bits have been done on the margins, that bits have been added here and there and that they have a good PR conscious Minister who is forever flagging things that cost buttons by comparison with what the health service needs, but that the health service in each of their constituencies is excellent and well funded. I then expect them to go back to their constituencies and tell the people who work in the health service that the health service is excellent and well funded; “the Taoiseach says so and we believe it”.

Everybody in the country knows that the health services are a mess. Quoting numbers in absolute money terms does not get away from that fact. I have no wish to recite all the things that are wrong but one item that appeared in the newspapers at the end of last August sums it up. Consultants in the James Connolly Memorial Hospital, Blanchardstown, were told to reduce their workloads because they were overloading the hospital's administrative system. The doctors were working too hard for the bureaucrats. Was the solution to make the bureaucrats work harder or to simplify the system? No, it was to deal with fewer patients.

That sums up the crisis in the health services, quite apart from the 28,000 people who are waiting for services, the number of people who turn up in hospital accident and emergency departments and wait endless hours for treatment and the large number of people on middle incomes who find the prospect of needing a GP for their children horrendously expensive. There is a degree of detachment among many people in Irish life when they can think that spending £25 on a GP is something nobody need worry about. People should look at the Revenue Commissioners' returns to see the number of couples with children who live on less than £20,000 per year, perhaps less than £15,000. For those people, £25 is an enormous amount of money. If they have two or three children they have to think about whether they should ask the doctor to look at the child because he or she might have meningitis or take the chance that the child is okay and keep the money to pay for something else.

It is one of the myths of the last five years that this type of thing no longer exists. The reality is that GPs in the private sector can charge what they wish. Demand for their services to a large extent exceeds supply. However, and I must say this before Senator Fitzpatrick jumps down my neck, the GPs' part of the GMS, as far as it goes, is the best part of the service. Nevertheless, it is over-stretched with an ageing population of doctors and increasingly reluctant to get involved in single practices for all sorts of reasons with which nobody could argue.

Do we need further examples of the crisis? There are 800 hospital beds for planned medical admissions in the Eastern Regional Health Authority area, which serves 1.6 million people. That is probably about 50% less than is needed. In fact, the Eastern Regional Health Authority estimates that it needs a further 325 beds in this category but it only has the resources to produce 53. One can go through every health service in the country. Last September the Inspector of Mental Hospitals said there were not enough psychiatric beds to deal with psychiatric admissions, long stay and acute.

How many more facts need I put forward to convey the message to the governing parties? They will get their answer in the general election; of that I have no doubt. A previous eminent Leader of Fianna Fáil admitted during a general election that he did not realise how bad the health services were. That election exploded in his face. It will become the main issue in the next general election. If Fianna Fáil is to do anything about it – the Progressive Democrats have effectively ceased to exist as an independent entity – the fundamental conflict at the core of that party will have to be resolved. That conflict arises from the fact that the problem with our health services is that they are hopelessly under-funded, by any international comparison, to the tune of billions of pounds annually.

When the Minister, Deputy McCreevy, who controls the purse strings, wonders aloud why things have not got better after his spending so much money, he is illustrating the nature of the problem, which is that he and some of his colleagues will not listen. The Secretary General of the Department of Health and Children explained to him in Ballymascanlon precisely where the money went. It was used to replace clapped out equipment, to fill some of the major gaps that were created by the disastrous cutbacks of the 1980s, to provide additional services for children and to provide the necessary additional services for those with disabilities. Little of the money needed to deal with acute hospital services and the general medical service was provided. This country was the only member of the OECD to reduce the proportion of GDP devoted to health care between 1980 and 1990. All member states encountered an economic crisis during that time, but Ireland was the only country to make such a reduction.

The Minister for Finance does not understand where the money is going because the Government does not want to understand, which brings me back to the fundamental conflict. The conflict does not centre on the way in which my party or Fine Gael believes health services should be run, but it is about whether one believes it is worth spending money to have a good health service. The fundamental problem we face is that the health services are hopelessly under-funded. The Government decided when it took office in 1997 that its priority was not to use our new affluence to provide better public services but to cut taxes time after time, loaded mercilessly in the direction of the well off. In the last budget, 60% of the cash dispersed by welfare increases and tax cuts went to the top 30% of income earners. While the top 30% of income earners may be the natural constituency of the Progressive Democrats, or what is left of that party, they have not always been the natural followers of Fianna Fáil. The fundamental conflict faced by Fianna Fáil is that it does not want to do what its constituency demands.

This country needs to resolve the conflict between the need to provide funding and the ideologically driven view that tax must be reduced. The issue of quality can be addressed following the resolution of the conflict. It is nonsense to suggest that one can talk about quality systems to those who work in a health service that is close to collapse and who suffer from exhaustion and overwork. If the Government says it will provide the extra billions of pounds needed each year to fund a decent health service, it can say to people "in return for this money, we want to negotiate quality care systems". The way the Labour Party proposes is the correct way.

It would be wonderful to argue about how the resources needed for a health service will be spent, but we are instead faced with a dreadfully frustrating debate. Instead of a good and useful debate, the biggest political party in the State is pretending to be in favour of good health services and pretending that such services can be provided cheaply. The Progressive Democrats are involved in this conspiracy to deceive by claiming that our problems can be solved for £100 million per year. No member of the OECD has provided good health care with the levels of expenditure that have been committed to the health service by the Government and it will not be done in the future. Fianna Fáil, in whatever manifestation it takes after the next election and I hope it will be in opposition for a long period, has to reconcile itself to the fact that in a modern, social democratic Europe, good health care can only be achieved by paying for it. If Fianna Fáil does not accept that fact we are condemned to a succession of further disasters.

Senator Ryan has outlined clearly the shambles in the health system. I will listen carefully to what speakers on the other side have to say about the amendment they propose to make to the Labour Party's motion. It is a pathetic amendment, short on specifics. The assertions made in the original motion that the health service has suffered from "gross mismanagement" during the last four and a half years and that "untold suffering" has been caused to the most vulnerable in the community should be accepted. The Government should state what it intends to do about the problem.

It is incredible that the amendment refers to "unprecedented increases in health funding". How have the unprecedented increased funds been spent? The amendment says that additional funding has led to "significant improvements in a range of important services". Where are the significant improvements? I look forward to hearing about where they have taken place as I cannot see any evidence of them. It takes the biscuit that this House is called on to endorse "the process which has been adopted to facilitate the development of a new health strategy". After four and a half years, the Government is talking about a new health strategy. What has been done with the enormous wealth the Government had when deciding its last four budgets? We have had five surplus budgets in the history of the State and this Government has squandered four of them.

The health service, the most important service of all, is the most neglected. I can go through the litany of its inadequacies. In the last four and a half years, the Government has recruited 4,000 administrative staff but only 2,000 nurses, which demonstrates an unusual proportion of priority. We need people at the coalface to deal with the problem. During this Government's term of office, wards have closed, waiting lists have grown and there has been a shortage of all health professionals, including general practitioners, consultants, orthodontists and psychiatric care workers. There are acute shortages of people to work at the coalface as there has not been enough recruitment. Administration is the only area in which there has been substantial recruitment. The service has been mismanaged and nothing has been done to improve its efficiency or to reform it. It is the great black mark on the Government's record.

It is ridiculous for the Taoiseach to say that there is no crisis and that we have a good health service. He is the only person in the country who thinks so. I bet that no Senator on the other side of this Chamber, or the Minister of State, will say tonight that we have a good health service. The health service is lousy and in a mess.

No, it is not.

Every citizen, including Senator Fitzpatrick, the front bench spokesman with whom I share a constituency, knows as well as I do that the health service is a mess and I am sure the Senator will be forthright and will say so.

Waiting lists are a symbol of the failure. People are suffering everywhere as they do not know when they will be treated, which is a scandal. We must not forget that those on waiting lists are the vulnerable, the ill and the young. The health system has been ignored for four and a half years. What does our wonderful Minister plan to do? He will give us a new health strategy in the Government's last five or six months. It is ridiculous and an insult. The track record on this issue warrants a request for the resignation of the Minister and his Government who have failed to use money properly to provide a decent health service.

In my constituency, the Rotunda Hospital could not receive capital funding of £1 million for a pre-natal centre. The oldest maternity hospital in the world has been in danger of losing its status for four or five years. It only recently received some indication that it will be fine, but it had to wait until the last moment. Temple Street Children's Hospital is one of the most wonderful hospitals in the country and it has tremendous nurses. However, they and the doctors work in atrocious Third World conditions and there is no sign of the new hospital that was promised at the start of the Government's term in office.

The Labour Party has put forward a comprehensive health policy document. I hope the Minister has read it and that Senators on the Government side will also read it.

Was it circulated?

I will circulate it for the Senator. I am sure it would be good bedside reading for all the Senators on that side. However, our proposal is for a free GP service for everybody and a universal insurance service. As my colleague said, the cumulative amount of money spent on health was greater than in any previous year, but it is still proportionately one of the lowest figures in Europe; it is far behind the European average. The Labour Party has also proposed the immediate recruitment of another 5,000 nurses, 1,500 general practitioners, 800 hospital consultants, 660 physiotherapists, 660 speech and language therapists and 510 occupational therapists in addition to the provision of an extra 4,800 acute hospital beds and at least one new hospital in Dublin.

The Senator can take over in the morning.

This work would begin immediately and would be completed within a five year period. This would bring Ireland in line with average spending in the European Union. It does not involve a dramatic increase in spending; the sum involved matches the European average. This is the way forward and, in the absence of any other proposals, I hope the Government side will withdraw its amendment, read our document and decide to accept Labour Party policy on this issue.

The Senator should be careful or we might steal his ideas.

I move amendment No. 1:

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

"commends the Government for the unprecedented increases in health funding which it has been implementing since 1997; recognises that this funding had led to significant improvements in a range of important services; and endorses the process which has been adopted to facilitate the development of a new health strategy".

Undoubtedly, the Labour Party will support this amendment. I am glad Senator Costello recognised that the Rotunda Hospital received £1 million and he is aware that Temple Street Children's Hospital is moving to a new site on the Mater campus.

It has been waiting for four and a half years.

I was a member of the board of the Rotunda when things were much tougher. It is the outstanding maternity hospital in the country. It is the oldest maternity hospital and its body of knowledge and depth of expertise in the development of maternity services is equal to anything in the world.

The Fianna Fáil Party recognises that the delivery of health services is a major preoccupation of the public and we congratulate the Labour Party for giving us the opportunity to discuss the issue of health. We are extremely concerned about the health services.

Mr. Ryan

Where is the Minister?

Obviously he has nothing to say.

We are concerned that the effects of historic under-funding of the health service, which only ceased in 1997 when the Government took office, should be rectified. Our concerns and objectives are clear. We require an inclusive health service that provides the best medical care to the poorest citizens without undue delay or inconvenience. We are eager to hear about any policy proposals or constructive points of view the Opposition may have, but so far we have had 16 minutes of talk without any concrete proposals.

The Labour Party appears unwilling to engage in such a constructive debate. The motion is one of condemnation without productive ideas or policies or any regard to the undoubted improvements that have been achieved since the Government took office. The Labour Party's policies and record in Government in comparison to an outline of the Government's achievements in the area of health is relevant to this debate. The Labour Party's concern for the fate of our health services appears significant on the surface and the policies and alternatives it advanced deserve examination. The Labour Party's health policy is a quick fix approach that is uncosted and non-specific.

Mr. Ryan

No.

Not true.

Whoever wrote the Senator's speech for him should have read the document properly.

The insurance based system advanced by the Labour Party would increase the percentage of funding that goes to administration, thus reducing the amount spent on patients. Senator Ryan was worried about the administrators in James Connolly Memorial Hospital.

Labour Party policy is clear that public and voluntary hospitals will be required to cover their operating costs through income from health insurers and patients co-payments where applicable. Where a small hospital is unable to win a service contract from an insurer, it may be forced to restrict services or close completely. The party should try that in Bantry; it will run well there. The Labour Party's health policy would shut local hospitals.

Not true.

Mr. Ryan

Fianna Fáil is afraid of it. It is scaremongering

Universal health insurance has failed to deliver an acceptable quality and quantity of care in every country that has tried it. The Fine Gael Party appears completely confused on the issue of health. Just over a year ago Deputy Shatter, when speaking on the subject of an insurance based health service, said: "Whether the necessary reform can be brought about by the introduction of a universal health insurance system is questionable. What is needed is less, not more bureaucracy." The Fine Gael Party now advances an insurance based model.

The Labour Party's record in Government is less than auspicious. Between 1995 and 1997, a Labour Party Minister for Finance deigned to raise the health spend by just £400 million. The defence for such a meagre fiscal commitment to health, that the State coffers were in deficit, does not wash. The Labour Party has never had a problem with deficits. Its most recent fiscal policy, New Direction, New Priorities, would turn the budgetary surplus the Government has built up over four years into a 1997 style deficit. Obviously the party has no problem with deficits; it just lacks the commitment.

Recently Deputy Quinn, the former Minister for Finance in question, made the startling admission that his failure to heed concerns expressed regarding the future of our health services led to many of the difficulties that now face them. He said on 21 March 2001:

Just over six years ago, when there was a different Government in office, concerns about the future of the medical professions, particularly the nursing profession, were communicated to both the Government and the Opposition. Certain predictions were made about the changes that would occur, especially with regard to the numbers of people coming into the nursing profession and the availability of well motivated and qualified people in Ireland. I confess I did not listen to those voices at the time as well as I might have and the problems the Minister for Health and Children now has are in part related to that.

However, Deputy Quinn was not alone. Deputy Noonan, the then Minister for Health, at a time of relative fiscal prosperity cut the spending allocated for the reduction of waiting lists in 1997. As the Minister, Deputy Martin, outlined, this decision was taken at a time when waiting lists had already increased by 27%. This bizarre reaction to a 27% increase in waiting lists of cutting spending by 20% says it all.

What has the Government done in four and a half years?

The health services need massive investment and we have no problem with that.

They should have received it.

We have doubled the health spend from £2.5 billion in 1997 to £5 billion.

The Government had four years of surpluses.

The health services need reform. They must be efficient. We agree with the Labour Party on many aspects.

Four years on.

Moving forward, we need a health strategy to deliver this reform and efficiency.

Mr. Ryan

It took the Senator five years to figure that out.

The Government does not have a health strategy.

In the last year of the Rainbow Administration our health services received just £2.5 billion. However, that sum was doubled this year when £5 billion was allocated to the health services. No amount of spin or hot air can alter that fact. Deputy Noonan's reaction to this year's budget, which included the largest health spend in the history of the State, was to assert that the Government was spending too much money. The Minister for Finance has shown more commitment to the needs of the health services than his predecessors in the Rainbow Coalition. This additional investment is delivering. It has meant that 50,000 more day cases and almost 40,000 more in-patient cases were treated in 2000 compared to 1997. These 90,000 extra cases were dealt with because we have a Government committed to investment, efficiency and excellence in our health services. In addition, there are 400 extra doctors in our health services compared to 1997.

The tide has turned in just four years. It takes time, for example, to translate the largest ever capital investment in health, £2 billion, into bricks and mortar.

We are still waiting for a health policy.

Even if the Labour Party, with its grandiose ideas, hopes and piousness, tried to deliver it, it would not be done in ten years because the infrastructure must be put in place first. Senator Ryan knows that better than anyone else in this Chamber. There is a problem in the health services.

Mr. Ryan

Can I tell the Taoiseach that because he does not accept there is a problem?

The Taoiseach recognises that. One would want to be a fool not to recognise there are problems in the health services.

Mr. Ryan

He said it is well funded.

We must look at the delivery of care. The Senator is talking about hospitals. The delivery of care outside a general practice and in the psychiatric services is excellent and second to none.

Mr. Ryan

That is not what the Inspector of Mental Hospitals said.

I am delighted to support the Labour Party's Private Members' motion which condemns the Government for gross mismanagement and causing untold suffering to the weakest and most vulnerable of our people. I am interested in Senator Fitzpatrick's attack.

That is a strong word.

It is strong because it was an attack.

I would not dream of attacking anyone.

Senator Fitzpatrick has totally missed the point. We have heard much analysis of the problems in our health services. However, it is not just a matter of money but the fact there is no strategy. We now hear the Minister will wait to introduce a strategy until it is part of the Fianna Fáil manifesto. That is the difficulty Fianna Fáil faces in the health services. There has also been a failure to properly reform the system. We have been told on many occasions that it does not do any good to throw money at the health services. The Senator referred to Deputy Noonan when he was Minister for Health and to the Labour Party's policies, but he did not address the main issues. I am not sure if he mentioned the patients who are the most important people in this debate.

The motion refers to the "weakest and most vulnerable of our people". The Senator only engaged in mud slinging, particularly when he referred to the fact that both the Labour Party and Fine Gael have policies. It is extremely healthy if there are differences between Deputy Shatter, when he was the spokesperson on Health, and Deputy Gay Mitchell. That shows they are analysing the issues and using their own distinct strengths to assess the problem.

The Government is in its fifth year in office. Since 1997, when Deputy Noonan was Minister for Health, there have been unprecedented budget surpluses; yet we are still waiting for proper reform and a fairer system for everyone, which was not mentioned by Senator Fitzpatrick. The ESRI report and other reports have stressed that we must end the two-tier health system and arrest the deterioration in our health services. Despite the blip in our economic success, we must accept the fact we are one of the wealthiest countries in Europe; yet the Government devotes less of our income to health services compared to other countries. It has not taken the opportunity to address the need for strategic reforms. We need more beds, more manpower in certain areas, more emphasis on primary and preventative care and more accountability for the resources made available through the heavily taxed public.

The patients, or the "weakest and most vulnerable of our people", must come first. We meet them on the doorsteps and they make representations to us. They are the people who are fre quently mentioned in newspaper articles about the health system. We have set out our plan for the reform of the health services. This would help to create a universal health system where patients are considered for admission to public hospitals on the basis of their health, not their wealth. At present, it is based on a person's wealth, not his health.

There are many problems and obstacles in the system. Almost 60% of people, for example, are still on waiting lists in excess of the target time set by the Department. At our clinics we hear stories about individuals who go to accident and emergency departments with a stroke or heart attack and the place is full. There may be people there as a result of street brawls and this type of incident is not confined only to weekends. They see long suffering nurses and doctors trying to deal with such chaos. It is mind boggling to think about how they do it. Elderly people are the weakest in our society and they are often left for two days on a trolley.

We were all shocked when we heard that when the Taoiseach made a political visit to the constituency of Tipperary North – I am sure Senator O'Meara will refer to it in her contribution – a patient was hurriedly moved from a trolley in a corridor. The officials stated this was done to avoid causing stress and indignity to the female patient. However, we know it was done to avoid causing stress and embarrassment to the Taoiseach. That should not be allowed because it is only a smokescreen. We still see the problems when we visit hospitals. I have seen what happens in accident and emergency departments at weekends, where nurses and doctors are hard pressed throughout the night.

There is a long waiting list for people with special needs. Many have to wait for 12 months and even when they are seen, they must wait a further two or three years until the relevant procedures are done. Our life expectancy is two years shorter compared to that for people in other European countries. We are at the top of the list in terms of the number of women suffering from cancer and cardiovascular disease and at the bottom of the list in terms of the quality of care they receive for such life threatening diseases.

What is happening in the community? There are major problems in the community in terms of the provision of decent care. Carers are often left to deal with the problems associated with people in the community. Nursing home care and subventions are grossly inadequate. Families often have to find £14,000 a year to put their relatives in private nursing homes. As regards our primary care system, there is a shortage of capacity in hospitals and convalescent facilities. There is a shortage of capacity in hospitals and convalescent facilities. We could debate this issue for hours during Private Members' time.

The Progressive Democrats Party has suddenly realised there is a problem. The party has been in Government for the past four and a half years and only now when it realises the state of our health services will be an election issue, has it produced policies.

Why is the Minister not present? Why has he insisted on delaying the health strategy until it becomes part of the Fianna Fáil election manifesto? I cannot understand that and I hope the Minister is not putting politics before patients. Other issues in this area include a lack of orthodontic services, referred to by Labour Party Members, and a lack of physiotherapists and speech and language therapists. The list goes on and on.

The health service is a shambles and I have no faith in the Minister to do something in the remaining days of the Government. No Government has ever had almost five years to deal comprehensively with the health service with huge budget surpluses at its disposal. We are as badly off as we were when the Government took office. It has done nothing to arrest the decline of the health services.

I support the amendment. I am amazed to hear Labour Party Members criticising Fianna Fáil in regard to cutbacks. Have they forgotten Barry Desmond? I was almost thrown out of my party when-—

Mr. Ryan

Not a single employee of the health service lost his job during Barry Desmond's period in office.

Barry Desmond's budget proposal was the worst in the history of the State as it contained the most severe cutbacks.

Does the Senator recall Deputy Rory O'Hanlon who succeeded him?

One would think the members of the Labour Party were never Ministers in Government. When Deputy Howlin became Minister for Health he said he would work wonders and, to be fair to him, I have always given him credit for increasing funding to eliminate waiting lists but he did not succeed because he did not attack the problem. Money was buried.

Health funding has doubled from £2.5 billion to £5 billion while inflation has been running at 4%. It is disingenuous of people to say the health boards are in a shambles. That is a gross insult to the doctors, nurses and other professionals working for them who are doing a good job.

Mr. Ryan

Doctors are telling us it is a shambles.

There is a number of problems. Litigation is crippling health services. If one goes into hospital to get a thorn out of one's finger, one is transferred from one consultant to another because no one will make a decision because consultants are afraid of being dragged before the courts. This issue must be addressed.

Hospitals never have a difficulty dealing with emergencies, such as major accidents and so on, but there are major problems in the area of elective surgery. Private and public health care must be separated. Consultants should not undertake work in public and private hospitals at the same time. A county engineer cannot take on private work. One cannot serve two masters. Ní féidir dhá thrá a fhreastail or, as they said in my time, one cannot whistle and chew meal. One cannot do two jobs at the same time and radical change is needed in this regard. Sometimes relatives of people on waiting lists come home from America and tell them they will give them the money to go private. When this happens the operations they need can be carried out in the morning using the same staff in the same hospitals. Let us be honest. The value for money audit is the most important initiative that has ever been proposed because we are not getting value.

Various categories of staff have been mentioned in the context of the health strategy but domestics and nurses aides who relieve nurses of a great deal of work are not mentioned. There is also no point in hiring a consultant if he is not provided with support staff, including clerical staff. Who will look after his appointments? Should the consultant do all his own clerical work? Clerical staff are part of the strategy and the Minister is not over the top in this regard.

A number of years ago the standard for entry into the nursing profession was raised and many young boys and girls did not have sufficient points to take up nursing. Many of them went to England and trained as nurses. They are now back working in Ireland and we are delighted to have them, yet they were not good enough to be trained here. Members of the medical professions set those standards. Organisations representing doctors objected to the employment of foreign doctors in Ireland. They put up barriers to prevent such doctors from entering the country. Medical professionals must accept some responsibility for the problems in the hospital system.

I was a member of a health board for 20 years and I have a good idea about what goes on. The number of people who suffer from self-inflicted diseases such as alcohol, tobacco and drug abuse has put a significant strain on our health services. Funding has been increased in this area in an effort to try to protect people from themselves. Ambulances are out night after night picking up young people who suffer from abuse of the gargle, as they say in Dublin. They are drunk and disorderly, falling around the streets and getting involved in rows outside discos. Some are taken to hospital and take up beds that are needed by others. This problem must also be remedied.

There has been a great deal of investment in the health services during my time and much work has been done. I have spoken to many people who have had operations and so on and they wonder why people are saying our health services are poor because they were well looked after when they were in hospital. Many complaints are made by people who visit patients and who have not been in hospital themselves. They see something wrong and make a mountain out of a molehill.

I cannot speak highly enough of nurses and doctors but the system must be altered because it should not be the case that a person can be treated in a private hospital before a public hospital when the same medical professionals are employed by both hospitals. A distinction must be made in this regard. I congratulate the Government on the funding it is providing. I have always listened to health professionals. Increased bed capacity and more staff are needed, not money.

Mr. Ryan

Beds do not cost money.

The Senator probably knows more about hospitals and consultants than me but I was a health board member for 20 years and I also know a great deal.

I am delighted the Minister of State, Deputy Hanafin, is present but Deputy Moffatt and herself are sent into the House to bat on behalf of the health service more frequently than the Minister. While it is always extremely nice to address the Minister of State it would be good if our contributions were passed on to the Minister.

When one walks past the Government Publications Office on Molesworth Street, Dublin, one will see that one of the window displays is virtually devoted to reports on the health service. Such reports are laid before the Houses of the Oireachtas and it has been with the greatest difficulty that I have succeeded in getting any of them debated in my years as a Member. I sometimes wonder why we bother to commission them; they are usually commissioned by the Department of Health and Children but not a blind bit of notice is taken of any of them.

The Institute of Public Health has been established to examine health issues on an all-island basis and I am delighted that its director and one of her colleagues are present in the Public Gallery. They produce the most superb reports but none has been debated in the Houses. They have a report specifically on equity of access to public health services with some issues relevant to the Irish context. Not one word have I heard about it even though, on page after page, there are points relevant to what we are debating here.

Fianna Fáil congratulates itself on the increases in the money we are spending on the health service. This report concedes that the money has helped those with disability, children and the elderly. However, they point to the gaping holes which lead to inequity of access for people to the health services, even inequity of access to GP services. The proportion of people covered by medical cards has gone down and down under this Government. It is just over 30% now. It has been decreasing consistently. The amount of money has been increased and we do now spend more than Greece, Portugal or Spain per capita but the amount spent as a percentage of gross domestic product puts us at the bottom of the heap. This is extraordinary in view of the fact that we have had years of plenty.

Money is spent but we are still spending less than everyone else because medicine is so expensive. Senator Fitzpatrick knows that internationally, inflation in medicine is double that of any other commodity. We therefore have to spend more money just to stand still. When plans were made in the early 1990s, there was no account taken of the obsolescence of equipment, so we had to spend an enormous amount ten years later trying to catch up. I know this is irritating for those in power because they would like to see far more return for the money that is being spent but that is life. Report after report indicates that there is a serious problem in relation to access for the less well off. Deputy Moffatt and Senator Fitzpatrick, as general practitioners, know that they and the GP services are holding the dyke because the situation is so severe in general hospitals. I disagree with Senator Fitzpatrick about psychiatric services. We are in dire straits in this area too.

In view of the fact that the Minister for Health and Children is bringing forward his health strategy, I refer to two reports, Inequalities in Health in Ireland: Hard Facts, produced in September by Joe Barry, Hamish Sinclair, Alan Kelly, Ross O'Loughlin, Deirdre Handy and Tom O'Dowd from the department of community health and general practice in Trinity College, Dublin, and Inequalities in Mortality 1989-1998, an all-Ireland report on mortality data from the Institute of Public Health in Ireland. One of the most serious aspects about these reports is that they both point out that the data being used at the moment are in many cases incomplete and frequently out of date. For example, in the Republic of Ireland the data are much less complete than in Northern Ireland. This is astonishing. In the latter report, when deaths from diabetes were studied, the authors found that the people who had died in the Republic of Ireland were ten times more likely than those in Northern Ireland to have been categorised as 'occupation unknown'. Since the 1980s, when the report begins, computerisation has taken place throughout institutions and one would assume the quality of the data to be better. However, as one looks through the report from one year to the next, the number of people categorised as 'occupation unknown' actually expands. This makes it difficult to plan regarding the various socio-economic groups and deciding which ones are not gaining access to health care and which have greater morbidity and greater mortality rates.

I do not know how one can plan a health strategy when this is the quality of the data available. Regarding breast cancer in women the report states:

Occupational class differences in mortality from malignant neoplasms of the female breast were not assessed because of general problems associated with occupational coding for women.

The vast majority of women in the Republic of Ireland are not coded for occupation. They are not even coded when they are single mothers. This coding is important if one is trying to identify which socio-economic groups most need service provision. We know that most of them come from lower socio-economic classes but it is preferable to have the hard facts readily available.

One of the worst problems was identified in the Trinity College report. It pointed out that the peri-natal mortality rates had not been published in the Republic of Ireland since 1993. The peri-natal mortality figures are a combination of the number of still births and the deaths of new-born babies in the first year of life. This is recognised internationally as an important statistic to indicate the health status of the nation. We have had a huge increase in the number of HIV infections in mothers and problems with late arrivals of mothers in maternity units, particularly by those from abroad. The chief medical officer has said that access to hospitals for low-paid people in Ireland is significantly inferior to that in the rest of the European Union. The experience of poor Irish people must be regarded as intolerable.

We talk about the waiting list in Dublin but around the country the situation is similar. There are no neurologists in the Mid-Western, Midlands, South-Eastern, North-Eastern or North-Western health board regions. Is there no multiple sclerosis or Parkinson's disease there? There are no rheumatologists in the Mid-Western, Midlands or North-Eastern health board regions. Is there no arthritis in these areas? There are no urologists in the Midwestern, Midlands, South-Eastern or North-Eastern health board regions. Is there no prostatic cancer in these areas? The Midland Health Board features on all three lists. Important Members of this House are on that health board. This is extraordinary.

The Department of Health and Children sponsored a major inquiry into psychiatric services in the Eastern Health Board region. The inquiry by the Health Research Board reported in 1999, pointing out that there were insufficient acute beds, no alternative to hospitalisation for those who did not need an acute bed, no rehabilitation programmes, no regional service for very disturbed people when they became ill – they all had to be sent to St. Brendan's which was already full – no regional facilities for people with behavioural problems, no day hospitals or clinics for people around the country. Patients in acute beds had to be discharged back to their GPs. That is three years ago and not one of those recommendations has been put into force. I do not know how Senator Fitzpatrick can say that the psychiatric services are good.

This debate has been precipitated by a crisis in the health sector. Members on the Government benches will tell us that more money than ever is being spent on the health services. In money terms that is true. However, in 1980 we spent over 8% of our GDP on our health services. That declined because of the economic crisis in the 1980s. The most swingeing health cuts carried out in 1987 and 1988 had a serious effect on the health service as thousands of nurses were made redundant and taken out of the system and hundreds, perhaps thousands, of hospital beds were closed and some smaller hospitals were closed.

So fevered was the political debate at the time that in the 1989 general election a Dáil Deputy was elected from Longford-Roscommon on the basis of the health services in that constituency. It was clear in my constituency that the swingeing cuts had decimated the services of the county hospital to such an extent that it was on the verge of closing. It resulted in such public debate that somebody advocating better health services in that constituency was elected to the Dáil. That was the voice of the people speaking.

The Government needs to take note of these issues. Opinion polls have shown that the health service is the area of primary concern for most citizens. In 1980 we spent 8.1% of GDP on health services. In 1997, when the last Labour-Fine Gael coalition left office, GDP spending was 8%. There has been enormous growth in GDP compared to ten or even five years ago, but today the value of GDP spending on health is under 5.2%. That is almost a 2.75% drop in less than five years. This is the reality and the reason for the crisis. There are thousands of people on waiting lists for bypass operations, for hip replacements and treatment for a whole range of often life-threatening diseases that need simple medical or surgical interventions.

The increase in length of waiting lists for a range of procedures, some of which had no waiting lists at any hospital five years ago, has been dramatic. There is a total lack of direction in relation to health policy. Deputy Michael Noonan, as Minister for Health, concentrated on the prevalence of cancer, which is a serious cost burden on the health service – we have one of the highest rates of cancer among all ages. There was a strategy based on the many preventive measures which people can take to save themselves from that dread disease. Today there is no health strategy. We have a high level of cardiovascular disease because of lifestyle changes and so on, yet there is no strategy to deal with that problem. Unlike other diseases such as cancer, cardiovascular disease is often directly related to lifestyle. It has been proven in other countries that well-targeted education programmes and health strategies, especially for young people, can have a dramatic effect in reducing levels of illness in certain categories.

It is the duty of the Department of Health and Children and, above all, the Minister to take the lead in these preventive strategies. The Minister has contributed nothing and looks totally bewil dered to see the problems all around him getting larger by the day. He has an overwhelmed look when he tries, on television or here in the House, to defend his policies and the shambles that is the health service.

The OECD consists of 29 of the wealthiest countries in the world. We rank 22nd on the scale and in the European Union we are at the very bottom of the list. The EU average for GDP spending on health services is 8.6%. This includes countries we regard as poorer than ours, such as Greece and Portugal. Why was the level of health spending dropped so dramatically, by 2.75% of GDP? This amounts to hundreds of millions of pounds nowadays – 1% of GDP or of the national income is millions of pounds. Why did it become Government policy not to maintain the level of spending in GDP terms? There is no other way of making a realistic comparison. Given what was taking place in all 15 member states of the EU, or the 41 or 42 countries that now call themselves European, with governments of all shades, right, left and centre, why was there a policy decision to reduce our spending on health services so dramatically?

This is not due to economic problems. We have never had a greater level of economic prosperity than in the last five years. Our national income has grown in that time to an extent that we did not see in the previous 25 years or more. Yet all opinion polls say that this crucial issue is of greatest concern to most people whether there be good times or bad times. We have not even maintained the level of services at any benchmark level such as that of 1990, 1995 or 1997. It has gone down and this is manifested in waiting list increases. People on lower incomes, or who depend on the GMS to get into hospital or to obtain treatment, are suffering the most. These are important points.

My party is proposing that on return to Government we would, as an immediate priority, restore GDP spending on health in our first year in office to about 7%. This would have a dramatic impact.

I thank Senators Costello, O'Meara and Ryan for tabling this week's motion. As ever it provides a welcome opportunity to set out clearly the Government's record on health and the series of initiatives which are coming together in the context of the most comprehensive and inclusive strategy statement on our health services ever prepared. I welcome debate on our health system and am glad to hear any policy proposals which are broadly constructive and which may point the way towards further improvement and reform.

The Labour Party motion is plainly not constructive, nor does it point towards a means to assist with the very real work of reform in the health system. It offers no policy proposals, no alternatives and no reform. It is a disappointing reflection of the thinking of the Opposition on the issue of health reform. In the absence of workable, meaningful policy they chose to focus on the negative, to shout crisis at every opportunity and to offer little in the way of beneficial, practical policy ideas.

It is no coincidence that only a fortnight after Labour relaunched its health policy document it chose to make no reference to it in this motion. When it was initially launched in March 2000 the concern arose that it would shut local hospitals. These concerns were justified. The document was clear that public and voluntary hospitals would be required to cover their operating costs through income from health insurers and patient co-payments. What this meant was that smaller rural hospitals which could not win service contracts from private health insurers might be forced to close or at least to reduce services. This is the reality behind Labour's quick-fix approach to health.

The present party health document, relaunched only a fortnight ago, concedes that hospitals which cannot maintain cheap services could "find themselves excluded from insurers' lists of approved facilities." Again, where a small local hospital cannot compete with the larger urban hospitals it may be forced to cut services. In addition, all major studies of this insurance based system concede that it diverts more funding into administration. Plainly, what the Labour Party advances has yet to be properly thought out and we await its deliberations eagerly. We also await the day when the party is as willing and enthusiastic as the Government, the general public and health professionals to shape a progressive and equitable health service. It is understandable then that it has not sought to draw attention to its own health policies, but rather resorts to condemnation and attack.

Investment in and reform of the health service take time to show results. Why then in early 1997, in the face of a 27% rise in waiting lists, did the rainbow coalition decide to cut the funding allocated towards the reduction of waiting lists by 20%? Why did the then Minister for Finance, Deputy Quinn, and the then Minister for Health, Deputy Noonan, sit down and make that particular decision? In the face of an urgent need to provide additional nurse training places they refused to provide additional funding. Why? The Minister for Finance in that coalition, the present Labour Party leader, has gone so far as to admit, "I did not listen to those voices at the time as well as I might." He admits that the problems of the present Minister for Health and Children are, in part, related.

The Government is willing and able to justify its record. It is about time the Opposition parties moved from the rhetoric of condemnation to offer us a detailed explanation of their decisions, which have had long-term repercussions. Why did they cut funding for waiting lists reduction? Why did they not fund the necessary additional nurse training places? Why did they raise the health spend by a meagre £400 million? Why did they not initiate a value for money audit to ensure that pound for pound we get value for money for our health spend? The Government has no such problems in accounting for its record and present policies.

As a direct result of the Government's policies, 90,000 more treatments were carried out in 2000 than in 1997. This is a clear and empirical improvement for all to see. During the term of this Government to date there has been a doubling of the health spend to £5 billion. This has helped to deliver an increase in staffing in the public health service by 24% since 1997. This means 15,758 more people are working in the public health service and the investment is delivering. Between 1997 and 2000 we provided £74.5 million of dedicated funding for the reduction of waiting lists. In 2001 a further £34.5 million has been allocated.

This investment is making a clear difference. The number of patients on waiting lists on 30 June was 26,659, a drop of almost 5,200 on the comparative figure for June 2000, a reduction of 16%. Let me be first to assert that it is not enough. This is clearly not a time for back slapping or self-congratulation, but for a continuation of the clear commitment and resources which we, in the past four years, have allocated to cutting waiting lists.

Compare our record to the increase of 27%, or 6,600, under the rainbow coalition. Why the cuts in waiting lists under this Government and the increase under the Labour Party and Fine Gael? I return to the decision, which will haunt its protagonists, Deputies Quinn and Noonan, to cut the funding allocated to the reduction of waiting lists by 20% in the face of a 6,600 rise in those lists.

It was left to this Government to undertake the major review of the underlying causes of the waiting lists back in 1998. The expert group established to undertake this review proposed a series of short, medium and longer-term measures to cut waiting lists and deliver the results we are now achieving. The waiting list for cardiac surgery is down 52% since June 2000. Gynaecology is down 35%; ENT, 30%, and ophthamology, 23%. These are the sort of improvements of which the Government is justly proud, but we do not assert for one moment that all is well or that the work is done.

They would not need to.

Four years of investment and reform has plainly delivered improvement and we know that much remains to be done.

Anyone familiar with the realities of our health system will know that reforms take time to implement. Lengthy run-in times are often as necessary as they are frustrating. It takes time to build hospitals, wards and clinics and to train nurses and health professionals. If the reforms, investment and training had begun six or seven years ago, we would be witnessing the results now. Since 1997, however, right across the health service a similar story is told of increased funding delivering an agenda of reform and improvement.

For people with intellectual disabilities we have provided 1,600 new residential places and around 375 new respite places. For those with a physical and sensory disability we have provided over 50 long-term residential places and 95 respite places. We have also provided more than 400 new day care places and an enhanced level of home support services, including personal assistants. A capital sum of £150 million will be provided over the lifetime of the national development plan for mental health services. Additional revenue funding of £18.64 million was made available to these services in this year alone.

Real progress is also being made in cancer services. The establishment of the national cancer forum, the £60 million we have spent to date, BreastCheck and the national cervical screening programme are but a few of the concrete examples of commitment matched by funding delivering action, which is the hallmark of the Government.

This is also true in relation to the cardiovascular health strategy which was referred to earlier and to which £27 million has been allocated in the last two years.

We have the highest rate of cardiac disease in Europe.

This money is being spent on health promotion, nicotine replacement therapy, hospital services and cardiac rehabilitation.

Tackling manpower issues effectively is the key to reforming the health service. There are shortages of key health professionals across the system both in Ireland and abroad, but Government reforms are showing results. Across the board there has been a total staffing increase in the health service since 1997 of 24%, or 81,513 at the end of 2000. Since 1997 there are an additional 321 consultant posts, about 600 more doctors and 1,700 more nurses in the public health sector in Ireland. In the key area of nursing, for example, although there was a net increase of 1,702 nurses in the system last year and the number of vacancies is down by 5%, a considerable number of vacancies remain. To address the continued vacancies in these and other areas we are taking concrete measures which are delivering equally concrete results.

Nurse training places have been increased by more than one third – some 500 places. We have invested in marketing campaigns to encourage school leavers and mature persons to enter nursing training. We have introduced flexible working arrangements and agreed to pay fees to nurses undertaking part-time nursing degree courses. We have improved the package of financial supports to nursing students, including a 43% increase in the annual maintenance grant. We have also recruited nurses from abroad, introducing a new working visa-work authorisation scheme to facilitate the recruitment of nurses from non-EU countries. Since June 2000 more than 2,000 visas have been issued to these non-EU nurses.

In the light of these efforts and the continued vacancies, particularly in the area of nursing, I was astonished to find that the Fine Gael spokesperson on Enterprise, Trade and Employment, Deputy Flanagan, has called on FÁS to end its attempts to recruit key health professionals, including nurses, doctors and speech and occupational therapists abroad through the European Employment Network. His leader, Deputy Noonan, and party spokesperson on Health, Deputy Gay Mitchell, only a week before released the very same statement in each of their names which asserted that the recruitment of highly qualified nurses from overseas was the only thing preventing meltdown in our hospitals. This underlines the degree of utter confusion in Fine Gael in the area of health today.

Plainly, there is still an urgent need to recruit nurses and other key professionals from abroad to fill positions which are simply not being filled by Irish people. Opposition parties should be supportive of Government efforts to attract these health professionals. Throughout the health services, among the health professionals, administrators, patients and the Government, there is an understanding that the health system needs prolonged and continued reform at all levels. The delivery of such profound reforms, the provision of a responsive, equitable and high quality health service, which is responsible for the health needs of all our citizens, is a complex matter. Most of us who deal with the health services are aware of that, although it appears the Opposition is not so aware. It is not just a matter of making superficial reforms. Any meaningful and lasting reform must be thorough and must deal with the whole range of structural issues, including basic manpower deployment, contracts and planning. Shallow solutions cannot reform the deep structural problems of our health services. The quick-fix reforms proffered by the Opposition simply will not work. What will work to deliver a sound, deep foundation upon which to reform the health service and create an equitable health landscape for the decades ahead is the progressive programme of research and negotiation which was utterly absent before the Government took office in June 1997. This is the admittedly slow but necessary process needed for the delivery of an effective health strategy.

The Opposition claims we should have dealt with this earlier. This would have meant throwing a couple of initiatives together between pretty covers and launching them to great fanfare. We could have speeded up the process by failing to consult the public and the health professionals. We need not have bothered with the medical manpower report and the report on the working practice of junior hospital doctors.

Mr. Ryan

The Government could have had a policy when it came to office.

We could have neglected the value for money audit and been content to throw money at the problem. The medical manpower report and the report on junior doctor working practices have shown us the way forward to a radical improvement in the level and quality of hospital care. The Commission on Nursing has shown us what steps are necessary to attract, train, utilise and retain nurses. The value for money audit is dealing with how best to utilise and deploy resources within the health system. Other moves, such as the detailed strategic assessment of hospital capacity, the largest public consultation ever carried out in the health sector, and the establishment of a national consultative forum to represent a large cross section of health stakeholders are also central to the necessary preparations for the health strategy. I have no doubt that, when published, the national health strategy will shape an equitable, world-class and thoroughly reformed health service for the decade ahead.

The alternative is the quick-fix approach of Fine Gael and Labour. The alternative is to bulldoze the input of the public, the health stakeholders – doctors, nurses and administrators – and call for unworkable policies based upon political opportunism. The Labour Party has placed a motion before this House condemning the Fianna Fáil-Progressive Democrats coalition for gross mismanagement of the health services. I reject the original motion and assert that the record of the Government is one of commitment to delivering funding and reform. I urge the House to accept the Government amendment.

I regret the terms of this debate as there is quite a lot of party politics involved. Market research has found that health will be the principal area of conflict in the coming general election. That has been noted by politicians. It is not a coincidence that the Fianna Fáil spokesperson on health, Senator Fitzpatrick, and Labour's Senator Costello are from the same Dublin constituency and they are here in the Seanad backing it up. I am not interested in party politics, I am interested in the patients. I will reluctantly vote with the Opposition, but feel that the terms of the motion and the amendment are widely unrealistic. One says that everything in the garden is rosy, the other says that everything is rotten. I do not believe either is correct.

We have problems and we should use debate in this House to address them. This fact has been highlighted by a very interesting series of comparative articles in The Irish Times. That newspaper, on 23 October, referred to the health system in France. Professor René Caquet described the health care system which he helped to design as “a mixture of pride and amusement”. He said:

The French system is very . . . French. It's very individualistic. People want to choose their own doctor, and the doctor prescribes whatever he wants to. The Gallic attitude towards community is very different from the English-speaking world; the French spend more, and the deficit has to be financed. But at the end of the day, overspending seems unreal to the individual: it's the general public's problem, not his.

In other words, one has an ailment, wants it cured by having the best possible treatment and is unconcerned about the financial implications. This has problems, as Professor Caquet admitted. He said:

It is a very good, but expensive system with a lot of wastage. It is blurry, badly organised and costly – but people are well cared for.

What I would like to see in this country is a system that is not blurry, costly or badly managed, but still manages to deliver a good health service to the people.

Germany also has compulsory health insurance. It was the first country to introduce a national social security system under Bismarck in the 19th century. In The Irish Times of 22 October, Pádraig Ó Moráin, reporting from Germany, said it is very difficult to find a Berliner who will complain about the health service. They seem stunned when asked what improvements they want because they get everything they need, although there are some financial problems in the pipeline.

We return again and again to the problem of funding. Generally speaking, we are below the European Union average in that regard. I am not sure about what is contained in these health figures. Do they include various peripheral social welfare grants? If so, we are even further behind Europe. At Ballymascanlon earlier this year, Mr. Kelly, the Secretary General in the Department of Health and Children, was put on record as saying that our health service has been underfunded for years. That is a sad indictment not just of this Government but of previous Governments also. In the 1980s hospitals were closed with an enthusiasm that would have done Dr. Beatty proud, with his cuts on the railways.

Even if funding is available, what will it be used for? It has to be specifically, clearly and logically targeted. There cannot be more beds without more staff. If 1,000 additional beds are provided what will be done about staff? It is true there will be a training time lag. Where will these staff come from? One way of handling the health service would be to keep as many people out of hospitals as possible by developing the use of health centres. This already happens in private medicine. A couple of weeks ago I had a problem with a tooth. I had a major job done – the tooth was extracted and a bone graft was also carried out. I went to a specialist, he sent me to another specialist area for an X-ray. It was very efficient. Could this not be done in the public area? Health centres, equipped with radiographic machines and able to carry out simple procedures such as blood tests, could be developed and doctors would refer people to them. It would make the whole system much more efficient.

Nurses who have left the profession could be encouraged to return. There has been a flight from nursing but certain things can be done. I am glad the Minister referred to the flexibility of hours. We must really push this. The days of the battle-axe ward sister who set a rota in stone for a month in advance are gone. We must encourage people to come back on a part-time basis. One of the things that would facilitate that is the development of crèches in hospitals. Tax write-offs could be given to provide them, or their provision could be made part of the conditions of employment. The whole system should be made more nurse friendly. Account should be taken of the personality of nurses. It is right that some people should go along an academic route, but there is too much emphasis on the points system, degrees, universities etc. There are wonderful people who have a vocation to nursing and who bring human skills with them. Let us get them back into nursing. Let us not exclude them on a narrow, academic basis.

It has been said that there is a two tier health system. That is perfectly obvious to anybody with even one eye. Which system do the people who object to this want to drop? Do they want to drop the private system where people certainly get a much better service? If one looks at today's edition of The Irish Times they will find that Muiris Houston has an article where he recalls a paper by Dr. John McManus, delivered to the Royal Academy of Medicine.

Dr. McManus carried out a survey which was randomly selected and found that only 25% of medical card patients have had a coronary angiogram. The survey showed 77% of private patients had undergone this definitive investigation. Of 30 private patients only one did not undergo an exercise electro-cardiogram, another basic test of cardiac disease, whereas 15 of the 40 medical card patients had not undergone the test. His conclusion was that the poor not only have a much greater chance of getting coronary disease, but they also have a far lower chance of having it investigated and managed adequately. This is a disgrace and reflects badly on the whole provision of health services.

We need to bring public care up to the level of private care, a secondary wonderful impact of which would be to put manners on the VHI and BUPA. Private patient care in public hospitals should be encouraged. This creates a much better and greater range of expertise on site in the same hospital. What is the point of making doctors travel ten miles to look after their private patients? It is stupid. One thing about public hospitals is the food may not be as good as in private hospitals.

The Kennedy report was published in 1992 when the Tallaght Hospital project was under way. It recommended reducing the capacity of the hospital by one third, which put pressure on the hospital. When the Adelaide and Meath and other hospitals moved to Tallaght, they continued the perfectly reasonable practice of mixing private and public patients. In line with policy, the board then developed a private patient block or ward in a separate building into which all the private patients were moved. The public beds this left free, but empty, were all closed down. That is an exercise in insanity. It is the most expensive form of bed closure I have ever come across. This House should be directing its attention to the welfare of patients and removing the inequalities in the system, not simply scoring party political points.

I welcome the debate and the Minister of State. Following Senator Norris's comments, it is important that a consensus exists on certain areas. It is vitally important that we ensure the system of health care provides the best quality care to the patient, the customer so to speak, in an accessible and equitable manner, at the time and place he or she needs the service. Everybody in the House, both on the Government and Opposition benches, is agreed on those principles.

It is important to recognise we are in the run up to a general election which will take place at some stage next year. For that reason, we will have debates which are political in tone for the rest of the Seanad session. As a novice at this game I regret this, but it has been the way in the past and will be in the future.

To return to the point, we agree that throwing money at the health service will not solve its problems. We also agree there has been severe under-funding in the health service for many years. Many of the problems we see today, which have not been resolved in the past three or four years, are a result of that under-funding. We cannot build £90 million or £125 million hospitals overnight. That is evident from my experience in Galway. When I entered this House in 1997, a £25 million investment programme was under way in the city, which has since been completed. Another programme, phase two, worth £90 million has been initiated. We are starting the process of planning for phase three. However, phase two will not be physically finished until 2003. Unfortunately, regardless of my view on the matter, those blocks cannot be up in the hospital any faster, not even if I were to throw £180 million at it. Therefore, we must show a measured response which balances our words with our expectations.

In her speech the Minister of State said, "We do not assert for one moment, however, that all is well or that the work is done." That is the very clear message from the Government and can be seen by anybody who looks at the health service with a clear and constructively critical eye. What we have are four years of investment. A reform and set of clear objectives will be clearly laid out in the health strategy which will set out the way forward for health care.

One cannot dispute that the Government has delivered improvement. We acknowledge, however, that much remains to be done. We have shifted the focus from the length of waiting lists to waiting times. There is a consensus, I believe, that the number of people waiting, whether ten or 100, is irrelevant provided they all have to wait an acceptable length of time. People will accept that. We are entitled to be told how long we have to wait or if there will be a delay in receiving treatment. We are entitled to be communicated with in a proper manner. If, for example, a hospital cancels an appointment for whatever reason, it must make a new appointment to ensure the patient is not suddenly left in limbo with no idea what will happen next.

There are a number of simple changes which can be implemented throughout the health boards and hospitals over the next few months. Many have been made already. In the next few years, these simple changes will make a difference to how people perceive the service. They will know what to expect, so if they are told they must wait six months for a service, they know it means exactly that and not six years.

I recently looked at the waiting list for children's cardiac services. We have made changes in this area. The Government has rightly chosen to send some children waiting for cardiac services abroad because we have been unable to provide the service here within an appropriate time frame. If it were in power the Opposition might have done the same. Nevertheless, we can be proud of that action. I wish we could have provided the services here and that people did not have to travel, but I am certain the parents of children who chose to travel are much happier now their children have benefited from the service abroad.

Listening to the monitor in my office earlier I heard someone – Senator Costello I believe – describe the health service as "lousy". I completely reject that on behalf of everyone working in the health service. The one thing on which everyone in Ireland is agreed is that if one is admitted to hospital in need of an emergency procedure, or is very sick and requires the care and support of doctors and nurses, the health service provides that service. It delivers for the people in greatest need. If I were to have a heart attack now, I have no doubt an ambulance would come and take me away and I would be looked after immediately in hospital. The care and attention given under very difficult circumstances by staff, particularly in the hospital service, is second to none. Junior doctors and nurses, the people involved at the coalface of health care provision, deserve to be congratulated. Things are not easy or perfect, but to say the health service is lousy is a terrible indictment of the service these professionals try to provide on a daily basis.

To return to the idea that reforms take time to implement, I wish to specifically address the construction of infrastructure and the need for expansion of bed capacity. My plea to the Mini ster for Health and Children and his Department is very parochial. We have a severe bed shortage in Galway and the region. Our regional hospital, Merlin Park Regional Hospital, does not have enough beds and has suffered many years of inadequate infrastructure and investment. The Minister for Health and Children has on his desk a proposal for significant investment in the hospital. Without that investment, we will not be able to continue to provide the type of service available in the Western Health Board area in terms of reducing waiting lists or in areas such as cardiac and cancer care. I appeal to the Minister to consider the application and find some way of providing the resources we need to move forward.

Everyone who has encountered the nurses and doctors who work in the cancer care services will say that they are doing tremendous work. They work in very difficult circumstances, they deal with very sad and terminal cases and they make life just that little bit easier for those patients. I thank everyone involved in the health services at every level. They have a tough job in a tough environment but the new health strategy will deliver a system of health care we can be proud of.

It is difficult to know where to start when talking about the current state of the health service. Senator Cox talked about being parochial in her references and I will now be accused of being parochial by talking about the situation in north Tipperary and in Nenagh in particular. The reason I do so is because it represents a small but good example of how things are at the moment in the health service. It illustrates a number of fundamental issues which need to be addressed and a number of examples of the crisis which we now face. I am calling it a crisis and I know I am not the only one to call it a crisis. Despite what the Government might think and say, the health service is in crisis. The Government may seek to blame opinion polls, the proximity of an election and Opposition hyperbole for people's concerns about the health service. People are deeply concerned about the state of the health service because they have first-hand experience of the crisis. They are not concerned because we have told them to be, they are concerned because they have every reason to be.

Last week I spoke to a recently married young man who has a nine month old child. At three months of age, the child was referred to a consultant in Dublin because of a suspected serious problem. The original appointment was cancelled and that is understandable as these things can happen. The couple are covered by VHI but it is a one income household. The child's mother has chosen not to work because of the serious condition of the baby. She has given up her job and they must now fund a considerable mortgage on one income. The young man took a day's leave from work and the couple took the child to Dublin to meet the consultant. Despite the fact they had a letter confirming the date of the appointment, when they arrived they were told that the appointment had been cancelled. They were then told however, that they could see the consultant immediately if they paid a fee of £90. They were so upset and discommoded and worried about the baby that they paid the £90 which they could hardly afford. They still have not been given a diagnosis of the problem, but that is an ongoing situation.

This was a classic example of how the two-tier system, which Senator Norris does not seem to object to, has become institutionalised in the provision of health care. I regard the two-tier system as unjust, unfair and inherently wrong. It is causing serious distress to many people and is adding to the high level of public concern about whether one can access the health service without money. Clearly the view abroad is that one cannot.

The Taoiseach recently visited Nenagh hospital. His visit has been overshadowed by the controversy caused when hospital beds and trolleys were removed from the corridor minutes before he arrived and put back minutes after he left. This was done in order to avoid causing embarrassment to the Taoiseach even though, as Senator Jackman pointed out, the excuse given was that it was done to spare the patients the embarrassment. In fact the staff have informed me that the patients not only encouraged but in some cases tried to insist that they remain in the corridor so that the Taoiseach could see for himself how the situation was in Nenagh hospital, not only on the day he visited but as it obtains week in week out, month in, month out, all year round.

An application has been made to the Government through the national development programme for a significant increase in beds but we hold out no hope. There was a major capital investment in Nenagh hospital in the last two years but it has produced no additional beds. Further restructuring could reduce the number of beds available to patients using Nenagh hospital. That same refurbishment and extension work had the effect of a hopefully temporary closing of the elderly care unit. When the renovation was complete, the elderly care unit had disappeared and has not reappeared to date.

My colleagues on the other side of the House seem to be determined to convince us that the state of psychiatric services is very good. We have not one single residential psychiatric care bed in north Tipperary. A patient in need of psychiatric residential care must go to Clonmel, even though that is in the South-Eastern Health Board area. There is an unbelievable lack of decision making on that issue and we are still waiting for a psychiatric unit. We are about to face a crisis in nursing numbers in Nenagh. This year, for the first time, an advertisement for nurses yielded no response.

If the Government was to read the Labour Party policy document it would see a very well developed and fully-costed strategy. We are still waiting for the Government's strategy. It seems that, despite its own resources and spin doctors and PR experts, the Government can only, according to the Minister of State, conduct "research". Four and a half years on, we are still waiting for a strategy. Why did the Government not have a strategy when it came into office? We have a strategy in preparation for the coming election. We are proud of that strategy and we will happily stand over it. It contains a structure for fundamental and much needed valuable reform of the health service designed to end, once and for all, the crisis at the heart of the Irish health service.

I welcome the Minister of State to the House. I am delighted to participate in this debate on the health services and to see the investment and improvements that have taken place within the health services. A consultative process is taking place within the health services with a view to producing a health service that will be second to none in a growing economy that has the revenue and the strength to develop and put in the necessary resources for the future.

The Government must be complimented on its investment in the health services. Some 81,513 people work in the health services. That is a very high employment level and a major responsibility. From my experience of the health boards, I am aware there has been a restructuring of positions. The service provided to people dealing with the health boards is not as good as it was. A great deal of restructuring has taken place throughout the health services, but the quality of the service provided has not improved as a result of that investment.

I support the Government's approach of auditing the money spent and the revenue collected within the health boards to ensure the public get value from taxpayers' money invested by the Government in the future of the health boards by creating extended services within the system.

There is a need to change the contractual system of consultants. There is merit in the idea of contracting young consultants who are anxious to take on work and who could perform urgently needed operations to help reduce the numbers on the waiting list. I hope that matter will be considered in the new strategy. I accept there are precedents on consultation with consultants in this process, but this matter should be considered. Young consultants are anxious to do such work. One need only compare the procedures carried out in private clinics. The efficiency and effectiveness of the value for money audit that has been given and the throughput is very credible.

It must be recognised that £5 billion has been invested in the health services. The current capi tal programme of investment in hospital services throughout the country is the largest since the foundation of the State. One of the main challenges facing the health services is the delivery of centres of excellence and the provision of services in a modern and professional manner. A consultant gave me a booklet on this matter and said that one of the problems is the number of hospitals that need professional services. We cannot deliver hospital services on every doorstep. The challenge, financial and otherwise, facing us in the future is whether hospital services can be delivered in every county to the excellent standard expected. It may be possible to do so when there is a growing economy. A major challenge for the health services and Governments in the future will be the provision of services in every public hospital to the standard of excellence people expect today.

We have a growing population and many people are returning to live here, which increases the demand for health services. The Government is approaching this matter in a responsible and consultative manner with all the partners. Its experience of dealing with the nurses in terms of the consultative programme that was put in place, the structuring of an educational programme, the setting out of a career profile for nurses and the requirements within that are a lead for the Government in dealing with that sector. It also has a major responsibility from the point of view of providing necessary funding and facilities to deal with those requirements.

The Government has increased the number of nurses within the hospital services, which is to be welcomed. I hope the position will improve. Many nurses changed career because they considered there were jobs they would prefer that were more remunerative and suitable than nursing. That pattern might change in the future because of economic trends and the changes currently taking place. Changing that pattern is a major challenge.

The health Ministry faces the greatest challenge in the State as it affects almost everyone. At this stage of our economic development, the challenge facing the State is to ensure that the health system is equitable. I agree with previous speakers that medical card holders have to stand back while others can afford to gain access to the health services. That must be addressed in the future. The number of medical card holders has fallen on the basis that our economy has strengthened and more people are working, but 30% of people fall into that category and need to be looked after.

The Government has invested money in the structures and has increased the number of administrative and professional staff in the hospitals. The implementation of the national strategy, involving consultation with the people and the Government taking firm decisions, be it in the insurance or the consultative area, will provide the basis of ensuring a positive health service for the future for our people.

Mr. Ryan

I refuse to be excessively provoked by silliness about what the Labour Party did not do five years ago because this issue is much too important. Hindsight is 20:20 vision. I compliment the leader of my party on being, as he always is, honest about his achievements and mistakes, which he accepts. No doubt the diligent Fianna Fáil machine dug through the records to find that out to try to abuse another politician's willingness to be serious about a debate on a serious issue by turning it into political silliness. It is unworthy of the Minister of State who read that script because I regard her as a serious politician who often deals with issues in a serious way and has attempted to address serious issues well in her onerous area of specialist responsibility. Let us leave the silliness aside.

The Government did nothing and is doing nothing to deal with many of the issues which could be dealt with immediately. The crisis facing working families on average industrial wages, for whom paying for a visit to a GP poses a major cost, could have been dealt with. That did not need capital investment. The crisis in our hospitals existed and it is not helpful to look back and talk about what Labour did not do four or five years ago. Fianna Fáil is admitting it did not notice there was a problem then. I do not take the Progressive Democrats too seriously because they live on a different planet. The people who vote for that party do not need public health services. They are not that kind of people. Fianna Fáil's voters and supporters need public health services the same as my supporters, the Labour Party's supporters and a good section of Fine Gael's supporters. The Progressive Democrats' supporters do not need them. They do not worry about these things. They can produce pie in the sky nonsense from an obscure individual in Limerick, which suggests one can deal with health services and tackle the waiting list with £100 million a year. Nobody else in the world has done that, but the Progressive Democrats in Limerick have worked it all out on their own. I do not take them too seriously.

What I take seriously is human suffering. I find difficult the retrospective rewriting of history. Fianna Fáil is good at that. It wiped out Jack Lynch for a long time and then rediscovered him. It is now wiping out Charlie Haughey and presumably if his image changes he will be rediscovered.

The Senator will be rediscovered himself.

Mr. Ryan

The reason for all the developments in nursing, for which the Minister claims credit, is that the nurses went on strike. It was not that the Government discovered an enlightened new view but that the nurses on strike demanded those things. The Government opposed the reduction in the working week for junior hospital doctors and attempted to have it delayed so far into the future that even the Minister of State, Deputy Hanafin, might be retired, not to mention myself.

I hate the phrase "it will not be solved by throwing money at it". Of course, that is true but it is also a code for "let us not spend money on it". The fundamental issue, which the Minister did not address and which the Fianna Fáil-led Government will not address, is that we are not devoting enough national resources to the provision of a health service. I am aware that matters have improved in certain areas but our health expenditure is low by international standards. It is even lower than it appears because we classify as health expenditure things that are classified as social services in other countries. If that element is removed, our expenditure decreases further.

It is not an excuse to claim we spend much more now than was spent previously. The Government has had surpluses which, by the end of its term in office, will perhaps amount to £20 billion. It decided not to spend that money on things that could be done immediately in many areas of health care. Long studies and research were not required. Many hospitals had programmes waiting to be developed. Why does it take so long to appoint a new consultant? Why does it take Comhairle na nOspidéal an age to approve a new appointment? Why does it take the Local Appointments Commission an age to make appointments?

The real issues are will, resources and vision. The little piece in the Minister's speech about delivering a national health strategy is similar to the preface of every aspirational document produced by the OECD and I suspect it was copied from them. It says what we want but does not contain a single reference to what we will get. Tragically, the Government is caught in the dilemma that it has committed itself to the principle of low taxes forever but at the same time it wishes to persuade us that it will produce the type of health service that is only available in the civilised countries of Europe, countries which accept that one cannot have health care on the cheap.

Amendment put.

Bohan, Eddie.Bonner, Enda.Callanan, Peter.Cassidy, Donie.Chambers, Frank.Cox, Margaret.Cregan, John.Dardis, John.Farrell, Willie.Finneran, Michael.Fitzgerald, Liam.Fitzgerald, Tom.Fitzpatrick, Dermot.

Gibbons, Jim.Glynn, Camillus.Kett, Tony.Kiely, Daniel.Lanigan, Mick.Lydon, Don.Moylan, Pat.O'Donovan, Denis.Ó Fearghail, Seán.Ó Murchú, Labhrás.Ormonde, Ann.Quill, Máirín.Walsh, Jim.

Níl

Burke, Paddy.Caffrey, Ernie.Coghlan, Paul.Connor, John.Coogan, Fintan.Costello, Joe.Cregan, Denis (Dino).Henry, Mary.Jackman, Mary.Keogh, Helen.

McDonagh, Jarlath.Manning, Maurice.Norris, David.O'Dowd, Fergus.O'Meara, Kathleen.O'Toole, Joe.Ross, Shane.Ryan, Brendan.Taylor-Quinn, Madeleine.

Tellers: Tá, Senators T. Fitzgerald and Gibbons; Níl, Senators O'Meara and Ryan.
Amendment declared carried.
Motion, as amended, put and declared carried.

When is it proposed to sit again?

It is proposed to sit at 10.30 a.m. tomorrow.

Barr
Roinn