Léim ar aghaidh chuig an bpríomhábhar

Thursday, 29 Apr 2004

Estimates for Public Services 2004.

Vote 33 - Department of Health and Children (Revised).

I welcome the Minister for Health and Children and his officials. We are meeting to consider Revised Estimates for the Department of Health and Children - Vote 33. A proposed time table has been circulated for today's meeting. It will allow for opening statements by the Minister and Opposition spokespersons, followed by an open discussion on the Revised Estimate by way of a question and answer session. Is that agreed? Agreed.

We have briefing notes but do we have the Minister's speech? Is it the same thing?

We have heard it many times.

I am pleased to address the select committee on the Revised Estimates for 2004 for the Department of Health and Children. The Revised Estimates show a total gross Estimate of almost €10.08 billion for the health services. This is a significant milestone in funding for the health services and demonstrates the considerable investment over recent years. This consists of €9.57 billion current funding and €510 million capital funding. In day-to-day spending, this represents a 10.7% increase over the Revised Estimates for 2003, bringing the amount to €926 million, and a 9% increase over the outturn for 2003, bringing that figure to €782 million.

Given the overall increase in spending on public services and the Government's strategy to contain public spending levels in 2004, this level of additional funding underlines, once again, the Government's commitment to our health services. Much has been said of Ireland's position in regard to its level of health spending within Europe. Despite the negative comments made by some, the Government's investment record on health continues to be impressive, with percentage increases in double digits in each of the last seven years. In 2001, the latest figure for which comparable data is available, Ireland's publicly-funded health expenditure per capita was US$1,560 in purchasing power parities. This is 98% of the average spending of 14 EU countries, ranking Ireland ninth among 14 EU states in terms of per capita public spending on health. These figures show Ireland in an improved position relative to the EU average in 2001 compared with 2000. I am certain this position will be further improved when comparable figures become available for 2002, given the substantial increase in funding of 19.5% in that year.

The total spending figure, current and capital, for this year will be €6.58 billion, or 188% higher than provided in 1997. The Government has provided €6.2 billion in increased revenue funding in the past seven years. This represents a 185% increase on the 1997 figure of just under €3.4 billion and brings us to a non-capital Vote of more than €9.6 billion. This extra investment has brought about significant results, including record levels of activity in the acute hospital system and a range of additional services provided across all care programmes. For the first time ever there has been more than 1 million discharges and day cases treated in our hospitals. This represents an increase of 46,000 discharges, or almost 5%, over 2002. In the area of day cases there has been a massive increase of more than 190,000, or 76%, since 1997, giving a total of almost 441,000 at the end-2003. The total staffing figures for the public health service has increased from about 68,000 in 1997 to an end 2003 position of approximately 96,000 wholetime equivalents, a 40% increase. This figure excludes home helps who provide services direct to older people. According to the Brennan commission, ten out of every 11 additional employees recruited since 1997 are engaged in duties of direct service to patients and the public. Since 1997, an additional 482 consultants have been appointed, which represents an increase of 37%. Since the end of 1997, there has been a 130% increase in the number of occupational therapists, a 71% increase in speech and language therapists and a 37% increase in the number of medical-dental personnel working in the health services. In 1997, there were 25,233 wholetime equivalent nurses employed in the public health system. By the end of September 2003, this figure had reached 33,442, an increase of more than 8,000 during the period, or almost 30%. An additional 245 clinical nurse specialists have also been appointed in the cancer services area. Substantial progress has been made in recent years to ensure that those in need of mental health services receive care and treatment in the most appropriate setting. There are approximately 411 community psychiatric residences in the country providing over 3,146 places. This compares with 391 residences providing 2,878 places in 1997.

While positive signs are emerging of the economic climate, the Government needs to employ a cautious and prudent approach to the use of resources. The increases in funding available to my Department in 2004 must, therefore, be seen in that context. Notwithstanding this, I have secured a 9% increase over the 2003 outturn, which amounts to 27% of the overall increase in Exchequer spending in 2004 compared with the outturn for 2003.

The complexities of services now delivered within the acute hospital sector has increased enormously. Significant investment has been made in additional specialists and diagnostic and investigative processes. These have allowed for more emphasis on day care work, shorter lengths of stay and, overall, a greater turnaround of patients leading to better utilisation of beds. In addition, acute hospital discharges in 2003 exceeded 1 million for the first time and represents an increase in activity of more than 4% between 2002 and 2003. The early indications for 2004 suggest a continuation of this trend, with day case work again showing significant increases. This demonstrates the continued efficiency within the health system and the ability of the people in the health services to generate real value for money in the delivery of services.

New technology assessment has an increasingly central role to play in the use of value for money strategies and health boards were asked in their letters of determination to ensure that every effort continues to be made to seek out assessment of new technologies to guide their introduction so that tighter targeting of the use of technologies, combined with appropriate protocols, will ensure that new technology is employed only for those cases where clear demonstrable benefits exist and resultant costs are justified. In this regard, it is proposed that the health boards and agencies, pending the establishment of the health information and quality authority, should continue the development of a common approach to the assessment of new technology under the auspices of HeBE.

The attainment of better value for money through effective and efficient resources continues to be a critical objective for all health agencies. Health boards and agencies must continue to pursue VFM targets during 2004 and their determinations reflect an appropriate amount of VFM targets which apply across the boards to both pay and non-pay areas. In developing their approaches to achieving that target, they were also asked to take into account possibilities that will emerge from the procurement strategy for health services, which is being completed under the aegis of HeBE. It is critical that all health agencies use the skills and structures now in place to maximise co-operation and actively pursue value for money in materials management, particularly in the development of national protocols and contracts. The level of co-operation between boards to achieve greater VFM will be closely monitored by the Department throughout 2004.

The casemix programme, which was introduced in Ireland in 1991, is used throughout the world and is unique in that it is developed at international level by administrators, clinicians, statisticians and finance personnel all working together. The programme has proven itself and is tried and tested in Ireland. It has been developed to assess comparative efficiency and to create incentives for good performance in health care systems and has been endorsed in the health strategy. Following a recent view of the casemix system, the national programme will be significantly enhanced and expanded, allowing it to be applied to all acute hospital encounters and all acute and sub-acute hospitals by the end of the decade. At least 50% of acute hospital funding will be based on peer group related casemix performance by 2009. This is a significant development in the system and will greatly enhance resource allocation in the health sector.

I will now outline some of the features of this year's Estimate, beginning with acute hospitals. Under the bed capacity initiative, a further €12.6 million is being made available from overall funding in 2004 to facilitate the discharge of patients from the acute system to a more appropriate setting, thereby freeing up acute beds. Of this, €8.8 million will be made available to the Eastern Regional Health Authority and €3.8 million to the Southern Health Board. The funding will provide for the subvention of additional beds in the private nursing home sector and ongoing support in the community.

The strategic review of ambulance services recommends the elimination of on-call duties from emergency rosters and the introduction of other identified measures to improve response times. Some €3.2 million is being made available to meet the costs associated with this recommendation.

Since 1997, there has been a cumulative investment of approximately €550 million in the development of cancer services, including an additional €15 million being made available in 2004. This allows us to address increasing demands in such areas as oncology-haematology services, oncology drugs and symptomatic breast disease services. An additional 91 consultant posts in key areas of cancer services have been appointed since the strategy was begun. Since 1997, approximately €95 million has been allocated to cancer initiatives, including radiation oncology, the bone marrow unit at St. James's Hospital and €11.9 million for BreastCheck. The key goal of the national cancer strategy of 1996 was to achieve a 15% decrease in mortality from cancer in the under 65 age group in the ten years from 1994. I am pleased to report that the Deloitte evaluation of the 1996 national cancer strategy, published in December of last year, shows that this reduction has been achieved three years ahead of target.

Some €2.5 million of the €15 million revenue mentioned above is being used to implement the recommendations contained in the report on the development of radiation-oncology services in Ireland launched last year. I have approved the purchase of two additional linear accelerators for the supra-regional centre at Cork University Hospital and the necessary capital investment, amounting to over €4 million, to commission this service as rapidly as possible. Some €1 million in ongoing revenue funding is being made available for development of this service in 2004. On supra-regional centres and University College Hospital, Galway, the new radiation oncology unit has been constructed and equipment is being commissioned. A sum of €2.5 million in revenue funding is being made available for the development of this service in 2004.

The Hanly report published in 2003 set out the measures needed to comply with the European working time directive, to introduce the consultant-provided service, to reform medical education and training and, consequently, to reorganise the acute hospital system. Implementation groups have been established in the two areas covered. For the remainder of the country not yet considered by the Hanly report, a new committee established under the chairmanship of Mr. David Hanly will deal with that issue.

We have taken a number of steps to develop further the services being provided in smaller hospitals in the two areas covered by the Hanly report. For example, I have given approval to the appointment of a design team for plant and structural improvements at Ennis General Hospital. Some €15.5 million is being invested in a new community hospital in Thurles. This state-of-the-art facility will have 72 beds and a day hospital service with a further 15 beds. A new health centre being constructed in Nenagh will cost approximately €5 million. There was further investment in radiology services at Nenagh Hospital last year and again this year. There will also be further developments in primary care in the two areas covered.

I have provided, as mentioned, funding for the discharge of patients from the acute sector. I have given approval to the development of the emergency medical technician advance programme. Funding has been made available this year to enable the training programme to commence while considerable work has been undertaken by the pre-hospital emergency care council in conjunction with the Department in preparing the legislation necessary to give effect to the introduction of the programme in the current year.

Funding available for the waiting list initiative is being redistributed with an additional €12.2 million being allocated to the national treatment purchase fund, bringing its allocation for 2004 to €44 million. The balance of €31.6 million has been allocated to the health boards and the ERHA as base funding to support core services put in place over the years with waiting list initiative funding. Having a single funding stream through the national treatment purchase fund to reduce waiting times for patients is now seen as a more effective use of resources. The number of adults waiting more than 12 months for inpatient treatment in the target specialties decreased by 42% between September 2002 and September 2003. The number of children waiting longer than six months for inpatient treatment in the target specialties fell by 39% in the same period.

I have given a significant role to the national treatment purchase fund in 2004 in line with the health strategy recommendations. Significant progress has been achieved by the fund in targeting those patients waiting longest for treatment. To date, some 13,000 patients have had treatment arranged under the fund. It is now the case that in most instances adults waiting for a procedure for six months, or three months in the case of children, are facilitated by the fund. If patients are prepared to travel outside their local area, treatment can be arranged quickly.

Additional funding has been provided for renal services, an area in which there will be further developments later this year. In terms of blood policy, we are advancing the recommendations of the Lindsay report while funding is being made available for child care services, in particular foster care allowances which were transferred from the Department of Social and Family Affairs.

On services for the disabled, additional funding of €28 million has been made available to meet a range of services in 2004. This amount includes a sum of €10 million for additional services approved in July 2003. The position on physical and sensory disabilities is similar. More funding is also being made available to enable the implementation of the Traveller health strategy.

On mental health, approximately €1 million is being provided for forensic psychiatry, €1 million for the Central Mental Hospital and €3 million to enable the Mental Health Commission to put in place the various mechanisms required to support the mental health tribunal process. Total funding available to the commission in 2004 is €5.3 million.

Nursing home subventions are being increased by approximately €4 million. This brings the total available in 2004 to some €144 million, an increase of €89 million or 162% over the 1998 figure of £55 million.

Home help services have been expanded significantly while community care support services will receive additional funding. Funding is also available for backup of the smoke-free workplace initiative. Funding has been made available to the Office of Tobacco Control and the health promotion unit for the development of a number of campaigns in 2004 to deal with the issue. In this regard, the national quit line has been very successful. We will also develop a new campaign based on the success of these advertisements which will be targeted at children and young teenagers in an effort to reduce the numbers of those taking up smoking at a young age. Members will be aware that since the introduction of the smoke-free workplace initiative on 29 March, compliance levels are very high, a justification for the investment made. The decline in the number smoking is continuing - it amounts to approximately 100,000 between 1998 and 2002.

The implementation of the cardiovascular health strategy has reaped significant benefits, including a decline in death rates from heart disease, people are healthier for longer, those at risk of heart disease are receiving quicker and better treatments closer to where they live while people with established heart disease have a better quality of life. We have provided significant funding under the strategy with approximately 18 consultant cardiologists due to come on stream this year.

Approximately €6.24 million is being allocated to support the wider implementation of primary care projects. We have made significant progress in the general practice co-ops during the past two years and I hope to see full coverage during the next two years. An additional €127 million over and above the 2003 outturn is being provided to meet expenses of the GMS (Payments) Board to provide for the application of pay increases and increases in drug costs and prescribing fees, all part of the costs associated with the higher demand in respect of medical card holders.

Additional revenue of €4.3 million was allocated to meet increases in the dental treatment services scheme while the waiting list for orthodontic assessment has been reduced from 11,357 in December 2001 to 9,021 at the end of March 2004. Funding for the health boards in 2004 would have been paid over to the MDU and the NPS if I had not kick-started the clinical indemnity scheme this year. This issue is covered in my speech as circulated, as is the matter of private bed charges.

I thank the Minister for his presentation. I received this slim volume from the Department on Friday and sat down at my kitchen table on Sunday afternoon to read it. I was struck by the fact that this process was a total farce. If we are supposed to be scrutinising the spending of €11 billion and if we are the defenders of taxpayers' interests, they are being poorly served. I am no less qualified than anybody else present but we are not qualified or resourced to scrutinise the spending of such an amount. We certainly cannot do so in ten minutes. I do not blame the Minister in this regard. He has a panoply of advisers; we do not. The system is unbalanced and stacked against us in doing this job properly. We could not even scrutinise such spending in ten hours. This is a total charade, made more difficult by the manner in which the accounts are compiled. The way they are laid out, there is no possibility that they will ever reflect the information we would like to know in terms of how much is spent on the elderly. One has to dig into seven or eight subheads to get information on the sum being spent on any particular programme. It is impossible for someone who does not have backup or accountants available to him or her to make comparisons as between different areas or years. I am not accusing anybody of trying to fool us but it is almost a waste of time undertaking this exercise. I will quickly make some comments and ask some questions bearing in mind that it is probably a total waste of time in that there is not enough time to get to the bottom of anything.

Subheads B1, B2 and B5 cover large spending programmes. The proportion spent on pay as opposed to non-pay items is very large. Will the Minister say what the impact of the reforms will be on the pay bill or has that been calculated? Is it envisaged that there will be a change in emphasis in the pay bill and that it will involve more direct service provision rather than management and administration? If what the committee heard this morning from the interim Health Service Executive is true in that layers and fragmentation exist down through the service, it seems there is significant potential for saving on pay. Is it intended the reforms will do that?

Subhead B2 comes up every year. The drugs bill seems to be the one that is growing no matter what is done. It is growing despite the threshold being increased very considerably in the last couple of years. Is this a result of more drugs or the higher cost of drugs? I have a related question about subhead B3 which shows a 30% increase in fees to pharmacists. Is this as a result of more individual items being dispensed or as a result of increased fees for pharmacists? It seems unusual that the fee bill is increasing at a time when the number of medical card holders is clearly going down considerably as is evidenced by the reduction in money going to general practice. That is one of the few areas where there is a decrease.

The provision for the enhancement of the general practice service is also reduced. It has decreased by approximately €600,000. This is not a large sum but the sum being spent on general practice was not large to begin with. I ask the Minister to explain how that is consistent with the primary care strategy and his repeated commitments to enhance general practice. Will he agree it is a very short-term approach not to concentrate on health care demand reduction measures?

It was reported on the radio this morning that the diabetes shared care project in the North Eastern Health Board area is being abandoned due to lack of resources. It is not resourced at all as far as I could see. The chief medical officer was before the committee some months ago talking about obesity and the intention to develop a diabetes strategy. That is where the money should be directed if in the long term we want to save on the significant diabetes bill.

Subhead F deals with many of the bodies that have been set up over the years. I am not sure if they are funded directly by the Department or indirectly through health boards. Many bodies have been set up over the years for a variety of reasons. It is high time they were all incorporated into one body with one caveat, namely, any bodies set up to increase accountability in the system should not be incorporated into the health service executive. It is extremely important that any body or agency offering some level of independence and accountability outside the mainstream of the health service should continue to be funded.

I note the very significant annual bill to pay for the aftermath of the blood scandals. I believe not all the legal costs are included in the €130 million. It is a very large sum of money. I wonder if practices have changed in the IBTS sufficiently to ensure that such events will not happen in the future. The Minister may be aware that people who died years ago are still listed as blood donors, despite the fact the board was informed of these deaths. It seems to indicate appalling records management, despite all that has been said about the administration.

The subject of mental health was raised by the Chairman. Money must be spent on this area. It has been the soft option in terms of taking money away. It is appalling. The most shocking, frightening and heart-breaking details of underprovision given to the committee from all specialties concerned the area of mental health. It is not a black hole for money even though it may seem that way. It is not regarded as a sexy area. However, early intervention can cure people, keep people out of prison and minimise the damage. The Minister spoke about finding more appropriate places of care for those with mental health problems. It is good to take them out of institutions but not to have them in the doorways of Molesworth Street and in prison. Money must be invested in the service.

The Minister and the Taoiseach have stated that people are better off and do not require medical cards. I remind the Minister that some people are not better off. He stated that the CEOs of the health boards have flexibility and discretion. However, their discretion is dictated by their budgets. Apart from people losing medical cards because their income is marginally over the threshold, CEOs and medical officers cannot use the same discretion they applied in the past in the case of those with long-term illnesses who have large medical bills and real and genuine hardship is being caused. The IMO conference was told that 10% of those who need medical cards are not receiving them. Therefore, they do not attend their GP and instead end up in hospital. Money is not saved in the long run; it is costing us all money and is causing significant misery.

I share a certain sense of unreality for slightly different reasons with Deputy Olivia Mitchell. I am conscious that the committee will finish its deliberations soon. In my view it is irresponsible that such a short time has been given to this important debate. The situation should be examined. It is a reflection of how disconnected the Minister is from the real nature of the health service. The committee has heard the usual litany presented again. Nothing has been said about the following: the increase in population; the increase in demand on the health service; the ongoing shortage of nurses; the endemic crisis in accident and emergency departments; the gross deficiencies in a range of specialties across the country; the plans to downgrade local hospitals; and the plans to close accident and emergency departments in local hospitals.

The most glaring omission of all is the lack of comment on the failure of the Government to meet its solemn commitment to the Irish people to eliminate hospital waiting lists in a few days time. At this stage the Minister is no longer even releasing figures. There is no information about the waiting lists this year. I can only presume that numbers are still around 27,000, the last figures released.

There is a sneaky cutback in these Estimates regarding waiting lists. The Minister should not shake his head. Like everyone else, I can see what is being done. The waiting list initiative had reached a funding level of approximately €44 million. According to the Minister, the decision by the Government was to transfer the funding to the national treatment purchase fund. This was explained at the time following an investigation as to where this money was going. When these figures are closely examined, it appears that only €12.2 million has been transferred to the national treatment purchase fund. I have no problem with the decision to move it but my point is that only €12.2 million is being provided for the waiting lists initiative. The Estimates show the rest of the money has been absorbed into normal health board and hospital funding. That is a cutback no matter how it is dressed up. The dedicated funding that was there for hospital waiting lists was transferred to the national treatment purchase fund. That is an appropriate place for it to be although I believe the rules governing that fund should be changed. As a consequence, the national treatment purchase fund has only seen a tiny increase, even though the Government states this is a great success story. The fund now has a budget which including the waiting lists initiative has risen from €30 million to €44 million but the vast bulk of that increase is money from the waiting lists initiative. This is an issue that must be highlighted and exposed.

Another air of unreality surrounds the fact that there is no indication of the Health Service Executive input or its effect on the Estimates or the Hanly report. The chairman of the interim Health Service Executive informed the committee that it is busily making appointments and I commend its diligence. Appointments are being made which will ensure there is a parallel system of administration. There is a cost involved in these appointments yet I can find no dedicated money in the Estimates for the interim Health Service Executive. The committee needs to know where that money will come from.

The Hanly report promised the devil and all regarding improvements for local hospitals and community care services but there is nothing in these Estimates to indicate such a provision, other than the normal increases required for pay increases. The Minister is talking about a pittance and he should not try to fool the committee.

I have a question about the coming year and the working-time directive that must be implemented on 1 August. It is a paradox. On the one hand junior hospital doctors cannot be exploited beyond 1 August. The Minister stated he will not take on extra junior hospital doctors nor, according to Hanly, will he appoint extra hospital consultants. The consultants are refusing to co-operate because they are in dispute with the Minister. There is clearly only one way it will be done and that will be at the expense of patients. The only way the working-time directive can be met under the current conditions is to cut back on operating time and on out-patients. That issue was clearly signalled at the recent IMO conference because doctors are worried about what will happen to their patients after 1 August. It is important the committee is given a clear rather than a fudgy answer.

The situation regarding medical cards is disturbing. This is one of the richest countries in the world yet fewer and fewer people are able to avail of the protection of the medical card. That compares very badly with the Minister's predecessors. When the GMS was initiated this country was considerably less well off yet approximately 30% more people were covered by the medical card system. It has now dropped to under 30%. If the over-70s who can afford to pay for their care but have medical cards are taken out of the equation, it is well below 30%.

One quarter of the patients in one medical practice in Dublin were found to be unable to access the family doctor because they could not afford to pay him. Fianna Fáil recognised this was an issue. The Minister promised 200,000 new medical cards. Since that commitment was given, there has been a reduction of 100,000 medical cards. How does the Minister think these people are managing? He has increased the level of costs for medications. Doctors are increasing their consultation charges. People's incomes are restricted by penal thresholds. If I hear again the idea that it is up to health boards to determine eligibility, I will refuse to accept it because it is wrong. We all know that health boards are circumscribed by the scheme. The scheme is in place and unless there are extraordinary circumstances, people will be turned down no matter what their or their children's health care needs are. It is grossly unfair.

The committee is considering the Estimates for yet another year where these people are being put outside and marginalised again. It is untenable. I ask the Minister to deal with this issue. I ask him to forget about administration and think about families who are unable to access their family doctor. Ireland holds the EU Presidency yet in terms of delivery and access by those on low incomes, our health care system is reminiscent of a Third World country.

There is an item in the Estimates for statutory and non-statutory inquiries. Will the Minister clarify the position on the non-statutory inquiry relating to the patients of Dr. Neary and on nursing homes? Will the Minister state what can be done to ensure that people are able to access nursing home care? There are empty beds in nursing homes and there is a need to access beds but the system is not working. Many people are in hospital who could be in nursing homes if the system was working properly.

Since there appears to be only one spokesperson present for the Technical Group, Deputy Cowley has ten minutes' speaking time.

There is an air of unreality about this discussion. The Minister for Health and Children is present and he has told the committee about the money being spent. The acid test of the health service is whether people can access the services they require, particularly when their lives depend on it. People are not getting the health service they need and questions must be asked about that.

The Minister told the committee about increased spending but that has been said many times. A recently published report noted a link between low health spending and high winter months mortality. Ireland has the second highest winter mortality rate in the EU according to a study published in the Journal of Epidemiology and Community Health. The study related this to low spending. I acknowledge that spending has increased.

Canada has an excellent health service. It spends 9.1% of its GNP on health and Ireland spends only 6.7% of GNP. I question whether there is sufficient spending on the health service. The bottom line is that people are crowding out the hospitals on accident and emergency trolleys. It is impossible to get into the hospitals. In Mayo General Hospital there are frequently up to 21 trolleys in use in the circulation areas of the accident and emergency unit which are meant to be kept clear. It is difficult even to access seriously ill people. There are often two seriously ill patients per cubicle who have been referred to hospital by a general practitioner. They have been assessed as requiring hospital admission and yet they are on trolleys because there are no beds for them. The bottom line is that 3,000 beds were taken out of the system in the 1980s and never replaced. Despite all the promises and 120 reports on the health service, they have all failed because of lack of funding. It will be the same again.

It appears we are not prepared to address the real issues in the health service such as bed capacity. Until that is done adequately, we will continue to have patients on trolleys. People will continue to have problems accessing basic out-patient services. There is health apartheid in Ireland of the highest order. As a general practitioner, I am well aware, as is the Chairman, that if one has money, one can access a service within a few days. If one does not have money, one may well die on a waiting list, as people do. People do not die on private waiting lists if they have money, but they do on public waiting lists. That is the bottom line. As I know the names of people who have died, the Minister need not bother to tell me I am making this up. He has a responsibility to address health apartheid.

I see a lady with severe joint problems due to arthritis who travels from the very end of Mayo to Galway for rheumatology services. She had to wait four years for an appointment. As the Chairman knows, within a few months irreparable damage can be done to a person's joints. While that represents the acid test of a health service, I see no attempt to resolve the problem of people having to wait a long time for an appointment and, on receiving one, travelling such distances to keep it. There are no waiting lists in the local hospitals with consultants. The extensive waiting lists are in hospitals to which people must travel from far afield to obtain the services of neurologists etc. In my area alone, 1,000 people are waiting for urology services. They have to get up five times a night in the absence of an operation which takes 20 minutes to perform. If those people had money, the operation would be carried out next week.

People with cancer must wait terrible lengths of time for co-ordinated radiotherapy treatment which they cannot have because the Minister has plans not to look after the people in the north-west. I have yet to receive an explanation from the Minister or anybody else as to how someone is to benefit from the opening of a unit in Galway when it is further from the top of Donegal to that city than it is to Dublin. That does not make sense and I cannot understand how it is supposed to improve matters for these people.

Is the Deputy saying the unit should not be opened in Galway?

Somebody must——

Does the Deputy want the unit in Galway?

The Minister can answer in a few minutes. He has the power to give us extra time rather than have us thrown out after a few minutes.

I do not.

What is happening on cervical screening? We were promised this many years ago but it remains a pilot scheme in the mid-west. While people with money can access all these services tomorrow, people without it must wait. The same scenario obtains with BreastCheck of which there has been a great deal of talk and in which a great deal of money has been invested. However, it is being rolled out everywhere except the west.

We still do not have a helicopter emergency medical service, a proposal for which has been lying on the Minister's desk for a great deal of time since a report was published. The Minister has seen for himself people whose very ill children have died trying to reach the so-called centres of excellence in Dublin. He saw the other night on RTE the parents of children with meningococcal meningitis. Children have died from that disease. Seriously ill children have died in ambulances on their way to Crumlin for urgent operations. They died because there is no designated emergency helicopter service. I could go on and on.

I have figures which I can show the Minister on the ambulance service in my area. In the Eastern Regional Health Authority, 95% of calls are answered within 20 minutes whereas in rural areas only 60% are answered in that time. That is unacceptable. In our region, we have the unique distinction of having citizens outside the benchmark 20 mile radius from the nearest ambulance station. I could show the Minister a map detailing a number of areas which fail to meet this criterion, including Tuam in County Galway, Achill and Mulranny in County Mayo and Castlerea in County Roscommon. We in the west also matter and should also have access to the basic services we need. There is a golden hour which is the window of opportunity to get a person to services. I am sure the Minister is aware of it. How can that happen if it takes an ambulance over an hour to reach a person?

Medical cards constitute another area where the situation is ridiculous. As has been pointed out, the numbers holding medical cards have decreased by nearly 100,000 since Fianna Fáil and the Progressive Democrats came to power. The only time the number of people holding medical cards increased was prior to the previous general election when the facility was extended to everyone over 70 years of age. Can the Minister blame people for being cynical?

Did the Deputy have a problem with that? How can a general practitioner have a problem with it?

I have a problem with the fact that there are families and people earning the minimum wage who do not qualify for a medical card. As I said to the Minister a year ago, it is like having two machines. There was no point saying that as he did not listen. If one has two machines, one of which costs a couple of pence to run and the other several euros, one will use the less expensive one. People do not have access to primary care services. What money has been invested specifically in the primary care strategy? There is no designated money for that despite the Minister's promise in the health strategy of €130 million for the first ten years. In year one, the Minister provided €12 million, in year two he provided €4 million and this year there is no money.

Delegates from the mental health service attended the joint committee the other day. The service's budget has dropped from 11% of the total health budget to 6.6% in 2003. It is the lowest level of funding among the medical specialties. It is obvious that things are not happening as they should and this is so across the board. While I have all the time in the world for removing people from waiting lists, money should be invested in local hospitals where real work is being done and which people have an opportunity to reach within the golden hour. Is it right that people must wait up to seven months for an urgent ultrasound in Mayo General Hospital? Is it right that the orthopaedic unit in that hospital is still not open? Is it right that there continue to be problems of access to radiotherapy services for people in particular parts of Ireland? Will the Minister consider these issues which he is failing to address in the Estimates?

All Deputies have raised the issue of greater time. I have no difficulty with making more time available for discussion of this issue. I have no difficulty with equipping political parties and elected representatives with research services and facilities. I understand a working group of Senators and Deputies is to publish a report - if it has not already - on that issue. Other parliaments throughout the world make such resources available to parliamentarians and legislators. In terms of discharging one's duty effectively and ensuring accountability of Government, I am support Deputies in this respect.

It is too early to ascertain the impact of health reforms on the pay bill. Clearly, we are looking toward a more streamlined service with a key target of ensuring better value for money. We wish to see greater results from the money we are investing. While the rationalisation of agencies should generate economies over time, we have not yet had a chance to make a clear calculation of that. The drugs bill is increasing for multi-factorial reasons. While fees are increasing by standard rates in the context of Sustaining Progress, the real issue is the continuing rise in the cost of drugs. The number of prescriptions being written continues to rise as well, as does the number of items on each one. This is a global issue rather than just a problem for Ireland. From talking to my European Union colleagues, I know they all face similar problems. The agreement between Ireland and the pharmaceutical industry will be renegotiated in 2005, at which time we hope to achieve some economies in the context of any new pricing agreement.

We have developed within the Department of Health and Children a system of accountability in service planning, including evaluation reports, annual reports and financial controls. Details of the reports and controls are available to Deputies. The number of people availing of the drugs payment scheme continues to increase. The fact that the scheme is much more user-friendly than its predecessors has been a significant factor in the dramatic increase in the cost of the scheme in the past three years.

I will pass on Deputies' comments on the blood transfusion service to the Irish Blood Transfusion Service. While the IBTS can come before the committee to account for its stewardship, I point out that significant progress has been made arising from the various tribunals on the blood issue, including the establishment of new headquarters in Dublin. Only last week, I opened the national centre for coagulation blood disorders which will apply technology to the traceability of factor concentrates. This is the only centre able to do this in Europe. Representatives of the Federal Drugs Agency in the United States will visit Ireland to evaluate the centre and the world organisation responsible for haemophilia will also visit the facility.

The Department has funded and established a world-class facility which is moving us into a new era and leaving behind a bad chapter in our history in terms of how we dealt with these issues. All the stakeholders were present at the opening. We must acknowledge that this is a first-class, state-of-the-art facility.

As regards extending the medical card, there is no question that the fundamental reason for the decline in the number of medical card holders is due to the additional 400,000 people working here and the incredible economic performance of the past five years.

That is rubbish. The Minister has failed to increase income thresholds.

The Deputy does not have to believe me but independent reports confirm this. The Government has committed itself to increase the income eligibility threshold for the medical card in this term of office. We were elected two years ago and have several years of office left. I hope to be in a position to accomplish our commitment over the lifetime of the Government.

The Minister must believe he will be in office for life.

As regards Deputy McManus's point that I had presented the usual litany, she may view my statement from that perspective but I was outlining the effective measures I have taken to deal with increased pressures, an increased population and significant changes in recent years. I visited Portlaoise last week to open a new €35 million hospital with a paediatric facility, acute psychiatric unit, medical wards and coronary care units. There was no question that the staff at the facility were working in a transformed environment. This is just one illustration of the kind of improvements that have taken place, but are rarely acknowledged in forums such as this.

I must address a critical issue concerning waiting lists. It is outrageous to suggest that there has been a sneaky cut in the waiting list. I have increased funding to address waiting lists by more than any of my predecessors. When I took office, €30 million was available for tackling waiting lists. I allocated an additional €10 million immediately and recently allocated a further €30 million under the national treatment purchase fund, which amounts to a global sum of €70 million.

The Minister took it away again.

The Comptroller and Auditor General's report, which Deputies debated, illustrated this point.

We have a Dáil vote. Are Deputies happy to conclude this discussion now or would they like to return? I understand Second Stage of the Health (Amendment) Bill will be taken in the House shortly. Will the Minister be available in 15 minutes?

Yes, another Minister will be in the House to take the Health (Amendment) Bill.

It is unsatisfactory that the Minister is unable to take the first health reform Bill for many years.

I would like to be able to take it.

Is it possible to resume after the Bill has been discussed?

The room will not be available later in the afternoon.

I want to ask the Minister if funds have been designated specifically for the primary care strategy.

We need to resolve one issue at a time. I suggest we resume in 15 minutes and conclude as quickly as possible to allow the Minister to return to the House to take the Health (Amendment) Bill.

It is unacceptable that this meeting was scheduled to begin one hour before Second Stage of the Health (Amendment) Bill was ordered for the Dáil.

We were told by the Department that today was the only day on which it could facilitate us.

The Oireachtas is run by its Members, not the Department.

I am prepared to stay here all day. A Minister of State appointed by the Dáil to deal with issues pertaining to health will take the Health (Amendment) Bill. Parties also have their spokespersons and, like us, must work as a team.

We need more time as this problem constantly arises. The Minister will deal with four topics when he appears before us on 26 May 2004, including the important issue of orthodontics. We need time - at least four days - for him to answer our questions as these are issues on which people's lives depend.

Sitting suspended at 1.10 p.m. and resumed at 3.05 p.m.

I thank the administrative and technical staff for accommodating us. We were on general questions and answers and the Minister was replying to some questions that were raised. We have an hour.

On the drug payment scheme, it has been indicated that there was a significant increase in uptake. A total of 1.319 million people are now covered by it, which represents a huge increase on the position that pertained in recent years. Approximately 34% of the population avail of the scheme on an annual basis.

Before we concluded, I talked about the waiting list issues. There has not been a cutback in funding and it is wrong to say that there has been. The money is being used in a different way and is being redistributed. People knew since 1993 that some boards began employing temporary consultants as part of their waiting list initiative. Every year, the funding was going towards their employment and other initiatives concerning the waiting list. The report of the Comptroller and Auditor General does not garner from these facts the extent to which waiting lists were dealt with, but we know from statistics that activity levels increased significantly, not just because of the waiting lists but because of a range of other funding initiatives and capacity increases.

The report indicates that the Comptroller and Auditor General was of a view that the TPF had a certain transparency value and that one could see money equating with numbers on lists. Any funding that existed is still in the system in terms of the €43 million and the €33 million. We took €12 million and added it to the TPF's €13 million and the remaining €30 million that was part of what one might term the old waiting list initiative money has gone into the health boards and therefore they have not suffered any loss of money. If anything, they have fared better. They would argue differently but the reality is that all the money has gone in as core funding. It is a change in the methodology of how we do business and involves redistribution of funds in terms of the allocation. It certainly could not be termed a cutback because the total for last year would have been approximately €70 million. This total is exactly the same in 2004. The money now reflects more accurately what is being done in the system.

The working time directive was raised by Deputy McManus and, on the basis of the latest returns, 60% of specialities will be compliant with it. However, recently in the Dáil and in my recent speech to the IMO conference I outlined clearly the steps that need to be taken, which involve our partners, the IMO and the other interested stake holders who are refusing to come to the table in respect of the reduction of hours issue and associated issues concerning the working time directive. They are not participating on the implementation groups, either at national or local level. Therein lies the difficulty. However, we are progressing the issues. The Hanly report indicated ways of reducing the hours without necessitating the employment of additional consultants or junior doctors by August.

When I state we do not propose to increase numbers of junior doctors, this is a general view. It was strongly recommended in the Hanly report that we should not meet the working time directive by means of appointing junior doctors. We already have 4,000 junior doctors to 1,800 consultants. We do not want to worsen that ratio. If anything, we want to double the number of consultants and have a consequential reduction in NCHDs. There are obviously industrial relations issues at stake and I find it hard to understand how, in 2002, when there was a huge campaign by the IMO on junior doctor hours, the key issue concerned the need to reduce the hours and to get better rates in overtime but when we gave a very generous package on that occasion it seems that the enthusiasm for reducing the hours left the scene.

A positive side of that package is that the transformation from high-volume NCHD to high-volume consultant will not be as difficult financially over time as it might otherwise have been. That is another day's work. That is our position but we will continue to work in the context of the Labour Relations Commission and urge the IMO and others to get involved in the process.

I appreciate the difficulties the Minister has but I do not understand how he will deal with the matter on 1 August bearing in mind that there is no industrial relations process. How will the Minister deal with this?

It is too early to pre-empt that. If we are not in compliance by August, the State will be vulnerable to challenge.

What will the Minister do? Will he cut back on the level of patient care?

Is that a guarantee that no hospital will be cutting back on the number of hours and services?

We are not in the business of cutting back on patient care. There are modalities by which we can reduce the number of hours without impacting on the level of patient care. We have to comply with the law. There is more than just the Department at stake. All sides should be urged to come to the table. The very body which called for a reduction in the number of hours is the one which will now not come to the table. We will have to take it step by step.

On the Neary inquiry, I hope to meet the patient focus group shortly. As the Deputy is aware, we appointed the judge and the Government has agreed the terms of reference. I recently met the patient focus group as there were some issues which concerned it, especially the issue of compellability, on which I have an understanding with the chairperson of the inquiry and the Government. The chairperson is of the view that she can carry out an efficient inquiry in a reasonable timeframe but I want to consult further with the group before we sign off.

I have some differences with Deputy Cowley in the manner of his presentation on health issues. I believe he sees health as an issue of electoral benefit. He continuously made throwaway comments. I cannot understand his point about radiotherapy services. I did not know if he stated we should have such services in Galway where the development of a radiotherapy centre is of huge advantage to the west and north-west. It is the first time patients from the region will not have to travel to Dublin to undergo treatment. The Deputy should welcome this initiative instead of whinging about it.

Are we sure our colleague has been notified about the meeting?

I told him personally.

We have provided funding this year for radiotherapy services. We are also providing capital funding for the development of BreastCheck in Galway, where a cardiac surgeon has been appointed. With the exception of oral surgery, we are creating a centre in the west that will mean that patients will no longer have to travel outside of their area for major tertiary services. For Deputy Cowley, the glass is always half empty, which is fair enough as he advocates more. However, we need to acknowledge what has been done. In this regard, the Deputy needs to talk to his medical colleagues. There is a need for consensus in the medical community on what it thinks is the best configuration for medical services.

I have met many people about the radiation and oncology services report. We recently met the American cancer society to discuss the cancer strategy and smoking ban. It was very supportive of the radiation and oncology services report as an exceptional model. It claimed the strategy was in keeping with best international practice in terms of survival rates and outcomes. However, Deputy Cowley ridiculed it and suggested it had no value. He stated there was an air of unreality about the debate. I often think there is an air of unreality about the contributions he makes.

I agree with the Deputy that we need more rheumatologists in the west. The model brought forward is the consultant-led model providing for more consultants and greater regional self-sufficiency, a cornerstone of the Hanly report, yet the Deputy is the first person out of the trenches to demonise the report. There are ways of clearing the deficits in rheumatology services but there will also be a need for patients to travel to Dublin.

I do not agree with the Deputy in ridiculing the centres of excellence in Dublin. We have excellent paediatric teams in Crumlin, Temple Street and Tallaght but need to improve the physical infrastructure in Crumlin. This is under way. Children suffering from rare or chronic conditions need to be treated in a place like Crumlin where the expertise is available. We should, therefore, get rid of the disparaging language used. We cannot do everything in every hospital and should stop pretending that we can.

The Deputy made a point about mental health services, in respect of which we have increased the overall cake significantly over the last four or five years. It is now said mental health services used to account for 9% of the total health budget but that budget was much lower. Mental health services now account for 6% of a budget that has risen by 188%. In real terms, the level of funding, services and activity levels have risen. There has been significant reform and change but, undoubtedly, more needs to be done. The Government is anxious to concentrate on the capital development programme for child and adolescent psychiatry services. We have done a lot to improve old age psychiatry services in recent years. We are also developing consultant-led multidisciplinary teams in child and adolescent psychiatry services but there is more to do.

Was I missed?

No, I think the Deputy missed me.

Did I get answers to my questions?

Yes. I was dealing with mental health services. I recently opened the acute psychiatric unit in Portlaoise. We have also opened units in Ennis and Kilkenny. The Mercy Hospital is coming on stream while child and old age psychiatry services are receiving extra funds.

The ten implementation groups for the primary care strategy have been provided with funding. GP co-operatives have also been provided with a sum of €46 million this year. For a proper primary care strategy one needs a 24 hour out-of-hours service which we did not have four years ago. It began in Carlow and has been expanded across the country. I paid tribute to general practitioners who had organised such co-operatives and had worked with the health boards in developing them. I have stated I would like to see the service completed in the next two years and have more implementation projects up and running, especially in the two areas covered by the Hanly group - the mid-west and the east coast.

Notwithstanding the fact that the HEMS report will be published shortly, my priority will remain the ambulance fleet, on which we have spent a lot of money in recent years. We now need to invest in the capital needs of the ambulance service, in respect of which I have provided funding for EMTA training. Incidentally, people have great confidence in emergency medical technicians who are trained to administer treatment. The recommendations of the strategy relating to ambulances will continue to be implemented.

We will be sending the report on the helicopter emergency medical service, HEMS, to the Department of Defence, among others. Three models are outlined, the third of which is tertiary transfer, which is recommended, that is, transfers from hospital to hospital. Perhaps the committee will return to discuss the options outlined in the report in greater detail. I have had a preliminary look at its recommendations.

The hospital in Castlebar has done well under the Government. I disagree with Deputy Cowley when he states everything comes down to a lack of funding. I would welcome him to a bilateral meeting with the Minister for Finance any day to see how he perceive the level of funding allocated to health services in recent years. The level has been significant. The difficulty is that the health services employ staff and that benchmarking, both last year and this year, is taking a huge slice of the increases allocated.

I arrived late when the Minister was talking about radiotherapy services. I want to ask about private sector provision of such services. The Minister mentioned Limerick but I understand it is proposed to provide a service in Waterford. If that service goes ahead, will the Department commission services for public patients from Waterford? While I acknowledge it is difficult to give a complete commitment, it does not seem to make sense to refer such patients to services in Dublin when there is a facility available locally.

The committee also needs to adopt a position on this, although I accept that its members may have different views. The committee received a submission from the Hollywood group. Did it meet it?

We were given different versions of what was to be done.

There is international opinion indicating that what we are doing is excellent and that if we could produce this model——

That was not the conviction of all the members.

Of the committee.

No, all the members who made the presentation. They were not convinced.

We had others making the presentation.

Yes but the report was produced. The oncologists I have met, internationally and nationally, state it is a "no-brainer". The Deputy is saying the choice facing us is a network of two linear MAC facilities. I say that is one choice. If the Deputy is saying that would be better than having eight machine multidisciplinary centres of excellence, about which we should forget - I do not have an endless budget - and that somehow patients would derive greater benefit if we facilitated the establishment of two linear MAC facilities, separate from the teaching hospitals, I would have a difficulty with that view. On the other hand, we have stated in the strategy that there is room for satellite services in the north-west, the mid-west and the south-east. We have also stated that before we go anywhere, there is a need to build a national backbone in the service - all one has is St. Luke's Hospital. A national backbone means a Dublin-Galway-Cork axis, creating enough volume with enough machines and expertise in a multidisciplinary team. That is where the money will go in the short term.

The fastest way to increase capacity is as follows. The Galway facility has three machines and we will add three more. The Cork facility was rebuilt a number of years ago. All that was needed was extra bunkers for extra linear MACs as well as extra teams. The expert advice is that one will only be able to attract people with expertise to these centres; that they will not come back to two machine facilities. That is what I am told.

I am not asking where the State will make the big capital investment. I broadly subscribe to the findings of the Hollywood report. I understand the important point is to increase capacity rather than provide it everywhere. I also understand the problems encountered in accumulating expertise, that one will only do so in a concentrated way in facilities where there are more than two machines. However, my question is this. What if somebody else is doing it?

People can do it. I cannot stop them.

I understand that. If somebody is providing a service for private patients, is there any ideological reason the State cannot commission services for public patients whom one would be asking St. Luke's Hospital to treat if such a facility was not available in Waterford?

The second related point is that the Hollywood report is founded on the provision of three centres. The people of the south-east maintain that they have surpassed the threshold of 450,000 necessary for the setting up a full integrated service. Is there any reason the State should not co-operate with the private sector to enhance what is being provided privately? Is this a possibility?

I was unable to be present at 3 p.m. because, as I told the Chairman, I had tabled a priority question in the Dáil.

I have asked the Deputy to speak now.

I have been trying to do so since I arrived.

I am very concerned. I ask straight questions. What is the level of funding provided? Are there designated funds for the primary care strategy? However, the Minister replies to such questions with other facts. There is supposed to be a sum of €130 million available for the primary care strategy for the next ten years but nothing has happened. Some of the money has been provided but not €130 million. That is the reality.

The group which appeared before the committee this morning stated primary care was extremely important and should be properly funded. The Hanly report also states strongly that it should be properly funded. However, the Minister is not doing this and seems to be going around in circles.

I was the first person to bring people in to talk about co-operatives. The Minister may find this hard to believe but that is so. My practice in a remote part of County Mayo operates a one and one rota. When I am not available, I have a locum working full time. There is no co-operative operating in the area. What is needed is adequate investment in primary care.

The Minister stated he would abolish waiting lists. The reality is that patients have to wait four years for a rheumathology appointment and six and a half years for a urology appointment. To say anything different is gobbledygook. The only way I, as a general practitioner, have been able to get an urgent appoint for a patient is to say he or she has cancer. That is the only way I can get a patient seen within a few weeks but by then it can be too late.

People living in the north-west, the south-east and the mid-west also matter when it comes to radiotherapy services. If they had money, they would have access to such services almost immediately. However, they do not have it. Therefore, they do not have such access.

The Minister has still not answered my question. Neither Professor Hollywood nor anybody else has answered it. How will the people of the north-west be better off according to the Hollywood report?

Capacity will be increased nationally.

What good is extra capacity in Dublin if one cannot get there?

Extra capacity means faster access to good quality treatment. That is how patients will be better off. Currently, there is just one centre, St. Luke's Hospital. There is inadequate capacity.

How will patients get there in the first instance? That is the problem.

No, it is not. Following a survey, public opinion overwhelmingly——

It was flawed.

It was not.

It was based on patients who lived down the road.

People want the best outcomes.

The reality is that the survey was deeply flawed and its findings would not be accepted by any reputable medical journal.

As a doctor, will the Deputy agree that if he told a patient he or she had two choices, a centre where outcome levels indicated they did not have all of the necessary expertise available and another more advanced centre 50 miles down the road, the patient would travel 50 miles down the road?

That is like holding a gun to one's head.

It is not. There was nothing available in the west or north-west. The Deputy appears to be saying making an investment in Galway is a problem.

I am not saying it is a problem. I am just saying it does nothing for patients in the north-west.

Does it do anything for patients in the west?

I am talking about the north-west.

Does it do anything for the people of the west?

The Minister knows it does nothing for the people of the north-west.

Is it good for the people of the west?

I am not a parochial politician; I think nationally. I also think about the north-west.

All roads lead to Castlebar.

That is nonsense.

Will the Deputy answer my question? Will he make the following statement: "Deputy Cowley welcomes radiotherapy services in Galway?"

I am on record as welcoming them. What I did not welcome was the delay. I welcome the fact that the provision of services is imminent but it has been imminent for a long time. I would not like if it was someone trying to go to the toilet.

They would need to see their GP.

This tertiary service has been long recognised and recommended in the report on the ambulance service. There is no need for a big song and dance about having a dedicated service. The Air Corps search and rescue service is currently providing a service. However, as it has other work to do, it is not a dedicated service. There is no need for this delay. There should be a proper hospital retrieval service in place. This is the only country in Europe which does not have a dedicated helicopter medical emergency service, which we should have had in place a long time ago.

The Minister referred to the Hanly report, the recommendations of which are being implemented without providing the wherewithal to replace the services it is intended to remove. However, the recommendations in regard to the hospitals in Ennis and Nenagh have been turned around. Previously the service was nurse-led but it will now be physician-led, which is helpful. However, that is not what will apply in Limerick.

What do they have now?

They have a consultant-led service.

They do not.

They do not have a casualty consultant but they do have a——

Why give the impression that there is a 24 hour consultant-led service when everyone knows that is not the case? The Deputy is instilling these fears for his own political electoral purposes.

That is nonsense.

What the Western Health Board is proposing is better than what is currently available. We could go on about this forever but if we are talking about the health service, we need to discuss——

There is no point in the Minister denying that he is proposing to provide for a nurse-led service, whether it be from 9 a.m. to 5 p.m., 9 a.m. to 9 p.m. or 8 a.m. to 8 p.m. When I visited Ennis Hospital, it struck me that it was just like Castlebar Hospital before it received funding. It was under-funded and under-developed. We had to fight very hard for everything we have in place in County Mayo.

There is a Fianna Fáil-led organisation in County Mayo which the Deputy does not acknowledge. He is not the sole provider for the west.


We must confine ourselves to dealing with the Estimates. This is a question and answer session, not statements.

The Minister should look at his conscience as regards the Hanly report. He should look at other options and consider supporting local hospitals rather than removing services from them. The same applies to urology services, in respect of which the Western Health Board has a big waiting list because the service is localised in Galway where a consultant attends once a month. When he is on holiday, there is no consultant service available. How can one deal with 1,000 patients if just ten per month are seen, although this may not happen all the time? Perhaps only five new patients are seen per month. What sort of service is this?

The bottom line in respect of rheumatology services is the Hanly report, the cornerstone of which is a consultant-led service, a doubling of the number of consultants with additional consultants in the regions to provide much greater capacity. That is the answer in respect of rheumatology, urology and all of the other specialties. This aspect of the report has never been articulated or trumpeted by the Deputy who has always demonised certain elements and ignored the core principles - a consultant-led service with regional self-sufficiency. The report did not invent a 48 hour working week; it was developed by employment Ministers. All stakeholders in the health system must grapple with this aspect and come up with solutions by 2009. We can all play politics but that is the reality facing whoever occupies this chair. The best way to solve the problem in respect of rheumatology services is to provide for a consultant-led service. That would mean providing for a new consultants' contract prior to employing 1,000 consultants over the next five to ten years.

Will we have it in County Mayo?

It would also mean regionalised clinical networks. If the regional groups in the mid-west and on the east coast come up with solutions to meet the challenges posed by the 48 hour working week, that is something we could accept, as I have said publicly from the beginning. We will never get to where we would like to be if we continue our dependence on high volumes of doctors in training, as currently happens in the accident and emergency service, of which nurses are the backbone, particularly experienced staff nurses who help SHOs coming out of college. With registrars and junior doctors, nurses are crucial. Together they form the backbone of the service.

There is a tendency to undermine the role of nurses. We have invested a lot of money in clinical nurse specialists and advanced nurse practitioners but we need more. The health economist used by the Hanly group acknowledged on radio that in other countries advanced nurse practitioners were significant players in emergency services. Combined with a medical presence, they can meet some of the needs of the services. In some hospitals one is talking about treating two people per night between the hours of midnight and 8 a.m. This is the number who turn up at the accident and emergency unit in Nenagh. One does not need 21 consultants to provide a service for two patients.

I am not saying there should not be a consultant-led service. I am saying there could be more NCHDs and consultants. The Minister is saying he would deprive Mayo General Hospital of a consultant rheumatologist.

I did not say that.

I thank the Minister. I am delighted that we will get one.

I never said that. How dare the Deputy put words in my mouth? I am saying that, given what is stated in the Hanly report, the Deputy would get a rheumatologist, that he would get many more.

The Hanly report does not state that.

It does.

We have a copy of the Hanly report. We do not have a copy of the Hanly II report.

The Hanly group has not looked at the position in Mayo. It has only looked at the position in two areas.

That is true.

The new group includes people who come from rural Ireland.

As regards the IMO and so on, there is a training element, on which the IMO would insist.

Not the IMO.

Deputy Cowley must ask a question.

There are 20 doctors per 10,000 people in Ireland whereas the EU average is 33 per 10,000. Even if all the necessary senior hospital doctors and consultants were appointed, we would just about reach the EU average.

In my area, where one of the pilot schemes is in operation, St. Columcille's Hospital is extremely busy. Although smaller than St. Vincent's Hospital, in a typical week 500 patients attend its accident and emergency department. In a typical week at St. Vincent's Hospital accident and emergency unit approximately 750 patients attend. This shows that St. Columcille's Hospital where I have been many times in the middle of the night has an extremely busy service. It would be ludicrous to replace it with a daytime nurse-led unit. That would make no sense.

St. Columcille's Hospital accident and emergency unit is specifically referred to in the Hanly report as one which will be replaced by a nurse-led, daytime, minor injuries unit. I do not know which copy of the Hanly report the Minister is reading but the one I am reading specifies St. Columcille's Hospital as losing its accident and emergency service and getting a minor injuries unit. At the very least, the Minister should make himself aware of the actual need in St. Columcille's Hospital and the catchment area it serves.

It appears that most of the increased funding is going on pay, employer's PRSI contributions and so on. Does the Minister have an overall figure for the proportion of the increase going on those purposes? It looks as if the bulk is going on them, by a great margin.

The Minister has seen the report produced by Professor Gerry Bury which gives a red light signal that something must be done to provide training for Irish doctors. There is an over-reliance on the money which non-national doctors bring into the country. They undergo training but then leave. We are simply not creating the capacity we need, particularly if our ambition to double the number of consultants is to be realised, but also for general practice. I ask the Minister to respond on this point.

Subhead A7 deals with consultancy services but there is no money for IT consultants. This used be the reason given for the large amount spent on consultancies. The Minister has employed several consultants to compile all sorts of ambitious reports which, I am sure, are piled up on shelves somewhere. Surely he has come to the end of his use of consultants. Why is there no reference to IT consultants under this subhead and who are the other consultants?

There is a separate subhead for IT under the capital programme of more than €60 million. It embraces IT consultancies.

That would not be normal under this Administration.

They are general consultancy services. We have doubled the budget this year for IT to more than €60 million. It is provided for under the capital heading.

Does it include spending on IT within the Department of Health and Children?

Why has spending on other consultancy services almost doubled? Numerous consultants have been employed. More than 150 reports have been commissioned while task forces and commissions have been employed. I thought we had come to the end of that phase and had arrived at the implementation phase. Spending on consultancy services has almost doubled and none of them relates to IT. Are these the consultants who are promoting the Minister's explanation of the Hanly report which is so confusing that he needs consultants? What are they for?

First, I will deal with the pay issue as raised by Deputy McManus. Drug use trends in the GMS account for €237 million overall and there are further special pay awards of €50 million and €14 million, respectively. The overall increase in pay is approximately €450 million in a total increase of approximately €890 million. Approximately 55% of the increased spending this year went on pay. The bulk is taken up by increases in pay and the GMS scheme.

Is that 55% of the increase in the entire health budget?

I would have thought it was more.

No. It is high enough.

Is the Minister saying 45% goes on non-pay issues?

That does not include capital items.

The remainder includes drugs and the GMS, which is another €200 million and more. That brings the figure to over €700 million. Inflation and other factors are also taken into account.

Some money was saved on general practitioners.

That is a pay issue.

Fees form one element but the bulk goes on payments on drugs and trends in prescribing. There is more prescribing every year. Relative to other OECD countries, Ireland still has a low rate of prescribing but the news for the Department of Finance is not good on that score.

I believe I heard that the figure for pay was closer to 90% of the total health budget. I am surprised it is so low.

It accounts for 70% of the total budget. The increase in spending on pay arises from benchmarking and Sustaining Progress. We also did a parallel benchmarking deal which had a heavier impact on the Department of Health and Children than on other Departments. This had to do with craft workers in the health service. The full year cost is now filtering into the system.

From where will the indemnity deal come?

The manifestations could appear next year. It depends on what deal is done. We have been paying out approximately €30 million on the reimbursement of doctors' premia to the Medical Defence Union and the Medical Protection Society. Because we brought the clinical indemnity scheme into operation we reckon it will cost us €12 million this year. This will allow €20 million to the health boards to spend on acute services. The deal may involve certain up-front payments by the Department.

Ms Manus

The new scheme will mean a saving for a number of years until claims come through.

Yes. Costs will arise in coming years. They will not come in one sum. They will have to be absorbed by the clinical indemnity scheme. Negotiations with the MDU are ongoing and the due diligence process is under way. The actual liability is being identified by independent persons. The process has not been fully completed.

What about consultancies?

Changes in the General Register Office are eating up consultancies. I can get further detail on it for the Deputy. I am advised that the changes in the GRO is eating up a fair degree of consultancies.

What is the GRO?

The General Registry Office, which is being decentralised to Roscommon. The changes taking place at that office are very significant and the figures relate to the modernisation and transformation of the office.

Is there a separate section dealing with that? Why does that figure come under administration?

I will try to get an explanation for the Deputy.

I am waiting for a reply to my question. The Minister tried to answer it but Deputy Cowley then asked his questions. What is the position regarding the private radiotherapy unit?

There is no ideological reason why one cannot do that. There are two problems, one of which relates to the availability of funding. We want to concentrate and prioritise funding on the revenue side.

That is not the issue. Such people would be referred to Dublin or Cork for treatment.

The problem is that we do not have enough capacity in the system. In other words, we do not have enough capacity for the number of cancer patients that would require radiotherapy treatment. Such treatment is available in St. Luke's Hospital. The report sets out how one could deal with the problem. One could do nothing but buy services from anyone who has a machine. In that regard, one would not be developing, on a revenue or capital basis, the backbone recommended by the radiation oncology report. That is the dilemma with which we are faced.

Is that a "No?"

No, it is not. I am basically saying that, in terms of 2004, we are concentrating our revenue funding on Galway. Some €2.5 million is being provided to ensure that facility is up and running this year.

The Minister must understand the situation.

We had to deny funding to the mid-west because money had to be invested in Galway, in which we also invested money last year for the recruitment of staff. We cannot fund everything. The Mid-West Health Authority pointed out that it has a trust and will raise funding to cover the public system. They agree with the broad thrust of the Hollywood report and have told me they will deal with the public system. I agreed to that.

Does the Minister realise that is untenable politically to allow the building of a private facility for people who have insurance and can afford treatment?

I know where I would go.

There is no point saying that. The reality is that there are two machines in Cork. Many people are going to Cork for treatment. There are also two machines in St. James's Hospital and many people are going there for treatment. It is not valid to say that it is all right to use these public facilities but if a similar private clinic is available they are not good enough. The Minister cannot do that politically and defend it.

The Deputy is prescribing a recipe for more of the same that has dogged the radiotherapy sector in the past 30 years. We have an opportunity to provide a first class model of radiotherapy.

Would the Minister not grasp this opportunity and be part of it?

What opportunity?

To build——

The Deputy said she supported the Hollywood report. Either that is true or it is not. The Deputy cannot play it both ways. If the Deputy accepts it she should support the build-up and allocation of resources in this area.

What I am saying is, if there is somebody willing to pay half the amount required, could the Minister not agree to pay for the other two machines? Why can Dublin people not travel to such a facility for treatment? The Hollywood report envisages the construction of a service in Waterford eventually.

I have to get funding to pay for the revenue needs of Cork and Galway and, eventually, Dublin. The second issue is one of equality. I asked whether Deputies believed we would be better off having a necklace of two machines operating throughout the country. That is another option.

I am not suggesting that.

The State could stand back, not build any unit and simply fund any private operator that comes along. That is the other option. Is the Deputy suggesting we go down that route?

That is the choice the Deputy is asking me to make.

I am saying the Minister should capitalise on the opportunity being offered.

We can always do that.

I do not wish to over-dramatise the situation, but the fear is that this argument will continue and nothing will happen.

The option of buying treatment from private facilities is always open to the Minister. It is open to the Minister to buy services from any facility that opens. The Deputy says the fear is that nothing will be done. I can guarantee her that I am determined in terms of my capital and revenue estimates to implement the report and something will be done at long last. I will not preside over what has been in place for the past 30 years - an inadequate system for public patients in terms of access to high quality multi-disciplinary radiotherapy services. That system will be changed through the provisions I will put in place and the prioritisation I am giving to implementation of the report through the revenue and capital moneys available to me.

I would like to refer to page seven, mental health services. Last week, we had a meeting with psychiatrists from the Royal College of Surgeons, psychiatric division. The contribution to the psychiatric services since 1997 has dropped from 11% of the overall health board to 6.69%, half the UK figure.

It was pointed out to us last week that the services are appalling due to a lack of support and funding. One psychiatrist told us he is actively treating 480 live patients. The number of support staff in terms of psychologists, psychotherapists, occupational therapists and so on is appalling. Everybody was appalled and alarmed at the statistics they gave us in that regard. It is reported that one in four people will suffer a psychiatric condition at some stage. Why then have we dropped our contribution from 11% to 6.69% in six years?

The Minister mentioned the increase in the drugs budget. Does he have a breakdown between the GMS drug budget and the drugs payment scheme budget?

Yes. The GMS budget is €127 million. Together they amount to €237 million.

Where is the increase?

The increase for DPS is €50 million.

What would be represent percentage wise?

Drug trends in GMS amount to €237 million. That includes pay issues within the GMS.

Does the Minister have a breakdown?

The Minister has reduced the number of medical cards available and now pays less for doctors. How much of an increase has been achieved from the drugs schemes?

The most recent increases relates to peptic ulcer drugs.

I do not want to know what type of drugs have increased. I want to know what proportion of the increase in the drugs budget is going to medical card patients and the drugs payment scheme.

The higher proportion would be on the medical card side.

Is the Minister sure about that?

I will obtain the information for the Deputy. The figures on the GMS side are much higher in terms of the increase.

Thank you.

On Deputy Neville's point, I regard percentages as a fairly bogus approach——

That is not what was said last week.

I am saying it now. There was no comparable investment in mental health services prior to 1997. Historically, they have been underfunded. The 1984 document, Planning for the Future, was a good one. Significant progress has been achieved in the intervening years by changing to a community based service. I have had a number of consultations with the chief inspector of mental hospitals who has told me that while in some respects, progress was slow in transforming from an institution based to a community based service, lessons have been learned because of the delay and that as a consequence, there have been many improvements. It is wrong to state there have been big cutbacks when 11% of nothing is nothing——

It is 11% of the total budget.

The health budget is now €10 billion. It then stood at €3 billion. It has risen by 188%. It is a cheap shot to try to cleverly manipulate statistics.

The incidence of psychiatric illness has risen, not gone down.

The figure stood at 11% of €3 billion. It is now 6% of €10 billion which is higher than 11% of €3 billion. Services have expanded. The acute psychiatric units now in place are superior to anything in place in the past. There is no comparison between them. Deputy Neville should have been in Portlaoise last week when I opened the new psychiatric unit, or in Kilkenny when I opened the new unit there, or Cork University Hospital, or Ennis. As far as he is concerned, the glass is always half empty, never half full, which might be reasonable from an Opposition perspective. We have improved certain psychiatric services but I acknowledge that we have a lot more to do. I am not saying we have caught up, given the underfunding of the mental health services historically. The Deputy is an activist and meets those involved in mental health services which there is a need to reorganise. It is not all about money.

The Hanly report ignored them.

It did not deal with psychiatry. There is a separate group.

He told this committee that he was dealing with them.

He is not undertaking a mental health services review. The Deputy knows well that there is a national group examining the issue as part of a strategic review in terms of the modernisation of the 1984 plan.

Psychiatrists were interviewed by the Hanly group.

Is a psychiatrist God as far as the Deputy is concerned? We all have an input to make. Just because someone comes in, we do not all kneel and genuflect.

We are not talking about genuflection.

We all have views. We have improved the level of funding significantly for mental health services. Psychiatry of old age is a recent development. Much has been done for those suffering from dementia.

What about psychiatric services for adolescents between the ages of 16 and 18 years?

While we have not done the business, we are developing child and adolescent units.

A total of 40 beds instead of 175.

I know there is a lot to do.

The Minister is not doing it.

We never have as far as the Deputy is concerned. He has never acknowledged what has happened.