SENATE SPEECHES

Health Services: Motion 28th June, 2000 Mrs. Jackman: I move: That Seanad Éireann condemns the Government for its failure to deliver its commitments in the provision of essential health services, particularly in the area of accident and emergency, waiting lists, psychiatric services and preventative measures in the general health services. I welcome the Minister of State at the Department of Health and Children, Deputy Hanafin, to the House. I am shocked by the amendment the Government has tabled, particularly in light of the unprecedented double apology the Minister for Health and Children had to make in the other House a short while ago regarding the unprecedented deaths of two elderly people as a consequence of major failures in the health system. One of those deaths occurred in the mid-west region where a 66 year old woman had a very unhappy end to her life, having had to journey in an ambulance over a ten hour period from Limerick Regional Hospital to a psychiatric hospital in Ennis and to the general hospital in Ennis. What maddens me about the Government amendment is that it is aspirational and contains language one would expect to hear at a conference on health at which the Minister would set out his or her agenda for the future. There is no action word in the Government amendment as to what should be done now. It contains terms such as "customer focus", but I question whether our health services are customer focused. It refers to a strategic approach to dealing with waiting lists and waiting times and commends the planned, structured and strategic approach being taken, but there is no planned, structured and strategic approach to our health services. It angers me that the words in that amendment indicate a sense that the Minister is suggesting the health boards should do everything, which would mean we do not need a Minister for Health and Children. I had hoped the Government would have indicated in its amendment that it is doing its best and supported the Fine Gael amendment in an effort to try to do better. That would have been far more honest. We consider it essential that we address the issue of health, particularly in the dying hours of this session. I had hoped the Minister would have learned about the urgent need to address this issue from Tipperary South by-election campaign. When canvassing there constituents expressed their anger and frustration about the lack of delivery of many essential services in the health area, not only in terms of the numbers on the waiting lists but the waiting times and the general management of the health services. Senator Mary Henry, who will contribute later, tabled a motion two weeks ago which deplored the lack of any sense of urgency by the Government in addressing the medical and nursing staff shortages in hospitals. It is unusual for Private Members' time to be used in almost consecutive weeks to address a matter relating to health services. Fine Gael Senators find it necessary to use Private Members' time again to condemn the Government on its failure to deliver on its commitments. I have highlighted four areas in my amendment and I could have highlighted many others. Accident and emergency departments deal with 1.2 million people annually and 14 consultants cover those departments. There are one consultant and four junior doctors on duty in the casualty department of Limerick Regional Hospital. That casualty department dealt with 112,000 people in 1998, 10% of the total national figure, and I am sure the figure for 1999 is higher. The shortage of junior doctors in our large hospitals which deal with maximum numbers of accident and emergency patients has reached a crisis point. The casualty departments in small hospitals also experience problems. Such hospitals are located in Letterkenny, Cavan, Navan, Drogheda, Naas, Portlaoise, Kilkenny, Tralee, Castlebar, Sligo. Another problem that has emerged is the lack of anaesthetists. Those small general hospitals have maternity units and pregnant women in those areas would like to have access to epidural facilities. Access to epidurals is severely curtailed and in the case of two of those hospitals the facility to have an epidural is available only every second day. The shortage of anaesthetists on duty in the maternity units of those hospitals is creating a major problem. I cannot dwell on the problems experienced in psychiatric hospitals owing to the shortage of junior doctors, nor do I have figures on the numbers on waiting lists, which is a matter I will examine further. The Minister is putting legislation through the Dáil providing for an extra two year contract for junior doctors. Their contracts expire at the eleventh hour, 30 June. That emergency legislation will enable the employment of only a small number of additional doctors, perhaps 20 to 25. I wish the Minister had examined the needs of junior doctors who wished to register in a hurry. Does he realise the logistical difficulties regarding registration that must be ironed out with the Medical Council? Although it is an independent authority, that does not preclude the Minister and the Department from co-operating with it. I hope officials of the Department are liaising with staff in the Medical Council to ensure there is no delay in the processing of such registrations. Has the Minister contacted the aliens office about the need to fastrack the processing of visas? We know how difficult it is to get a visa at the best of times and how difficult it must be to get one in a hurry.

We need more medical students. The National Manpower Forum seems to be at a standstill, although it has highlighted the need for a significant increase for consultants. I hope the Minister of State has specific figures on these matters. In the case of overcrowded accident and emergency units, we need to divert ambulances to hospitals that can take the overflow, but that requires a degree of co-ordination and I question if there is such co-ordination. We are blue in the face from going through the waiting lists. Despite all the claims the Minister may have made that the numbers on the waiting lists have decreased during the past three months, waiting times have increased. In other words, a greater percentage of people have to wait longer for their operations. I have the facts and figures. In March 2000, 72.39% of people were waiting over a year for cardiac surgery as opposed to 69.19% in March 1999. Some 92% of children have been waiting over six months for cardiac surgery as opposed to 74% last year. I did not make up these figures. They are in breach of the Department of Health and Children guidelines. The waiting time for cataract operations increased by 64% in the past three years. This means that people are effectively blind and almost 36% have waited over 12 months for their operations. These figures are shocking. People are needlessly disabled because the health service is in crisis. I do not wish to go through all the figures because it would take up too much time and they are available for the general public to check. There are long waiting times in areas that should be dealt with. For example, in cardiac surgery the waiting time since March 1999 has increased by 3.2%, cardiac surgery for children has increased by 18%, for ear, nose and throat for children it has increased by 3.5% since March 1999. I have already mentioned ophthalmology. It upsets me that when going through all the material the changes are all percentage increases in waiting times. I would not be too worried about the waiting times for plastic surgery if it were for cosmetic reasons but I would be very worried if it were for severe accident cases. The waiting time for surgery in general is 2.64% and for children 6.77%. These figures come from replies to parliamentary questions that I have checked. There are 3,542 children on waiting lists for listed procedures and 2,724 are waiting longer than six months. This gives the breakdown of the 76.9% in breach of Department of Health and Children guidelines. Given that millions of pounds are spent on waiting list initiatives why do we still have these figures? I cannot understand it because I know the money is going in. Is it a problem with the health boards? Is it a management problem? We need answers. I wish to refer to the preventive measures. If the Minister were here, coming from a teaching background as he does he would know we are talking about prevention in relation to tobacco, alcohol and their effects on the body. I would hope not to have to dub him the "Minister for Sickness" because he wishes to be known as the Minister for Health and Children. We have to address this positively. Messages have to be reinforced to children, teenagers and adults in a creative and innovative way. I am sorry Deputy Shatter's anti-smoking strategy has not been adopted in full because it is an holistic approach to the problems arising from tobacco. The cancer figures are frightening. The waiting list for 1996 was 20,865 and for 1997, 21,450. It is interesting to note there are no national figures available for the time lapse between presentation and actual treatment, which is vitally important when attempting early intervention and treatment for cancers. These are the facts from the National Cancer Registry Board. If I have the opportunity after the recess I shall table a Private Members' motion on cancer. However, other speakers will raise this issue which is not getting the airing it needs. Prevention is of major importance in relation to cancer for males and females. I hope the Minister will address this issue urgently. Acting Chairman (Mr. Mooney): The Senator will have an opportunity to respond to the debate. Ms Keogh: It give me great pleasure to second the motion moved by Senator Jackman condemning the Government for its failure to deliver on its commitments in relation to the health services. We are all aware of the increased resources that have been poured into the health services. There is a common perception that the money is being wasted on bureaucracy and administration. There are huge gaps in the delivery of services. I happen to be chairperson of the Well Woman Centre in Dublin. The Well Woman Centre was founded in 1978 and its original purpose was to provide women with access to family planning information services. That clinic has developed significantly in the past 22 years and it now offers a broader health care service primarily to women but also to men. We operate three clinics in the Dublin area - Coolock, which has a number of GMS clients, Pembroke Road and Liffey Street - and see over 55,000 clients annually. Although the clinics operate in the Dublin area, women come from all over the country to avail of the services provided. Will the Minister of State will convey to the Minister for Health and Children that women want delivery and choice within the health service? I speak from a base of 55,000 people. The overall comment from our clients on why they wish to use our service is that they find the medical system as it operates hierarchical and unfriendly to women in many instances. They also complain about the amount of time wasted on waiting due to inefficient appointment time management. There is a great deal of criticism of the point of delivery of services. While they will cite that individual clinics or hospitals may do their best, their management is seen as a waste of resources. I agree with Senator Jackman that the amendment only serves to underline the shortcomings in the health service. There is something radically wrong with the service and we all have to admit it. I am sure it will be admitted on the other side of the House. I wish to concentrate on two main areas of critical importance to women's health, one of which is breast cancer. A survey was conducted by the Women's Health Council on the views and perceptions of women who attended symptomatic breast clinics. It is empirical evidence that women referred by general practitioners or by the Well Woman Centre for investigation and diagnosis in relation to breast cancer report delays in their first appointment and insufficient clinic time being available to them when they get to the clinics. This leads to enormous anxiety for women at a vulnerable time. The research by the Women's Health Council shows that between 50% and 100% of women suffer extreme anxiety in the period leading up to their first appointment. That is not good enough. Those women state that the medical staff appear to be under severe time pressure, chemotherapy is not available on site to them and there are practical and emotional problems for those who have to travel for radiotherapy. Women have to rely on family or friends to take them for treatment because there is no logistical help available. They site the lack of formal services as adding considerably to their anxiety and distress during very traumatic times. There are some practical suggestions that could be made. I do not speak specifically about women in this instance but it is my particular area of expertise. Why not allow medical card holders free transportation by taxi, hackney or whatever other means? This would be a simple straightforward logistical help for those suffering trauma. Other specific concerns are that specialist nurses such as breast care nurses are diverted to other areas and thereby the necessary supports are not provided to the patients. These are the nurses who can identify those in need of counselling and in greatest need. If they are not there they cannot do it. There do not appear to be any formal links at delivery level between the Department of Health and Children and the clinics. There might be information available on the Irish Cancer Society, checklists and so forth but that is dependent on the individuals working in the clinic. That must be addressed. There is grave concern about how resources are being targeted. The other issue I wish to raise is cervical cancer. The new plan for women's health must succeed in reducing the number of women who contract cervical cancer. It is so sad that, according to the statistics in the plan for women's health, 60% of deaths from cervical cancer can be prevented by a screening programme for women between the ages of 25 and 60 years. This programme was to be established three years ago but the start up date has been delayed again because of the shortage of cytologists to read samples and, remarkably, delays in establishing an accurate population register of women aged between 25 and 60 years. The latter is unforgivable. The 1997-9 plan for women's health promised that the national screening programme would commence in 1999 or earlier if resources permitted. The resources are there but where are they being used? I have been signalled that I have no more time but I feel strongly about this issue. At present, clients of Well Woman clinics wait an average of 12 weeks for smear results. There are at least a dozen vacancies for cervical cytologists. If the Department can get nurses from the Phillippines to fill skills gaps, it should also examine the skills gap in the recruitment of cytologists. It is not right that people should have to wait so long for these results. It is an extremely anxious time. The population register for the cervical screening programme must be compiled now and the programme must be implemented on a national basis. We need action now. If there is no action, there will be a greater requirement for costly medical attention and, tragically, lost lives. That is the worst scenario. Dr. Fitzpatrick: I move amendment No. 1: To delete all words after "Seanad Eireann" and substitute the following: "(1) welcomes the unprecedented increase in capital and revenue investment which is being committed by this Government to the development of all aspects of the health services; (2) supports the structured approach being taken by the Government in the creation of a customer focused health care service; (3) welcomes the continuing development of the accident and emergency services and the strategic approach being taken to deal with waiting lists/waiting times; and (4) commends the planned, structured and strategic approach being taken in the development of both the acute and non-acute sectors of the health services." I recently read in The Irish Times, an organ not noted for supporting the Government or containing anything remotely favourable to the Government, that Ireland's health system is among the top 20 in the world. The French system tops the list with Ireland in 19th place, behind the UK. One can criticise the parameters used. The United States spends 13.7% of its GDP on health services yet it has one of the highest perinatal mortality rates in what we call the First World. One cannot, therefore, believe all statistics or the grading and monitoring parameters used. They do not mean the same thing to everybody. However, a number of points should be made. In 2000, total health spending will amount £4,221 million, an increase of 14% on last year. The capital allocation is £231 million, a 35% increase on 1999, in the first year of the national development plan, which has committed £2 billion for the period 2000 to 2006 in respect of the capital programme for health. This is treble the amount of capital funding in the years from 1993 to 1999. There will be an increase of £95 million for people with disabilities this year, a 116% increase on 1999. The cardiovascular strategy, to be funded by £12 million in 2000, will have a full allocation of £24 million in 2001. This funding will come from a tax on cigarettes, a subject we discussed in this Chamber last week. In the mental health sector, an area in which I have a great interest, there are substantial improvements in the forensic psychiatry services and new consultant appointments will liaise with the Prison Service regarding the provision of appropriate services in prisons. These are the people who are really marginalised and it is time we spent money on them. These people have little or no voice and have the least claim on our attention. We should have been doing this in the past. In the case of other medical specialties, a consultant will usually get access to the nine o'clock news and strongly press their case. The psychiatric services do not have that access for reasons I have never understood. Funding for a new suicide prevention programme provided six new consultant posts and 80 additional nurses are being provided for palliative care services. Palliative care is another growing health care area. No matter what we do to limit the incidence of cancer, it will occur. People are living longer so we will need more palliative care, not less, in the future. Another area where money will have to be spent is pain control. Medicine does not have the answer for every person's pain; it never did. At least we can control pain and help the sufferer. Senator Jackman pointed out that over one million people attend hospital accident and emergency departments every year. I wonder how many of these cases are genuine accidents and emergencies. A sorting system is needed. Many of these people do not need to go to the accident and emergency department. They clog up the departments. One can talk at length on this subject. Senator Jackman and Senator Keogh made their points and I could make mine. However, I agree that there is a problem. In fact, two problems face the Government over the next five to ten years. We are moving from a health service that was previously vocationally driven, in other words, people became doctors or nurses because they felt they could help people. That attitude is changing rapidly. During the last debate on this subject, Senator Leonard said - I will paraphrase her because I do not wish to misquote her - that medical personnel do not wish to be seen as people who are vocationally driven. Instead, they wish to be seen as professionals who are properly remunerated with proper hours of work and full support structures in place. Despite the amount of money in the country, we cannot deal with that issue overnight. It will take some years to tackle. The other problem faced by the Government, indeed politicians in general, is the perception that access to VHI, BUPA or finance can help a patient leapfrog the waiting list, even though in many cases the same consultant is in charge of both lists. This perception is a problem and it must be challenged and dealt with. I believe the only criteria for accessing treatment should be clinical, not one's ability to pay for the procedure one thinks one needs. I hope we can deal with that issue soon.

There are problems of perception. We could deal with them if we used more of the facilities available in the medical services. I can see no reason that a patient with a general medical services card should not be treated in the Blackrock Clinic or the Mater Private Hospital if there is a clinical need. Clinical need should be the only defining reason for a patient to move up or down the waiting list. We are talking here about access to surgical procedures and I always tell people there is no surgical procedure that is without risk. There is no such thing as minor surgery or a simple procedure such as cataract operations, and I am not making a pejorative point. These procedures are not simple; they can be difficult, life threatening and they can go wrong. I welcome the Minister of State to the House. She has a difficult job to get the point across. I welcome also the extra expenditure in the health services. However, money is not the problem. Getting trained staff is the problem. Surgeons do not grow on trees; it takes 15 years to train a surgeon. It takes five to ten years to provide nurses with adequate training and experience. Experience is very important in medicine. This is a first world country, not a Third World country, and there are deficiencies in the delivery of our medical services which we must address. We have been told we are training more doctors than we need. However, one of the reasons doctors emigrate is that they have no properly structured career path. They have no guarantee if they pursue a certain specialty that they will find employment in this country, even though the need exists. Mr. Glynn: I second the amendment. I am pleased to speak to the Fine Gael motion, which is somewhat of a surprise given their track record in Government. Some of the points raised by my colleague, Senator Fitzpatrick, are well worth noting. I have some knowledge of the success of providing services to people suffering from intellectual disability and autism. It is interesting that last year the Government announced a commitment to meet the identified needs of persons with intellectual disability and autism within a defined timeframe of three years, beginning with a major acceleration of investment in the year 2000. The additional funding in 2000 is designed to support the setting up of additional services at an annual cost of £35 million. Because of the timeframe involved in bringing on stream all the new services planned for 2000, the actual cost of those services in 2000 will be £28 million. This funding is in addition to the £10.7 million already allocated to the services in 2000 to meet the full year costs of the 1999 developments and identified needs of existing services. This brings the total additional funding provided in 2000 to £38.7 million, increasing to £45.7 million on 1 January 2001. The additional funding of £35 million will provide 555 additional residential places. This has been called for ad nauseam by the parents and friends of the mentally handicapped who have an abiding interest and who do great work in providing services on a voluntary basis for people suffering from intellectual disability. Some 185 respite places will be made available, which is very important to carers of people suffering from intellectual disability. Another 700 new day places and health related support services will be provided for people suffering from autism. An additional £20 million is being invested this year to provide services for people with physical and sensory disabilities. I recall all those who came in wheelchairs and so on to the gates of Leinster House calling for those improvements and I am pleased the funding has been made available to provide these essential services. A total of £30 million in additional revenue is being made available for child care services. These resources will allow more emphasis on the prevention of problems through supporting vulnerable children in the family and community setting, while ensuring services are promptly available to children at risk. There is no point closing the stable door when the horse has bolted. This is a pro-active move on the part of the Minister, which I welcome. Everyone accepts the current economic climate and statisticians have said we are an aging population, the reason being that there are better health services and people are living longer. If we have more older people, we must provide proper health care services for them. The initiative in providing additional sub-acute places to relieve pressure on acute hospital beds does not stand alone. It complements an established programme of developing services for older people which has gained considerable momentum since this Government came into office. I would like to outline some of the developments. Excluding the nursing home subvention scheme, the amounts of additional funding provided for services for older people by the previous Government in the years 1995-97 was £2.1 million, £2.5 million and £3 million, respectively. In 1998, an additional amount provided by this Government was £7 million and in 1999 the figure was £16 million. I do not need to labour that point, which is well made. When this Government took office in 1997 the then Minister for Health and Children, Deputy Cowen, increased the waiting list allocation by 50% within a very short time. I am surprised that despite substantial increases in funding by the former Minister - I am sure that practice will be continued by the present Minister - waiting lists have increased. However, a report published recently showed that waiting lists decreased for the first time this year. In tandem with that, the Minister has provided substantial funding to reduce further these waiting lists. I was pleased to speak recently on a motion in this House on the availability of psythiatric nurses. Last year was one of the most successful years to date in recruiting psychiatric nurses. Given that the Midland Health Board is one of the smallest of the eight health boards, I am pleased the provision of an acute psychiatric unit at Portlaoise General Hospital is at an advanced stage in the planning process. The Midland Health Board recently signed off, so to speak, and referred to the Department of Health and Children the next phase of bringing on stream the facility which will be provided in phase 2B. This is a constructed shell which was built in tandem with phase 2A. We had to wait for the Minister, Deputy Cowen, to come into office to provide the necessary funding to open that facility because the Fine Gael Minister of the day failed to provide the funding to commission phase 2A. Members on this side of the House have a lot to be thankful for to the previous Minister for Health and Children, Deputy Cowen. The present incumbent of that office, Deputy Martin, brings to his new portfolio a record of success in the Department of Education and Science and I am sure he will be a great success there also, as is the Minister of State, Deputy Moffatt. I can only speak about my own health board and the services available there in highlighting the success brought about by this Government. In the project team's report, which was not included in the original brief, the provision of a 36-bed psychiatric unit will be provided in phase 2B. Therefore, one health board will provide two acute units. Furthermore, after 14 years of calls from me the Minister has provided the funding for the establishment of a college of nursing. A number of consultant posts has been approved in histopathology, haematology and oncology. I do not claim everything is perfect but the Government is making major strides towards providing the best possible health service. Senator Henry shares my abiding interest in mental health. Before the year is out the new mental health Bill will be before the Oireachtas. As a former member of the psychiatric nursing profession, I look forward to contributing to the Bill, especially on Committee Stage. Dr. Henry: I welcome the Minister of State to the House. I know Government Senators and the person who framed the Government amendment mean well but I query the wisdom of their self-satisfaction about the health service when the public knows it is in the most appalling mess. If the amendment had proposed that Seanad Éireann supports the Minister for Health and Children who is doing the best he can in very trying circumstances, I would have had to support it because I believe he is, but the Government amendment is quite ridiculous. I know Senators Glynn and Fitzpatrick mean well but simply to describe throwing large amounts of money at the health service as doing something is patently silly. Our problems are due to a lack of forward planning in the past few years. Current problems in the health service have been coming upon us for the last three years. When the Medical Council described the changes they were going to make for training posts which non-EU doctors could take up, some Senators must remember my predicting trouble in the non-consultant hospital grades. Half our staff are non-EU doctors, particularly outside Dublin, Galway, Cork and Limerick and non-EU doctors will not take up posts which are not approved for training purposes. The day I predicted has come. This week's medical papers contain advertisements for positions to be filled on 1 July. Not only is it worrying that these posts are still unfilled but hospitals will now become so desperate that they will accept any candidate. I do not mean to be derogatory about people who apply for these posts but hospitals will not be in a position to insist on quality people to fill posts. In places like Kilkenny which never had trouble filling jobs before, no one has turned up for interview for some posts. We are in a dreadful situation and it would be wiser if we recognised that. Two things will make the situation even worse. The Institute of Obstetricians and Gynaecologists has said it will not recognise for training, junior posts in a single or two handed obstetrics unit. The last two single handed obstetricians in the British Isles are working in Monaghan and Dundalk. This is totally unsafe. The last nine two handed practices in the British Isles are in this country. None of those hospitals will be recognised for training. The Minister of State, Deputy Moffatt, knows this. The next piece of good news is that the Royal College of Surgeons in Ireland has given hospitals a deadline of 18 months in which to address training deficits or lose accreditation. If this does not happen more of our small hospitals will have no junior surgical staff. These problems can be seen in advance. They have nothing to do with money. They have to do with organisation. I was very disappointed during Private Members' time two weeks ago when the Minister for Health and Children, for whom I have expressed admiration, said we must decide whether we want the health boards to have autonomy. Of course we want them to have autonomy but they must also be organised. The other day Senator Finneran said there should be more co-operation between health boards. The Minister must organise this co-operation. I have been involved in North South co-operation and Senator Maurice Hayes, who is chairman of the Mater Hospital in Belfast, has been very good about trying to organise this. However, it is from the top that this organisation must come and it is not simply a question of money. The situation is very serious yet at the end of May the Minister of State, Deputy Hanafin, whom I know to be a truthful woman, told the Dáil there was no problem. A week later the Minister, Deputy Martin, said there was a slight problem. Now we have a truly dreadful problem. I am told only a small number of jobs remain unfilled but I am inclined to wonder. Sligo Hospital, a very good hospital, is advertising this week for a senior house officer in accident and emergency, a registrar in accident and emergency, a senior medical house officer, a senior house officer in ENT, a registrar in ENT and a senior house officer in obstetrics and gynaecology. All these posts are to be filled by 1 July. Manorhamilton is looking for a senior house officer, Letterkenny is looking for a senior house officer/registrar in anaesthetics, a senior house officer in geriatrics, a senior house officer in medicine and a senior house officer in psychiatry. Are these hospitals wasting the health boards' money advertising posts which are not vacant? Similar advertisements have been placed by every health board. The Southern Health Board requires a senior house officer in paediatrics in Tralee, a senior house officer in medical oncology, a basic surgical trainee, registrars in accident and emergency and a senior house officer in orthopaedic surgery in Cork University Hospital and a senior house officer in general surgery in Bantry. Are these health boards wasting their time advertising jobs which are actually filled? The Southern Health Board has advertised for an anaesthetic registrar, a radiology registrar, a rheumatology registrar and a medical senior house officer for Waterford. St. Luke's Hospital in Kilkenny, where I was told the other day that no one turned up for interviews for some jobs, requires a senior house officer in medicine and a senior house officer in paediatrics. Cavan, Monaghan, Navan and Drogheda have terrible problems. Why are we being told only a few jobs remain to be filled? Why are health boards advertising for staff? Statements are made by Senators with the best of intentions but they cannot be factual. Senator Glynn said the other day the Midland Health Board has a rheumatology service. Can he tell me the name of the consultant rheumatologist because I know of no record of one? The Midland Health Board is one of the boards without a consultant rheumatologist. Who is running the rheumatology service? Is it a reflexologist or what? It is pointless to make statements we know are incorrect. We can fill posts if we make a proper effort to organise matters ahead of time. Nine oncology consultant posts were filled within a year and a half. Neurology posts can be filled with a little organisation and planning. Senator Chambers spoke the other day about stroke treatment. One cannot have stroke treatment without a neurologist. I beseech the Minister not to introduce a prostate screening programme because there are no urologists to whom patients can be referred. I am extremely disappointed. I know Senators are not trying to mislead the House but we would be better advised to call on the Minister to close down units, particularly accident and emergency services, which do not have adequate staff and which are dangerous. The shortage of anaesthetists is particularly worrying. The mental health Bill will not come before the select committee before the end of this year. This gives us an idea of the priority given to psychiatric services. This is the most important legislation to come before the Oireachtas but I am told it will not even be considered in committee before the end of this year. Miss Quill: I am glad we are having this debate this evening because the nature and quality of our health services is uppermost in the minds of every family here. This country is doing exceptionally well in other areas. Without doubt we have a First World economy, nobody disputes that. However, in many respects we have a Third World health service. Senator Henry, who has a detailed knowledge of the situation on the ground, has painted a very grim picture. Last week a Richter scale was put in place to show expenditure on health and Ireland was ranked marginally higher than Britain in terms of expenditure and customer service. Our position should cause us all to reflect on what we are doing and on what we should be doing. Throwing money at our health services will not yield the kind of results we need and that need to be yielded without any delay. There must be a root and branch investigation of every element of the health services, from administration to the delivery of services and the customer service or lack of it. This must be done but it has not happened so far in my political lifetime. I listened with interest to the Minister for Health and Children, Deputy Martin, speak on "Morning Ireland" this morning and took great heart from what he said. At the outset he said that the hierarchy in hospitals here had not changed between the turn of this century and the turn of the previous one. No one had the political guts or will to tackle entrenched positions and vested interests within the health service. I was happy to hear from the Minister, for whom I have extraordinary respect, that he will tackle this situation. He also plans to tackle the problem that has arisen in respect of junior doctors. Unfortunately, I cannot discuss this matter because I have only eight minutes at my disposal. I am satisfied, having listened to him this morning and knowing his credentials, that he will be the first Minister in my lifetime to begin to tackle the junior doctor issue. This is a fundamental issue in dismantling and addressing the many structural faults within our system. I wish him luck and all speed in making this happen. Senator Henry painted a very grim picture of the training, or lack of training, that is available in the services. In-service training is available in every other industry. On the job training is a feature of the times in which we live. Very little of this has happened in the health services because of the entrenched positions adopted by people in positions of privilege and power. This is one of the first issues the Minister will tackle. He must deal with a management problem in the health services and its organisation and I wish him well in his endeavour. We must look at how our health boards are managing in terms of forward planning and how they predict where vacancies will arise. We must see how they plan, prepare for and address these vacancies. Unfortunately, this has not happened in most of the health boards that I am aware of. We must examine how they deliver their functions within the overall spectrum of the health services. Staff shortages in key areas will cripple the services for a great many people this year. I advise the Minister to tackle the differences that exist between public and private patients. He has the intelligence and integrity to do this. People are waiting for hip replacement operations. They are suffering acute pains and a marked deterioration in their quality of life and productive input. Public patients must wait months, and in many cases years, for such operations while people who are VHI members can nominate the time for their operation. This must be tackled. I ask the Minister and the Government to dedicate a team of surgeons to deal with public patients. With regard to customer service, if the health services were in any other sector and if people did not badly need these services, no one would go to them. Patients are given appointments and told to turn up at 8 a.m. They take their place in the queue and if they are lucky they may be seen by 4 p.m. It is a disgrace that appointments cannot be organised and time allotted so that people who can be seen at 4 p.m. are asked to turn up at 3.45 p.m. The way people are treated in hospitals is a disgrace. It is time we stood up and faced this problem. The rectification of this problem needs to be identified. People who deliver a poor level of customer service need to be told that it is unacceptable to the paymasters here. Senator Keogh made great play about women's health. I want to talk about women's health issues and how they have been treated here. I want to advert to how the women who suffer from hepatitis C were poisoned by officialdom within the health services and treated politically. It is true that Mrs. Brigid McCole had to die before the then Minister of the day, Deputy Michael Noonan, took action on the hepatitis C issue. In any other civilised country he would have been asked to resign and he would have had the decency to do so. Many of the problems that we still suffer in terms of the financing of the health service originated from the time when a tax amnesty was given by the then Minister, Deputy Ruairí Quinn. If the people who availed of the amnesty had paid their taxes we might have been able to provide a reasonable health service. I have heard persons call for a vote of no confidence and the resignation of upright honourable politicians and persons of integrity. It is about time we got our thinking straight. I do not know whether it would take a psychiatrist or a psychologist to get us to think straight about these issues but it is only from a position of truth that good things happen and flow. I am confident that the present Minister for Health and Children, and he has a mountain to overcome, will bring our health services to where they should be, a position where citizens would have equal rights and entitlements within the services. Unfortunately, this is not available at present. I am glad that Senator Jackman, who is very concerned about these issues and has impeccable credentials, has given us the opportunity to comment on the health service. There is a great deal more detail that I would like to put on record but I do not have time to do so. Mr. O'Dowd: This is an important and timely debate. An indicator of any society is the care it offers to those who are ill. As an indicator of an advanced society, our health service leaves a great deal to be desired. There are very serious shortages and shortcomings in our system which have not been addressed by the Government. I refer in particular to waiting lists and times. The number of adults waiting longer than one year to have a procedure carried out is disgracefully high. At Our Lady of Lourdes Hospital in my home town, Drogheda, over 252 adults are waiting longer than one year for their medical procedures. That is disgraceful and unacceptable. If the norm set by the Minister is a maximum of one year it is seriously put at risk in our hospitals where that time limit means nothing because the resources are just not available. The number of children, nationally, on a waiting list for longer than six months is disgraceful. This Government seems to be in a state of paralysis and seems unable to do anything about it. Despite the fine words of Senator Quill, I find that this Government is not showing the same care and attention that Deputy Noonan did when he was Minister for Health in the previous coalition Government. I laud him for his cancer strategy and for the effort and commitment he put into improving our health service when times were much more difficult than at present. A gentleman came to my clinic recently who could hardly breathe and was in some distress. He told me he had never been to a politician before. He was on a cardiac emergency waiting list for over three months. His doctor was to be back from leave at the beginning of the next month, although there was no criticism of the doctor concerned, but as he was a medical card holder and could not get his operation when he needed it. He felt the only person he could come to was someone like me. This demonstrates that there is a serious problem in our system. People who need operations should not be queuing up to see politicians, they should be lying in wait, whether in Dublin, London or wherever else we buy them the care and the operations that they need. If we cannot provide for them in the State, we should insist they are provided for outside the State and the money must be provided for those operations. There has been some progress made recently on a new initiative by the Minister for Health and Children but it is not good enough. It is not good enough that poor man had to come to see me. Hundreds of thousands of those people are on waiting lists in hospitals countrywide and they are absolutely sick of it. I received a letter from the North Eastern Health Board about the number of people waiting for treatment in Our Lady of Lourdes Hospital, Drogheda, which is greater than 1,500. It may be a regional hospital but the specialties are not being provided under this Minister. The ENT list is in excess of 375 people. The surgical list is in excess of 309 people and it goes on and on. Over 287 people are on the urology waiting list. That is utterly unacceptable and totally disgraceful. This Government needs to take a fresh look at the shortage in the resources on a regional basis. The fact that so many specialties are based in Dublin needs to be re-examined because people in the regions and the regional health boards are not receiving the services there and we have to re-examine that. One critical factor is that there are serious shortages of nurses in the health system, particularly the specialist nurses. In Our Lady of Lourdes Hospital, there are 55 vacancies for nurses that cannot and will not be filled. The health board has made very positive effort to recruit these people but it has not been possible to get them in the State. What is the Minister doing about it? What policy has he to improve conditions for nurses who work in our hospitals and to improve their career options? He should make it a much more attractive career for those people who want to care and who want a career in nursing but who find the money and the career structure is not there for them. In the short term, the Minister needs to go abroad to recruit nurses to bring into our country. He needs to do this quickly because the system failing fast. It is disgraceful. Another issue that arises is the number of people in acute hospitals who cannot go home because they are not well enough but who do not need full acute services. A significant number of step-down beds are needed throughout the State. This Minister is doing nothing to provide them. It is disgraceful that elderly people are sometimes sent home to an empty house with a coal fire and no help. It is impossible to get home helps. One cannot get a home help in Drogheda because they are not being paid enough. They receive a disgraceful sum of money to do their job. The Minister needs to examine the fact that we need full-time carers and that health boards should offer a career of carer, that is, a person who will work for the health board in a full-time capacity, who will travel around and look after the people who are ill in the community, not on an hour by hour basis as happens at present. It should be a full-time, pensionable job. People are ready, willing and able to take up that challenge. Is the Minister able to do something about it? Of course he is, if he wants to. It is time he improved the services for senior citizens. The position with regard to services to children is disgraceful. Hundreds of children who need speech therapy cannot and will not receive it under this Government. Children in the North Eastern Health Board or Louth community care area who are unable to speak or have very serious speech problems will have to wait a year before they have receive an appointment. I am sorry I have no more time as there is much more I would like to say. I will say it at another forum. It is time the Government got a good shaking up and did something about the health services instead of paying lip service to them, while all around us, people are seriously ill and cannot get the services they need and the care to which they are entitled.

Minister of State at the Department of Health and Children (Dr. Moffatt): I welcome the opportunity to address this House on the Government's commitment to the provision of our health services in the areas highlighted by the distinguished Fine Gael and other Senators, accident and emergency services, waiting list or times, psychiatric services and preventative measure in the general health services. The Government has already put in place a range of programme improvements and funding expansion which means that today there are more people being treated by the health services, more people employed in the health services and more capital projects planned or underway than at any time in the history of the services. I assure the House that the Government is totally committed to ensuring that we have a health service which is responsible in meeting the health service needs of our people despite what has been said this evening. The health service is the focus of considerable ongoing attention which intensifies when the standards expected of the service are not met. It is seldom, however, that the improvements in the services are given proper acknowledgement. Since the Government took office, there have been many positive developments which must be acknowledged. Not least among these is the unprecedented level of capital and revenue funding which is being provided for these developments. When the present Government took office in 1997, the revenue provision for health was £2,754 million. The provision for the current year amounts to £4,297 million, which represents an increase of 56% in funding. This increase in long awaited resources has allowed for a major acceleration in the development of a range of health services. The Government has also recognised that, in moving forward, the current health infrastructure is inadequate for the delivery of a truly modern and efficient service. Under the national development plan £2 billion in capital spending has been made available to develop health facilities of the highest order, which will include addressing geographic imbalances in the health system. The inclusion of health in the NDP was a statement of priority in its own right since it is recognition, for the first time, of the central importance of health facilities in Ireland's social and economic infrastructure. The £2 billion provided is almost treble the capital resources provided over the previous seven years. The first fruits of the NDP are seen in this year's Estimate where there is a record capital provision of £231 million. I appreciate that funding, while vital, is only the starting point in accomplishing radical improvement. There is always scope to improve standards of customer service and all those engaged in the health sector must put this concern at the centre of all of their operations. It has been highlighted in the debate that more needs to be done in certain areas and further planning needs to be assessed. The way the service is organised, managed and delivered is undergoing considerable change and these improvements must continue. Patients availing of health services, in every area of the country, are entitled to expect a quality service. We want to see performance rewarded and health agencies have been informed that this is the basis on which additional funds will be made available. The Government will continue to work with all concerned in investing resources and energy into the improvement of services. We will take all opportunities to bring the necessary services on stream quicker and will lead reform for the benefit of the public patient. I believe that we already have a strong health system and that it compares well internationally. The challenge is to modernise it further so that we can compare with the best in the world. I make no apology for such an aspiration. We can harness our already skilled staff, our growing resources and our committed managers to achieve this objective. We have begun this process already. Substantial initiatives have been taken in many areas of both the acute and non-acute health services sectors to ensure that services are reformed, reorganised and properly geared to meet the needs of our population. I do not propose to dwell on them at length, but briefly they include the recently launched cardiovascular health strategy, which provides for achieving an integrated approach to the prevention and treatment of cardiovascular disease. An initial investment of £12 million this year is the first in the history of our services. There has been investment of £4.9 million in 1998, £5.5 million in 1999 and £3.6 million in 2000 in cardiac services, including cardiac surgery, to support the objectives of the wider cardiovascular strategy. The continuing implementation of the national cancer strategy with funding this year of £2.98 million, is already improving the availability of cancer treatment services throughout the country. More than £41 million has been allocated under the strategy since 1997. A plan for the development of renal services is being prepared which will involve an investment of £20 million over the next three years, £6 million of which will be spent this year. A medical manpower forum is being established to review key aspects of medical staffing in our public hospitals. There will be a review of the adequacy of bed capacity in both the acute and non-acute settings. This review will identify capacity issues against the background of substantial increases in demand as a result of changing demography and advances in medical treatment. It is my intention that the results of this review will be addressed in the context of next year's Estimate. There was an investment of £53 million up to the end of 1999 for persons with intellectual disabilities, with a future investment of £38.7 million in the current year increasing to £45.7 million in 2001. This compares more than favourably with the contribution of the last Government with its minimum investment of £12 million. There is continued investment in services for persons with physical and sensory disabilities. Additional revenue funding of £20 million is being provided in the current year. There is a committed approach to tackling hospital waiting lists so scandalously neglected by the Senators' party when in Government. The funding for waiting lists was cut back from £20 million to £12 million at one stage. The new hospital at Tallaght has been opened. Within the time period of the NDP, and because of the additional resources now available under the plan, major projects will proceed, including the joint Mater/Temple Street development, St. Vincent's Elm Park, phase I, St. James's Hospital, phase IH, Cork University Hospital and St. Joseph's Hospital, Clonmel. Other works and planning will be undertaken in the Dublin maternity hospitals. In addition, planning will continue on the Mater Hospital phase I and Crumlin hospital - new theatres. Projects in the Border, midland and western region will include Tullamore, phases I and II; University College Hospital, Galway, phase II and Portlaoise General Hospital and Castlebar General Hospital, County Mayo. There is ongoing investment in child care services. Funding made available in 1998 and 1999 provided for additional much needed staff resources. This investment is being built upon through the provision of additional funding of £30 million for this service in the current year. There will be a continuation of the established programme of developing services for older people which has gained momentum since the Government took office. I now turn to the specific issues raised by the Senators in their motion. I am happy to do this even if only to refute their charges against the Government's record on these issues. A major commitment of the Government when coming into office was to address this area. Strategies for cancer and cardiovascular services, to which I have already referred, clearly span the acute and non-acute sectors. However, specific attention must also be paid to performance within acute hospitals. The Government is providing for an all out assault on waiting lists. Waiting lists for a number of procedures are unacceptable and will be reduced. In reviewing the overall performance of the current system, in-patient waiting lists represent just 4% of the total discharges from acute hospitals. While waiting lists are unacceptable and must be addressed, let us not forget the level and quality of service provided to the other 96% of patients. The new Eastern Regional Health Authority has already established a dedicated team to address this issue and my colleague, the Minister for Health and Children, Deputy Martin, has agreed accelerated work plans for addressing waiting lists with each health board. A total of almost £33 million will be spent on addressing acute hospital waiting lists this year. During the first quarter of this year waiting lists fell by 2,485, which was not noted by the Opposition. This was an encouraging reduction, particularly since, traditionally, elective work suffers in the early months of the year as the number of emergency medical admissions increases. Last month the Minister announced a targeted initiative to deliver an additional 7,600 waiting list procedures by the end of the year to accelerate progress in this area even more quickly. These procedures will be over and above the waiting list activity agreed with agencies at the start of the year. This latest initiative will cost £10 million. In many ways, the availability and quality of hospital services set the context for the perception of the health services as a whole. There is no escaping the fact that certain key areas, particularly waiting lists and accident and emergency services, are critical to the public perception of the health services. Only when the performance in these areas is improved and hospital services are integrated properly with primary and community care services will our health services be seen as meeting the best standards. What is also clear is that problems in areas, such as waiting lists and accident and emergency services, cannot be solved in isolation. Integrated solutions are the key. This will involve continued development and refinement of appropriate roles for acute, primary care and community services. For example, the £35.4 million in additional funding this year for services for the elderly has a key role to play in putting in place the community facilities, home help and nursing supports required to allow older people to move out of the hospital setting once the acute phase of their treatment is completed. This investment will be complemented by dedicated funding of £5 million for tackling difficulties in accident and emergency services. This funding will go in large measure towards increasing the number of sub-acute beds, particularly in the Dublin region, to allow acute hospitals to free up beds occupied by the elderly and chronic sick. Integration of strategies for the development of services for older people and accident and emergency services offers the best means of meeting the policy aim of supporting older people in the community and achieving the best possible performance within hospitals. This Government has provided additional funding to acute hospitals providing accident and emergency services to enable them to implement a range of initiatives in the medium term aimed at addressing the difficulties being experienced in their accident and emergency departments. This additional funding amounted to £2.3 million in 1998, £2 million in 1999 and a further £2 million in the current year. It has enabled hospitals providing accident and emergency services to continue to implement a range of initiatives aimed at alleviating pressures in accident and emergency departments, particularly during periods of peak demands which occur most frequently during the winter months. These initiatives include measures to free up beds for emergency admissions through the provision of alternative step down facilities for patients occupying beds in acute hospitals for lengthy periods. They allow for the provision of enhanced staffing levels, the development of rapid diagnostic systems for common emergency presentations, continued development of treatment/observation areas in accident and emergency departments and improved access for general practitioners to urgent specialist opinion. Difficulties in accident and emergency departments are most acutely felt in hospitals in the eastern region, which deals with in excess of 45% of all accident and emergency attendances. The Eastern Regional Health Authority has already decided that improvements in accident and emergency services are a priority and has established a dedicated team to examine in detail the existing services in the region as a whole, including paediatric services, and to bring forward a comprehensive policy for the development of accident and emergency services in the region generally. The team will review issues affecting accident and emergency services in terms of the principles of access, time, appropriateness and quality. It will be seeking to ensure that patients presenting at accident and emergency departments within the region have access to an appropriate service that deals with their needs in a timely and comprehensive manner. The review will address a variety of issues to include the examination of services within accident and emergency departments and the examinations of policies procedures and protocols for emergency services. It is hoped that examination of these areas will generate solutions for current problems occurring in some hospital accident and emergency departments, such as long waiting times for diagnosis and treatment, long waiting times on trolleys for patients awaiting admission and overcrowding in accident and emergency departments arising in part from delays in admission of patients. A review of alternative options for care will also be conducted. These options will include the development of out of hours GP services at community centres or in a hospital setting and the development of satellite and community based units for minor injury and illnesses. The initiative of the authority in this vital area of health services provision will result in a much improved service for patients presenting at accident and emergency departments. The role of primary care, and in particular of GPs, is also of central importance within the overall system. Under the NDP there will be very significant development of primary care involving investment in multi-purpose health centres. These will be local hubs for the provision of a range of primary care health and personal social services leading to a more comprehensive and integrated service to patients. Under the Programme for Prosperity and Fairness, the Government is committed to establishing at least four primary care pilot projects which will allow for the development of 24 hour, seven day services. A sum of £1 million has been made available for this purpose in the current year. Already the GP pilot project in Carlow, CAREDOC, is operating successfully as are initiatives such as DUBDOC in Dublin, centred around St. James's Hospital. A further pilot project in the Northern Eastern Health Board is due to commence in July. The roll-out of a properly evaluated primary care model will be of major importance in allowing patients to access health care at the most appropriate level. I note the Senators' outdated terminology when talking about mental health services. These services continue to improve and much progress has been made in the past number of years. It is acknowledged, however, that much still needs to be done. The commitment to transfer all existing admission acute units from psychiatric hospitals to units in general hospitals continues. The advantages of providing acute services in general hospital settings are obvious. Apart from the substantial improvements that such units offer in terms of structure, decor, furnishings and general comfort, the close proximity to and the availability of general medical and surgical services to those suffering from mental illness are obvious. Furthermore, the availability of psychiatric teams to the general hospital through liaison and consultation services is an important input to the general hospital services. At the end of the period of the national development plan in 2006, it is hoped that the programme of acute psychiatric units will be significantly advanced. This will mean acute admissions to the old psychiatric hospitals will become a thing of the past. Approximately £150 million capital will be provided over the lifetime of the national development plan for mental health services. A significant part of this funding will go towards the development of acute psychiatric units linked to general hospitals as a replacement of services previously provided in psychiatric hospitals. The plan will also provide for more community facilities such as mental health centres and community residences which will accelerate the phasing out of the old institutions. Additional funding of £12.25 million is being made available to the mental health services in 2000 to develop community mental health services, to increase forensic psychiatry services, to provide rehabilitation services, to increase child and adolescent services, to provide liaison psychiatry services in general hospitals and to enhance staffing levels. This additional funding represented a 100% increase on the additional funding made available in 1999. It is intended to accelerate the provision of community based mental health services for persons with mental illnesses throughout the country. Such residential accommodation in 1994 stood at 368 providing 2,685 places. This total increased to 398 in 1999 with 2,923 places. Between 1994 and 1998 the number of day hospitals and day centres increased from 159 to 176. Additional revenue of £2.9 million is being allocated in 2000 towards the further development of community based mental health services, including the improvement of the psychology and social work services. The lack of multi-disciplinary teams in many areas of the mental health services has been highlighted by the Inspector of Mental Hospitals in his most recent report. It is necessary to develop special rehabilitation programmes for patients who have spent long periods of time in hospital in order to facilitate their transfer to more appropriate accommodation in the community. In pursuance of this objective £250,000 has been allocated to the Western Health Board to fund a dedicated rehabilitation team which will commence a rehabilitation programme for long stay patients in St. Brigid's Hospital, Ballinasloe. If this pilot project is successful, a similar approach will be considered for other hospitals. A start was made in 1999 on strengthening forensic psychiatry services. It is necessary to increase the number of consultant forensic psychiatric teams to adequately deal with the level of psychiatric morbidity within the prison system and to facilitate better management of disturbed behaviour within the mental health services and thus prevent unnecessary admissions to the Central Mental Hospital. A total of £1.35 million additional revenue was allocated in 2000 towards substantial improvements in the forensic psychiatry services in Dublin, Cork and Limerick. Priority is being given to the development of mental health services for both older people and children and adolescents. Revenue resources totalling approximately £2.5 million were made available by the Department in 1999 to enable improvements to be effected in these services. An additional £1.1 million was allocated to further developments in child and adolescent psychiatry services this year. This funding will provide for the appointment of additional consultants in child and adolescent psychiatry and for the development of multi-disciplinary teams to focus on specific areas, such as attention deficit/hyperactivity disorder - AD/HD. A working group has been established by the Department to review child and adolescent psychiatry and to finalise a plan for the further development of this service. The group held its first meeting on 15 June. The increase in the number of people living to advanced old age requires the development of specialist mental health services to meet their specific needs. In this area, services have been expanding in recent years and £1 million in additional funding has been provided for the mental health services in 2000 towards the provision of additional consultants in old age psychiatry. It is intended to allocate additional resources to enable these services to be further developed over the next few years. It is also intended to increase the level of capital funding available for the development of mental health facilities in the community as part of the national development plan in order to make services more accessible. At national level, priority is being given to education awareness and to promoting a better understanding among the public of mental health, thereby facilitating a greater and more positive acceptance of the transfer of mental health services from institutional to community-based settings. Links with the voluntary sector continue to be strengthened, both at national and local level, and an additional £300,000 has been made available this year to strengthen these links and services. There is ongoing co-operation between the boards and several voluntary organisations such as AWARE, GROW, Schizophrenia Ireland, the Samaritans and local branches of the Mental Health Association of Ireland. Any suggestion that the Government is failing in its commitments in this area is outlandish. Evidence of our work in this area is crystal clear to anybody who cares to take even a cursory look at developments. As regards preventative measures, a number of significant programmes are under way in this area. I would like to highlight some of these, the first being the national breast screening programme. In March 1997, the then Minister announced the introduction of a major action plan to implement the proposals contained in the national cancer strategy. Included in the plan were proposals for the introduction on a phased basis of a national breast screening programme. Phase 1 will cover the Eastern, North Eastern and Midland Health Board areas and will target 120,000 women in the 50-64 age group, which represents approximately 50% of the national target population. The decision to proceed on a phased basis is a reflection of the complexities involved in the screening process rather than the costs involved and my Department's key objective is to ensure that the programme meets the necessary quality assurance criteria. It is for this reason that the national breast screening programme must be driven by international quality assurance standards and best practice. Specifically, the phasing will take account of the following critical success factors: the achievement of acceptable compliance levels among the target population; ongoing evaluation of the programme from a quality assurance perspective; and availability of the necessary clinical expertise to conduct the programme. The service is being delivered by two central units, the Eccles unit on the Mater Hospital campus and the Merrion unit on St. Vincent's Hospital campus, with outreach to the community by means of three mobile units. Limited screening commenced in both units in March, without publicity, to test equipment, systems and procedures. Decisions in relation to subsequent phases of the programme will be guided by the experience gained from putting phase 1 of the programme in place. Phases 2 and 3 will involve the extension of the programme to the rest of the country. The steering committee has recommended that phase 2 of the programme should follow phase 1 as soon as possible. My Department is conscious of the importance of early access to symptomatic mammography services, and of the provision of an equivalent standard of excellence in both symptomatic and screening mammography services. At the request of the Minister, Deputy Martin, a review of the symptomatic breast cancer services has been undertaken by the national cancer forum. The Minister has received the report of this group, which he is considering. He proposes to make funding available under the national cancer strategy to develop further symptomatic breast cancer services throughout the country. My Department also recently raised the issue of mammography referral practices with the health boards. The Department's key concern is to ensure that all women, irrespective of age or where they live, have timely access to symptomatic services. A critical factor in this regard is referral by GPs to local diagnostic mammography services in the first instance. This should result in a reduction in average waiting times at all mammographic units, thereby improving access for women and at the same time ensuring that expertise levels are maintained and developed in diagnostic units around the country. Improvements will be taking place in the dental treatment services scheme, which Senators have alluded to. Medical card holders will be entitled to receive a dental examination and a range of treatment from the dentist of their choice. This year over £32 million is being provided for the scheme. In addition, it is proposed to extend entitlement to dental services to children up to the age of 16 who have attended national school, with effect from 1 August 2000. Ophthalmic services are also being examined and improvements will ensue, with funding totalling £3 million having been provided this year for the implementation of improved services. The maternity and infant care scheme provides for pre-natal and post-natal care, free of charge for all women regardless of means, and for their babies up to six weeks of age. The report of the maternity and infant care scheme review group advised that a system of combined care, i.e. where the expectant mother is under the care of both her general practitioner and hospital obstetrician, is the best and most convenient form of ante-natal care for the majority of mothers. The report contains 109 recommendations, including a revised schedule of visits for mother and baby.

The national cervical screening programme is another scheme dealing with preventative medicine which is under way. These new developments represent progress, but they have not been highlighted by the Opposition. Child health is another area that is receiving attention from the Department. The report, Best Health for Children, published in the latter half of 1999, is a review of child health services undertaken by the chief executive officers of health boards. Further improvements have been made in immunisation programmes. The unsatisfactory uptake of childhood immunisation is a matter of concern and my Department is working with the health boards to develop strategies to maximise the uptake. Boards have been asked to make every effort to devise strategies tailored to local needs, employing innovative approaches, if considered necessary, in order to achieve significant improvements in uptake. If a 95% uptake can be achieved, the eradication of a range of serious diseases will be achievable. In relation to MMR immunisation, which is of particular concern, the office for health gain has recently developed a new campaign to heighten public awareness about this issue, and this was launched on 20 June. New vaccines are coming on stream to protect against group C meningococcal disease and we hope to have them by September. Despite what has been said by a number of Senators, much progress has been made since the Government took office. We are not saying that everything is hunkey dory; naturally there are problems. No service is perfect but we are examining the matter in a pragmatic, phased and rational manner. We are not throwing money at the problem for the sake of doing so. We have a plan and are working with health boards and the voluntary sector to achieve results. Appropriate health care provided by professionals in proper settings is the cornerstone of an effective health care system. The Government is fully committed to the development of a comprehensive health service that is capable of responding fully, quickly and effectively to the health service needs of the people. We are proud of our record since taking office of delivering on our commitments in the health area. Much has been achieved and important developments have commenced under the Government. We also recognise that there are problems with the health services and we do not wish to understate these, as I said. However, we do not wish to exaggerate their magnitude as this only serves to undermine the confidence the public has in the services. Senator Henry referred to all the advertisements in the newspapers for personnel at present. However, this is the time of year that health boards advertise for staff and they are having difficulties in some areas. However, that is not unexpected. The Senator also mentioned the obstetrician and gynaecology services where there is only one gynaecologist. Progress has a price and there is a price that people will pay. People expect better services but, in the long term, they may only be provided in bigger units. This aspect must be considered; people must be given what they request. It is essential that the opportunities the resources now available provide are fully realised and that real and lasting improvements are delivered. The challenge facing everybody working in the health sector is to ensure that the public gets the maximum benefit for their resources and that the delivery of a quality health service to all who need it is achieved. This should be achieved in the short term rather than in the long term. This is the only Government that will ever deliver on the health services. Our track record speaks for itself in spite of the comments of the former Minister, Deputy Noonan, in relation to his tenure of office. The situation left much to be desired when we entered office. Mrs. Jackman: The Minister of State is very defensive. Dr. Moffatt: We have implemented measures and improved the situation dramatically in the past three years. Ms O'Meara: I wish to share my time with Senator Norris. Acting Chairman (Mr. Dardis): Is that agreed? Agreed. Ms O'Meara: I acknowledge the comprehensive nature of the Minister of State's speech but I was reminded during it of an article I read recently in one of the daily newspapers by Terry Prone, the well-known communications specialist. In it she mentioned a trap in which every Government falls. This trap appears mid-term when a Government starts to get defensive, outlines what it is doing and where money is being spent and wonders why people are not more grateful. This Government is not the first to fall into that trap, which Ms Prone likened to a person going to a hotel, paying for a room and being expected to be grateful that there are sheets on the bed. The Minister of State's contribution reminded me of that, particularly when he said that the maternity and infant care scheme provides pre-natal and post-natal care free of charge to all women regardless of means and their babies up to the age of six weeks. It should do so, and much more besides. This is a basic matter and nothing about which the Minister of State should crow. The public knows that, given the current state of the economy and the resources available, the Government's performance with regard to health issues is not good enough. I support the motion tabled by the Fine Gael Party which refers to a number of issues of obvious concern to the public. There is a failure to deliver on the provision of essential health services because they are in crisis. I agree with other speakers that it is not a case of throwing money at the services, although funds properly spent would help. It is a question of tackling fundamental problems in the health services of which we have been aware for some time. Senator Quill referred to some of these problems, but particularly the fact that, due to the neglect of the Minister's predecessor, the services are lurching from crisis to crisis in terms of the shortage of nurses, junior doctors, waiting lists, etc. There is almost a state of emergency with regard to the provision of junior doctors. Everybody is aware of this fact and that the gap in terms of services for public and private patients is widening daily. In spite of the Government's laudable remarks about equality and delivery of services, it is not happening. I cannot deal with the fundamental problems in the health services and suggest an alternative in the short time available to me. Ms Leonard: Just suggest the alternative. Ms O'Meara: We at least have put forward an alternative. Ms Leonard: We have seen it. Ms O'Meara: Yes, and the Government has misrepresented it at every available opportunity. Acting Chairman: Senator O'Meara without interruption. Ms O'Meara: It has been deliberately misrepresented. As I pointed out in my local media, the Senator's colleagues in the other House have deliberately misrepresented our policy document because they know it is correct and they are afraid of it. The issue is live and people are very angry about what is happening in the health service. People know because they see it happening. For example, this week I received a report from Nenagh General Hospital that there are people on trolleys in corridors at this time of the year. When the Labour Party's spokesperson on Health, Deputy McManus, visited Nenagh General Hospital recently, she made the point, which was supported by the hospital administration and senior staff, that small hospitals such as Nenagh General Hospital should be allowed to diversify. The Minister of State mentioned certain services only being available in large hospitals and I disagree with him in that regard. There is huge potential for small hospitals to develop specialties, for example, in surgical procedures. This would give increased value for money in terms of the services delivered by hospitals. At present, one cannot get an appointment in Nenagh General Hospital with a physiotherapist because there is only physiotherapist instead of three. This is an example of the current staffing crisis and public patients are suffering as a result. This is only one example of what is happening around the country and what is making the public angry. If one asks why the Government cannot do better, there is no answer. The Government's actions are similar to shifting the deck chairs on the Titanic. It is lurching from one crisis to another. I do not question the Minister of State's commitment but I question the Government's ability to introduce the fundamental changes necessary to generate a health service that, as he said, would be of benefit to everybody. face="Arial, Helvetica">Mr. Norris: I thank Senator O'Meara for sharing her time. The Minister of State and the Minister for Health and Children are decent, well motivated people. However, if it takes the Department of Health and Children as long to deliver the health services as it took the Minister of State to deliver his speech, we will be waiting a considerable amount of time. The Committee on Procedure and Privileges should consider the need to exclude the time given to the Minister's contribution from the calculation of Members' time. The Minister of State had many important things to say, and we welcome them being said in the House. It was a carefully thought out speech, but it should not have taken up a third of the time allocated to a debate to which many Members wish to contribute. The provision of a decent health service is one of the critical criteria by which a decent society is judged. The late Noel Browne took on a difficult situation and got money, and money is important. It is not an instant solution but the problems facing us today relate to the training of doctors and nurses and getting people into the system. There are plans and equipment but we do not have the personnel and this is a significant problem. The points system also needs to be considered. My information from friends who are nurses is that, to a certain extent, we do not always get the right people. They are not properly motivated and they do not consider it a vocation. It is a vocation as are politics and teaching. I was involved in two of those; I have not yet become a nurse but if the situation becomes critical, I will volunteer. We need to attract people and we need to train them properly. One of the reasons I will vote with this side of the House is that the amendment is too strident and shrill. How could I vote in favour of paragraph 3 of that amendment which seems to suggest there is nothing wrong with the accident and emergency services? Within the past week there was a sad piece in the newspapers about an elderly woman who was a resident of what I knew as the governesses' home in Harcourt Street. She was 80 years old and still fairly mobile. She was on a bus which stopped suddenly and was thrown forward. When brought to hospital she was left waiting for eight or nine hours. She was not too seriously injured but the shock caused a drop in her blood pressure. She should have survived if she had been given treatment immediately. However, the queues meant she was placed in jeopardy. I am not a coroner so I cannot say she died as a result of it, but that story tells us something. If an elderly person of 80 years old is placed in that situation, there is something wrong. The accident and emergency service is not good. It is not the fault of any one party or Government but we must honestly address these issues because they affect our citizens. This was a reticent private family, yet her two daughters released this story to the newspapers because they did not want it to happen to anyone else's mother and they were right. We know how barbarously junior doctors have been treated and how outrageous it is to think they can wait ten years to be given humane conditions. We would not allow lorry drivers to work the hours these doctors do because of public safety. I am not pointing the finger at any particular Government because they have all been the same. The dental system is daft. A person can offset cosmetic dentistry against income tax but if he or she has a gumboil or an abscess, he or she must pay for it. That is outrageous. I am delighted to hear about women's health. However, we must also hear something about men's health. We must hear about testicular cancer and men should be shown or told, if they are too thick to know it themselves, how to examine themselves. We should also look at prostate cancer. These are killer diseases. I regret voting against the Government, although I hope it happens twice because it will shoot up my voting average, but I must do so because of the seriousness of the issue. However, I will not do so to score points against the Government. If the other parties were in Government and they were making the same case, I would vote against them too. Mr. Farrell: I wish to share my time with Senator Leonard. Acting Chairman (Mr. Dardis): Is that agreed? Agreed. Mr. Farrell: I support the amendment, although both it and the motion are before the wrong body. We should remember that the health boards were set up as statutory bodies to look after people's health. It is only the Minister's job to provide the money to do so. Some years ago we said our services were a shambles because enough money was not provided. We now have more money than we can spend but we do not have sufficient personnel. The Medical Council has a case to answer in this regard because it stopped non-EU doctors from coming into the country, claiming they were not competent, they could not speak fluent English and were unable to take proper instructions. Few Members of the House did not have queues of mothers outside their doors seven or eight years ago trying to get their children into nursing. However, we set the standards so high they could not get into nurse training because they did not have the points. Those people trained in England and when they came back here they got top jobs because they were highly proficient. Did they not have the ability to become proficient before they went to England? Why did they have to go to England to train? The medical profession is a locked shop. We have heard the gap is widening between private and public health care. Do we realise the same doctors and consultants are dealing with private and public health care? Senator Henry said that soon no one will be working in one unit. I was for 20 years a member of a health board which closed many small hospitals because consultants could not get a full backup service. However, when the VHI was set up, nursing homes were closed and private hospitals were established. Where is the backup service in a private hospital and who is working in them? The consultants from the public hospitals are doing so. The Minister must tell consultants to stay in the public service and serve the public if they work there and that anyone who goes into the private service should not have the cushion of the public service. Council engineers are not allowed to have private and public practices. Why should consultants do it? We must carry out a root and branch examination of this area. A few years ago there was a big waiting list in the Southern Health Board area for hip operations. Deputy Allen was chairman of the board at that time and he sent busloads of people to England and Northern Ireland for them. The Medical Council said they would not be treated properly and that they would not get a good service. Since I did not hear those who came back complaining, the service and the hip replacements must have been good. As a result, hips were fitted at a rate of three or four a day in all the hospitals throughout the country because they knew they would lose business to England. I compliment the Minister on making money available to send patients out of the country and to pay for their operations. That is the only way we will break the monopoly of the medical profession. I defend the accident and emergency service. Many people complain about it but I have availed of it twice in the past five or six years. I was in the accident and emergency department of the Mater Hospital where everyone received great treatment. I lay on a trolley for a number of hours but I got as good a service as I received in a private ward afterwards. I defend the nurses and doctors. People shout about being left waiting for seven or eight hours, but they get full treatment. Many people who came into the Mater Hospital had drink and drug related problems and the Garda had to be called a few times to move them. They should not be allowed to block up accident and emergency departments. It is time we stopped people from using accident and emergency services who do not need to use them. People lying on trolleys are well cared for. I am speaking from experience, not on the basis of dúirt bean liom go ndúirt bean léí. Ms Leonard: Senator O'Meara said everyone is entitled to a basic health service, particularly an accident and emergency service. However, the public has a duty to be responsible. A survey was done for one of the national newspapers today which shows that the majority of patients attending Beaumont Hospital during a three week period could have been treated adequately by their GP or nurse practitioner. Out of 676 patients examined, it was discovered that only 137 needed to be at a high technology facility such as Beaumont Hospital. What do the public perceive accident and emergency departments to be? I do not generally believe what is written in newspapers, but I know from personal experience of working in one of the busiest children's hospitals in the country that parents bring their children to an accident and emergency department on a Sunday afternoon to sit for approximately four or five hours with a problem which the child has had for two, three or four days. One does not need to be a genius to realise that is not an emergency. There is a responsibility on the public to use accident and emergency departments for accidents and emergencies. We talk about the health service being delivered from a central level and that is something that the people on the ground can examine. The Minister of State, Deputy Moffatt, referred to some of the preventative measures that can be taken. Vaccinations are available free of charge to parents for the benefit of their children. Senator O'Meara talked about the health service being for the benefit of everyone. The MMR vaccination is available free of charge to parents. All they need do is go to their clinic or their general practitioners, yet only 75% of parents are doing that. Children are being neglected to a certain extent despite the fact that the service is available free of charge. Whose responsibility is it to vaccinate children? It is the parents' responsibility. The service is there, let them use it. We are talking about preventative measures and that is one basic preventative measure that parents can take. We debated the health services two weeks ago and the question of centralisation. The services were decentralised when the health boards got control and we are now blaming the Minister for everything. What did we put managers into the health boards to do? They are supposed to be managing the services and preparing for the development of the services within each region, yet they abdicate their responsibilities. I am sure every Member will agree with me that there are more facilitators, co-ordinators, programme managers and area managers than we need. There are so many titles, the list goes to the end of the page. What do these people actually do? Perhaps we have too great a hierarchy in administration in the health service at all levels, not only in hospitals. I am well aware of the hierarchy in hospitals having spent ten years in that sector. I have experience as a public representative and of dealing with the health boards, but most of the time I cannot explain the titles and they change so often I do not know the actual responsibilities. If we had more analysis of the responsibility of some of the personnel in the administration of the health boards we could put the actual resources where they are needed - towards the basic care that people deserve. Some of the Senators opposite had the decency to acknowledge that increased resources have been made available. I welcome all the measures that have been taken. Two weeks ago we talked about the nursing shortages. Nurses were treated so badly years ago they left the system, or they did not get into it, and I would not blame them for doing that with the treatment they got at the time but the Minister and the Minister of State have taken measures which I hope will encourage more people to enter into that field. We recognise that there will never be enough money in the health service. Part of the reason for that is the advancements that are taking place not only in technology but also in medical and surgical procedures. Every day new advancements are made in these areas. Only last week enormous advances were made in the field of genetics. That will take from our resources in the medical field. We need to examine the hierarchy within the health boards and the jobs some of those people do. An Cathaoirleach: I ask the House to give me permission to allow Senator Burke five minutes to speak on the motion, and then I will call Senator Jackman. Is that agreed? Agreed. Mr. Burke: I thank the Cathaoirleach. I will be very brief because I realise we have gone over the time. I am delighted this motion is before the House this evening. The reason for it is the frustration felt by public representatives, particularly on this side of the House, with our health services. Senator Henry pointed out the state of the health services throughout the country and she highlighted the inadequacy of some of those services. At a time when the national surplus is £2.4 billion, more money should be put into our health services. Along with Senators from all sides of the House, I have been plagued by representations from people complaining about the health services over the past number of years. I understand the reason some of the Senators on the Government side got excited this evening about this motion. They are getting the same representations as those of us on this side. While I acknowledge that increased funding has been put into the health services over the past number of years, it is still not adequate. With the increasing population and the increasing needs in our health services, more funding is needed. Senator Quill pointed out that we should not throw money at the health services for the sake of it. No matter what changes are brought about, extra funding is still required. I want to ask the Minister of State about the cancer research forum group which issued a report recently on cancer facilities throughout the regions. Will he furnish that report to the Members of the Seanad and the Dáil since it recommends the closure of the breast cancer unit at Mayo general hospital? As has been pointed out by Senator Jackman, the incidence of cancer throughout the regions has increased. In 1996 the figure was 20,000 but in 1997 it increased to nearly 22,000, something which was pointed out by other Senators this evening. I ask the Minister of State to convey a strong message to the Minister that the closure of the breast cancer unit at Mayo general hospital will not be tolerated. It needs to develop along with other units throughout the country. I realise there are time constraints. I have a lot more to say on this subject but I will have to continue on another day. Mrs. Jackman: I thank the Senators who supported me. Indeed I detected support from the other side of the House, despite the fact that the Minister of State has been extremely defensive in the way he addressed the motion, aside from the 28 page "research document" which I will keep and with which I will benchmark progress by the Government. I detected an honesty from Senator Quill, which is typical of the Senator, in that she acknowledged that she is happy with what the Minister, Deputy Martin, has been doing recently but she also talked about the actual management of the services and the hierarchy of services, as did Senator Leonard. Senator Henry and Senator Fitzpatrick are practitioners and they acknowledged that there were problems. What disappointed me was the defensive nature of the attack. The by-election did not teach the Government much at all. This is a real issue which involves real people and I detected in the 28 pages of the Minister of State's script, being an English teacher, that everything was very much in the future tense. That is fine. The Minister, Deputy Martin, has only been a short time in his job but we can go back to the years when the previous Minister, Deputy Cowen, was in office. Reference was made to Deputy Michael Noonan's term as Minister. Two and a half years is a short time - and I am not making any claims with regard to what the rainbow coalition did in Government - and we were not talking about a bonanza with a financial give-away at that time in comparison to the figures to which Senator Burke referred. I am extremely disappointed by the defensiveness with which our motion was treated. There is a problem with the accident and emergency service. We are not making it up. One can see that any night of the week in the Limerick Regional Hospital and hear from the people about the length of time they have been waiting. It is not a case of going in with a cut finger or another problem that the GP could treat. People are very aware of what is happening now. We are talking about accidents and the two cases in which the unfortunate individuals died. This is the human aspect of the Department of Health and Children and we cannot walk away from it. If there is one issue I feel very strongly about, which was referred to by the Minister of State, it is attention deficit hyperactivity disorder and child and adult psychiatry. I accept that I should refer to mental health services rather than psychiatric services and I am glad I was corrected on that. There are at least seven or eight cases of children with attention deficit hyperactivity disorder currently before the High Court who have nowhere to go but to the High Court to seek access to basic health services. Such services are closely linked to educational services, which they are not getting. Their parents have sought redress for them in the High Court because the health services have let them down. Senator Fitzpatrick and I are members of the Committee on Health and Children. At a meeting of that committee ADHD, of which the former Minister, Deputy Cowen, had not heard, was discussed. A report, which highlighted the difficulties experienced by children with that disorder, was obtained at a cost £5,000 and a prevalent study is now being undertaken in this area. I am talking about children with real problems. If we criticise management personnel in the health boards, it must be remembered the Minister is the final arbiter in this area. If there is a problem in the eight health boards, it is up to him to approach management personnel in a gung ho fashion and tell them they are not managing the funds in an appropriate manner. Senator Leonard referred to glossy titles for various administrative personnel, but are they doing anything to improve the delivery of our health services? I do not blame the health board for problems in the delivery of our health services. I blame the Minister for not approaching the health boards, pointing out the problems and asking them how the money allocated to them is being spent. I am shocked, horrified and disappointed about that. I would like a future Private Members' motion to deal with problems in the delivery of cancer treatment services. I accept some cancers are fatal for men are well as women. We are not addressing the lack of delivery of such services. I would have been far happier if the Government amendment reflected the honesty displayed by Senators across the floor of the House who said it did not represent how they felt about this issue. It is a shame it is so vague and aspirational. I am disappointed this motion does not have the full support of the House. Amendment put. The Seanad divided: Tá, 26; Níl, 14. Tá Bonner, Enda. Callanan, Peter. Cassidy, Donie. Cregan, John. Dardis, John. Farrell, Willie. Fitzgerald, Liam. Fitzgerald, Tom. Fitzpatrick, Dermot. Gibbons, Jim. Glennon, Jim. Glynn, Camillus. Kett, Tony. Kiely, Daniel. Lanigan, Mick. Leonard, Ann. Lydon, Don. Mooney, Paschal. Moylan, Pat. O'Brien, Francis. O'Donovan, Denis. Ó Fearghail, Seán. Ó Murchú, Labhrás. Ormonde, Ann. Quill, Máirín. Walsh, Jim. Níl Burke, Paddy. Coghlan, Paul. Costello, Joe. Cregan, Denis (Dino). Doyle, Joe. Hayes, Tom. Henry, Mary. Jackman, Mary. Keogh, Helen. McDonagh, Jarlath. Norris, David. O'Dowd, Fergus. O'Meara, Kathleen. Ross, Shane. Tellers: Tá, Senators T. Fitzgerald and Gibbons; Níl, Senators Burke and Jackman. Amendment declared carried. Question put: "That the motion, as amended, be agreed to." The Seanad divided: Tá, 25; Níl, 12. Tá Bonner, Enda. Callanan, Peter. Cregan, John. Dardis, John. Farrell, Willie. Fitzgerald, Liam. Fitzgerald, Tom. Fitzpatrick, Dermot. Gibbons, Jim. Glennon, Jim. Glynn, Camillus. Kett, Tony. Kiely, Daniel. Lanigan, Mick. Leonard, Ann. Lydon, Don. Mooney, Paschal. Moylan, Pat. O'Brien, Francis. O'Donovan, Denis. Ó Fearghail, Seán. Ó Murchú, Labhrás. Ormonde, Ann. Quill, Máirín. Walsh, Jim. Níl Coghlan, Paul. Cregan, Denis (Dino). Doyle, Joe. Hayes, Tom. Henry, Mary. Jackman, Mary. Keogh, Helen. McDonagh, Jarlath. Norris, David. O'Dowd, Fergus. O'Meara, Kathleen. Ross, Shane. Tellers: Tá, Senators T. Fitzgerald and Gibbons; Níl, Senators D. Cregan and Jackman. Question declared carried. An Cathaoirleach: When is it proposed to sit again? Acting Leader (Mr. T. Fitzgerald): At 10.30 tomorrow morning. Speech Menu Top